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Name:
Management of Limb Length Discrepancy for the Orthopaedic Exams
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Management of Limb Length Discrepancy for the Orthopaedic Exams
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Upload Date:
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Transcript:
Language: EN.
Segment:0 .
So good evening, everyone, welcome to our teaching session. My name is Nicky Evans, and I'll be modulating this evening. We also have Mr honey, who is presenting an approach to leg length discrepancy, which is an important topic for the exam and can be confusing for some candidates. And he's going to make that topic nice and clear for us today.
I'd also like to introduce our other mentors, Mr swan, hinari and Mr trevisan. Following the presentation, we'll have time for some questions, and I'd like to ask you to write your questions in the chat box, which we will monitor, and we'll ask honey at the end of his lecture. If you missed any part of the lecture, don't panic. It is recorded and it will be available on the FRCS YouTube channel in due course.
Following the questions, we will stop the recording and we'll proceed to vyver practice again if you'd like to participate. We request that you raise your hand or identify yourself in the chat box along with when you're sitting the part two exam. We understand that putting yourself forward for these fibers can be intimidating and stressful, but it's really the best way to practice your exam technique and rest assured that all of us mentors have been through the same experience.
As always, we recommend our study guide, the concise orthopedic notes, which is available on Amazon and it's been written by our mentors and is a very good resource. If you require a CPD certificate, then please email us on the FRC. Yes, mentor at gmail.com. And without any further ado, I will pass you over to Mr Hannah honey Albanese for the lecture.
Thank you very much for the about approach to the discrepancy. It's very important topic. I actually I got this a case with a discrepancy in my clinical part of the exam, and it is very, very common. So I will try to go through a quick resistance to how to examine and do a discussion in less than five minutes. So usually this discrepancy will come at a short case.
So you have to do everything in 3 minutes and 2 minutes for discussion. So first, I want to share the bulk of the efforts, as mentors are concise automatic notes. I think it's very helpful book for the first exam. OK, so number three, so we have a three minutes to do examination, full examination of this case. And I think it's number three, you can, like, categorize everything in three points.
Whatever the reasons would approach how you manage everything, make it like a slick answer and will not forget that. If in your money, if you are in your mind, you have a category you have, you have organized your answer about that. So it is start that first, you will see a child in the exam and the examiner will ask you, just examine this patient. So have a look from the front, from the side, from the back and usually in the discrepancy you will we would see in balance, so have a look at the shoulder.
Have a look at the pelvis. Have locals, the knee of the knees and the fault. And as I say, look from the front, the side, look in the back, you might find scoliosis, you might find in any science and dimension everything about that. Then ask the patient to walk. So ask the Mason talk, just say simply, it's a short, limp gait.
So usually the examiner will not ask you about that, but if I asked you to comment about the shot, let me just ask this is a pelvic tilt down to the affected side. And to compensate the airlines and allow the ground clearance of the longer limp, so just for example, in through country shortening with abductor insufficiency, walking becomes difficult. And the fourth Mason by need or patience may work on the tools to compensate for the short, limp and the normal and be compensated by flexion of the hip and knee.
So that is why that is the short limit. If you, if you, the examiner, asked you to analyze what is a short lived gait but simply says observation to walk. And short limb gait then puts the patient on the table and just do measurement. So that's the true lens would start from two prominent I usually start from the antero-supero-lateral spine to the middle malleolus like in this picture.
OK, and the compare to the other side. Then don't forget to measure the apparent length. So start from the umbilicus, it's to the same point of the middle and. Now shows the difference, like if the true shortening is equal to the apparent shortening, it indicates there is no compensation, so there is no product from deformity in this case. If the true shortening is more than the apparent shortening, it indicates that the part of shortening has been compensated for.
And if the true shortening is less than the apparent shortening, it would suggest affected abduction deformity so the patient will abduct his leg to compensate this shortening. So usually when you ask the patient to put him on the bed on the table, so are you usually squared the pelvis and you will put the two limbs parallel to each other to make the true measurement?
However, in some cases, the patient has abductor deformities do not force the patient to like to become a square to square his pelvis, but say to the examiner, I am unable to bleed the legs perpendicular to the pelvis because abduction contraction does not hurt the patient. That's very important. The same thing if the patient has deformity like a valgus knee, so you couldn't put the two limbs parallel to each other, so say to the examiner, I am unable to place the legs straight because of the obvious need.
Don't force the patient to do anything. Don't hurt the patient, please. OK, so next, sometimes the examiner will ask you what is the reason for that? So many books mentioned like maybe a congenital disorder, hemi hypertrophy, all these things are true, but this is the wrong way to answer. So go back. Remember the number three?
So keep it simple but precise, so the leg length discrepancy may be from the spine, from the pelvis, from the lower limb and the floor from the lower limb. The femur may be from the tibia, maybe from the hind foot. And don't forget the high end. OK, so the female maybe sobre todo country or infratel country, I like to answer it like that, don't do like that. OK, flex the knees and do a test, so that will differentiate between, is it like a femur or tibia?
OK and you can see here if the female is longer than is a short thing in the femur, you will start in the upper left side and in the tibia, it will look like in the picture. See here. So it's very easy to differentiate between if the shortening is in the tibia audience, the femur. And don't forget for it as well. OK, so if the shortening in the femur, which is the most common thing, so you you need to differentiate if the shortening is softer country or country.
So differentiate between that. Between both of these, you have to do pliant triangle, so you lose three fingers. You will put one finger at the tip of the GT. The second finger and the entire superior experience. And you will drop your finger. Other singles parallel to it and you measure this line. So you will measure. I will from this here to this is a dotted line.
That's you. That's your own measure. This is a distance that you measure in the exam and you will compare to the other side. OK, sometimes two, to square the pelvis you like to do like a block to measure how many, how many like shortening the other limb, but you will not find that in the real exam.
OK, so, OK, it's examinations, you did your measurement, you found where exactly the side of shortening. So the examiner will ask you what you will do next. Do like an X-ray of the whole lower limb or scan, which is the most accurate measure for leg length discrepancy. OK, so now there is a three categories. So these are the shortening is from 0 to 2 centimeters or from 2 to 5 centimeters or from five or more than 5 centimeters.
OK, so and there is specific treatment for each of this one. So there is something called white Manila's method to like, anticipate how many groaning or how many growth remaining for the lower limb. And usually the knees grows by around 15 per year, and you will do like assumption that the boy will grow until 16 years and the girls up to 14 years. But this is like a rough estimation, and this most probably will find you will be asked in the first part in the MCU, but in the second part, I do not find it more practical.
So what you should do, look this graph, because it will give you standard deviation between the chronological age and the bone age, because sometimes the bone age is not matching with the chronological age. And so recently, so pallet growth, there is just a so-called multiplier. And this is an applications all the pediatric specialists in the UK and Ireland use.
This application is a multiplier or palate. So it's a very handy application. You will find it in Apple stores. So you will enter the age of the patient and the gender, and we and it will calculate for you. How many like when, when you will do like this on, will you do your surgery? It is very it's very good and it's very nice to mention in the exam if you know it and just download it in your mobile and try to measure one or two cases just to be familiar with it.
It is very important. And you might get an eight mark if you mention that in the exam. OK, so if the shortening less than 2 centimeters with no surgeries, so just show left will, you will give the patient in Seoul to compensate for the limp for the length discrepancy. As as you see, this child is smiling because I know this more than two centuries but usually up to 2 centimeters more than two centuries will have to do surgery.
OK so in 2 to 5 centimeters you will do start to do surgery here. We will do like a phase with these foods alongside or shortening osteotomy of the long. If the patient is mature for other patients, but for pediatric, we usually do before you decide of the long side. If it's more than 5 centimeters.
So you will go for limb lengthening, so you couldn't show make the patient shorter more than 5 centimeters and that is why we learned these short limp. So how you can do lengthening of the short side. So either like an external fixator or internal external fixator like in the roof, like this case will do destruction osteogenesis. So what the principle?
So you will vote that it is the roof or the frame, and you will wait for 5 to seven days for to start lines to begin construction, then you will do distract 1 millimeter a day. And following destruction. So that's because it's a fast question as well, so how many times you will wait after finishing the lengthening? So we have to it's in the same period.
So for an example, if you are going to length. The length about 10 centimeters that you will wait for 105 or 107 days and you will keep the Elisa roof for the same period, so you will wait almost 210 days, which is a very, very long time for the patient to keep the roof in the limb. So that is why there is medullary lengthening device with the growing nail.
It's very expensive, but I think it's better than the Israelis are off. And sometimes if this nail is not available, you can mix between the Lazaroff and the usual nail. And the reason for the nail just to remove the Elizabeth early after, after just finishing the lengthening. OK, so sometimes the legal discrepancy is associated with deformity, so like a vulgar deformity isn't the only pathology.
So in this case, you might use this aid plate, which is a hemi epithelial disease. OK, so sometimes you will the examiner will show you some x-rays about these eight plates, and I noticed something maybe advance it for day one consultant, but just to understand the principle of it, how, how, how, how like, what the principle behind the aid plate and how you can use it.
Simply, it is a cuteness you just open centimeters incision over the faces under image, you will pass the guidewire and the most important thing here. You have to put the wire central in the sagittal plane because if you put it entiere, that means that more growth will be posterior and that will give you a richer rhythm. And if you bought it slightly and steer it, grow more, and here that would be broken.
So make sure that the guidewire its center in the sagittal plane. And after that, you will put the plate and do both. This is two screws, or sometimes it's four screws, the paint depends and you should be parallel to each other. And so this is an X-ray and how you can differentiate between like if this aid plate it just applied or like applied one year ago or a few months ago. Usually you will find the screw is not parallel.
It start to diverge. That means that it grows to the other side and stop growing at this side. And the whole of the blade, if you have a look at the whole of the blade it allow, it allows the screws to divert. OK, so sometimes the examiner may in Survivor me start you with an X-ray like that and ask you just to comment so you will see from the X-ray.
So the screws in the medial side of the lower femur, it's not parallel. It's divergence. That means that it's old. It's not. It's not a new. So this surgery done maybe one year or more. And the patient becoming virus, so we'll ask you just to comment on the x-ray, so if you understand the mechanism of action of this plate, you know this is an old and this is a complication of the eight plate, which is the overgrowth like over the four, like the tuberosity and the deformity become more so.
It's converted from fungus to varus deformity now. And so it believed it should be like monitoring for it so that the patient should be follow up in the clinic and to monitor the growth and to avoid this complication. OK, so this is like a good example. You can see here, like the lens is well aligned and the screw is diversion, so that means it's not new.
And the lamp is, well aligned. No deformity, no, there is no Vargas. So now you can take it, take it out now and allow for normal growth. OK, so we'll take home message, so in the pediatric so we can start for show left if it leads to centimeter phase you judicious growth arrest if two to 5 centimeters if more than that, you will go for lengthening for the short limb.
And usually the same in the other two, you can use the Elisa roof and you can use the nail for lengthening, I usually I personally prefer the interim nail because most of the patients will not be happy with this result of two kept for about four or five months inside the lamp. And thank you. Planning for that very comprehensive lecture in terms of when you're monitoring eight plates.
Would you ask the patient to come and visit every year and do an X-ray or every month? Or do you leave it to the parents to watch for the week for the virus? No, actually, I will. I will not. I will not leave it to the parents. I have to see the patients and will do an X-ray and to measure how much like correction, because it's very always all the people will not behave the same.
OK and my second question is, in terms of timing of your surgery. That is why use application, usually my boss and all the pediatric specialists usually do use these applications. It's very handy. You just enter the patient date of birth, the gender and the like discrepancy in the lens, and you will let when to do the surgery.
And the aiming of the timing is everything. So my apologies. I misplaced that the aiming of the timing is so that the growth plate stops growing at the time. You yes, yes, yes, no, no, no, no, not forever. You have to take it out. Yeah, Yeah. I apologize, but I'm so.
OK, thank you very much. But thanks, honey, there's a couple of questions popped up. The first one is what about five steel bar excision? Actually, there is another option as well, but usually there is like a post-traumatic or like post infection. So something like physical power, so you have to do like a metaphysical window and we'll remove this power.
So yeah, it is one of the options one. OK, thank you. We've got a question from Melinda who says, please, can you explain how to square the pelvis? You adjust your hand. Just ask the patient to lie down and put your hand on the antero-supero-lateral iliac spines and make it square.
OK Muhammad has asked if we could write down the name of the app for him. Actually, just write multiplier in any like Apple store or anything. You'll find it. And in a way this like video will be like will be in the YouTube page. So actually, I can share I can share this picture from my presentation to the telegram group.
Hey, thanks, honey. We've also got some. When will we do permanent Odysseus for leg length discrepancy at any age? So if you like the remaining growth period, it just is a time to compensate the discrepancy. So you will keep it forever. You will do permanent, ok? And we got one from Adam who says in regards to less than 2 centimeters there is no compensation from the pelvis and spine.
I think that means, is there any compensation? That's really my two cents. If you don't, if you do like a short left can be compensated. So it's a very mild discrepancy here. I think the question is more will there be if you don't use this fine compensation? Well, yeah, yeah, Yeah. But it's better to if the patient is symptomatic just to give him a shot.
Yeah, it's also decreases the risk of spine problems as the patient gets older and/or more active. OK because a couple more questions. One just disappeared. How can we measure length, length, leg length in cases of flexion, contraction of the knee in knee arthritis and in case of trauma to medial malolos? OK, so will both the normal leg in the same deformity and the measures like that, and if it's a problem, is the medial measure in the lateral malleolus.
So any bony prominent but do the same to the other side. If there is a flexion deformity of the knee, both the same deformity of the normal side. Thanks, honey. And I think this is the last one. How regularly do you follow up when you put an 8 plate? Actually, between like every three to six months depends like depends on the surgeon preference, but almost about every six months, three to six months, it's OK.
OK and also, if the y if you use a wire knot screws to you, place the wire through the faces. Yes, we already do. We know that we like we have to start with the wire because the position is a trick in this surgery to put the plate in the center exactly in the center of suffices. So not anterior posterior, because that will do more like a deformity in the surgical plan.
So you have to survive first in the faces on the image. You have to take a lateral view in the X-ray. Make sure that it's central and after that you will put the plate. OK, thank you very much, Annie. Thank you, everyone, for your questions. So now we're going to stop the recording and we'll move on to the Viva sessions.
Segment:0 .
So good evening, everyone, welcome to our teaching session. My name is Nicky Evans, and I'll be modulating this evening. We also have Mr honey, who is presenting an approach to leg length discrepancy, which is an important topic for the exam and can be confusing for some candidates. And he's going to make that topic nice and clear for us today.
I'd also like to introduce our other mentors, Mr swan, hinari and Mr trevisan. Following the presentation, we'll have time for some questions, and I'd like to ask you to write your questions in the chat box, which we will monitor, and we'll ask honey at the end of his lecture. If you missed any part of the lecture, don't panic. It is recorded and it will be available on the FRCS YouTube channel in due course.
Following the questions, we will stop the recording and we'll proceed to vyver practice again if you'd like to participate. We request that you raise your hand or identify yourself in the chat box along with when you're sitting the part two exam. We understand that putting yourself forward for these fibers can be intimidating and stressful, but it's really the best way to practice your exam technique and rest assured that all of us mentors have been through the same experience.
As always, we recommend our study guide, the concise orthopedic notes, which is available on Amazon and it's been written by our mentors and is a very good resource. If you require a CPD certificate, then please email us on the FRC. Yes, mentor at gmail.com. And without any further ado, I will pass you over to Mr Hannah honey Albanese for the lecture.
Thank you very much for the about approach to the discrepancy. It's very important topic. I actually I got this a case with a discrepancy in my clinical part of the exam, and it is very, very common. So I will try to go through a quick resistance to how to examine and do a discussion in less than five minutes. So usually this discrepancy will come at a short case.
So you have to do everything in 3 minutes and 2 minutes for discussion. So first, I want to share the bulk of the efforts, as mentors are concise automatic notes. I think it's very helpful book for the first exam. OK, so number three, so we have a three minutes to do examination, full examination of this case. And I think it's number three, you can, like, categorize everything in three points.
Whatever the reasons would approach how you manage everything, make it like a slick answer and will not forget that. If in your money, if you are in your mind, you have a category you have, you have organized your answer about that. So it is start that first, you will see a child in the exam and the examiner will ask you, just examine this patient. So have a look from the front, from the side, from the back and usually in the discrepancy you will we would see in balance, so have a look at the shoulder.
Have a look at the pelvis. Have locals, the knee of the knees and the fault. And as I say, look from the front, the side, look in the back, you might find scoliosis, you might find in any science and dimension everything about that. Then ask the patient to walk. So ask the Mason talk, just say simply, it's a short, limp gait.
So usually the examiner will not ask you about that, but if I asked you to comment about the shot, let me just ask this is a pelvic tilt down to the affected side. And to compensate the airlines and allow the ground clearance of the longer limp, so just for example, in through country shortening with abductor insufficiency, walking becomes difficult. And the fourth Mason by need or patience may work on the tools to compensate for the short, limp and the normal and be compensated by flexion of the hip and knee.
So that is why that is the short limit. If you, if you, the examiner, asked you to analyze what is a short lived gait but simply says observation to walk. And short limb gait then puts the patient on the table and just do measurement. So that's the true lens would start from two prominent I usually start from the antero-supero-lateral spine to the middle malleolus like in this picture.
OK, and the compare to the other side. Then don't forget to measure the apparent length. So start from the umbilicus, it's to the same point of the middle and. Now shows the difference, like if the true shortening is equal to the apparent shortening, it indicates there is no compensation, so there is no product from deformity in this case. If the true shortening is more than the apparent shortening, it indicates that the part of shortening has been compensated for.
And if the true shortening is less than the apparent shortening, it would suggest affected abduction deformity so the patient will abduct his leg to compensate this shortening. So usually when you ask the patient to put him on the bed on the table, so are you usually squared the pelvis and you will put the two limbs parallel to each other to make the true measurement?
However, in some cases, the patient has abductor deformities do not force the patient to like to become a square to square his pelvis, but say to the examiner, I am unable to bleed the legs perpendicular to the pelvis because abduction contraction does not hurt the patient. That's very important. The same thing if the patient has deformity like a valgus knee, so you couldn't put the two limbs parallel to each other, so say to the examiner, I am unable to place the legs straight because of the obvious need.
Don't force the patient to do anything. Don't hurt the patient, please. OK, so next, sometimes the examiner will ask you what is the reason for that? So many books mentioned like maybe a congenital disorder, hemi hypertrophy, all these things are true, but this is the wrong way to answer. So go back. Remember the number three?
So keep it simple but precise, so the leg length discrepancy may be from the spine, from the pelvis, from the lower limb and the floor from the lower limb. The femur may be from the tibia, maybe from the hind foot. And don't forget the high end. OK, so the female maybe sobre todo country or infratel country, I like to answer it like that, don't do like that. OK, flex the knees and do a test, so that will differentiate between, is it like a femur or tibia?
OK and you can see here if the female is longer than is a short thing in the femur, you will start in the upper left side and in the tibia, it will look like in the picture. See here. So it's very easy to differentiate between if the shortening is in the tibia audience, the femur. And don't forget for it as well. OK, so if the shortening in the femur, which is the most common thing, so you you need to differentiate if the shortening is softer country or country.
So differentiate between that. Between both of these, you have to do pliant triangle, so you lose three fingers. You will put one finger at the tip of the GT. The second finger and the entire superior experience. And you will drop your finger. Other singles parallel to it and you measure this line. So you will measure. I will from this here to this is a dotted line.
That's you. That's your own measure. This is a distance that you measure in the exam and you will compare to the other side. OK, sometimes two, to square the pelvis you like to do like a block to measure how many, how many like shortening the other limb, but you will not find that in the real exam.
OK, so, OK, it's examinations, you did your measurement, you found where exactly the side of shortening. So the examiner will ask you what you will do next. Do like an X-ray of the whole lower limb or scan, which is the most accurate measure for leg length discrepancy. OK, so now there is a three categories. So these are the shortening is from 0 to 2 centimeters or from 2 to 5 centimeters or from five or more than 5 centimeters.
OK, so and there is specific treatment for each of this one. So there is something called white Manila's method to like, anticipate how many groaning or how many growth remaining for the lower limb. And usually the knees grows by around 15 per year, and you will do like assumption that the boy will grow until 16 years and the girls up to 14 years. But this is like a rough estimation, and this most probably will find you will be asked in the first part in the MCU, but in the second part, I do not find it more practical.
So what you should do, look this graph, because it will give you standard deviation between the chronological age and the bone age, because sometimes the bone age is not matching with the chronological age. And so recently, so pallet growth, there is just a so-called multiplier. And this is an applications all the pediatric specialists in the UK and Ireland use.
This application is a multiplier or palate. So it's a very handy application. You will find it in Apple stores. So you will enter the age of the patient and the gender, and we and it will calculate for you. How many like when, when you will do like this on, will you do your surgery? It is very it's very good and it's very nice to mention in the exam if you know it and just download it in your mobile and try to measure one or two cases just to be familiar with it.
It is very important. And you might get an eight mark if you mention that in the exam. OK, so if the shortening less than 2 centimeters with no surgeries, so just show left will, you will give the patient in Seoul to compensate for the limp for the length discrepancy. As as you see, this child is smiling because I know this more than two centuries but usually up to 2 centimeters more than two centuries will have to do surgery.
OK so in 2 to 5 centimeters you will do start to do surgery here. We will do like a phase with these foods alongside or shortening osteotomy of the long. If the patient is mature for other patients, but for pediatric, we usually do before you decide of the long side. If it's more than 5 centimeters.
So you will go for limb lengthening, so you couldn't show make the patient shorter more than 5 centimeters and that is why we learned these short limp. So how you can do lengthening of the short side. So either like an external fixator or internal external fixator like in the roof, like this case will do destruction osteogenesis. So what the principle?
So you will vote that it is the roof or the frame, and you will wait for 5 to seven days for to start lines to begin construction, then you will do distract 1 millimeter a day. And following destruction. So that's because it's a fast question as well, so how many times you will wait after finishing the lengthening? So we have to it's in the same period.
So for an example, if you are going to length. The length about 10 centimeters that you will wait for 105 or 107 days and you will keep the Elisa roof for the same period, so you will wait almost 210 days, which is a very, very long time for the patient to keep the roof in the limb. So that is why there is medullary lengthening device with the growing nail.
It's very expensive, but I think it's better than the Israelis are off. And sometimes if this nail is not available, you can mix between the Lazaroff and the usual nail. And the reason for the nail just to remove the Elizabeth early after, after just finishing the lengthening. OK, so sometimes the legal discrepancy is associated with deformity, so like a vulgar deformity isn't the only pathology.
So in this case, you might use this aid plate, which is a hemi epithelial disease. OK, so sometimes you will the examiner will show you some x-rays about these eight plates, and I noticed something maybe advance it for day one consultant, but just to understand the principle of it, how, how, how, how like, what the principle behind the aid plate and how you can use it.
Simply, it is a cuteness you just open centimeters incision over the faces under image, you will pass the guidewire and the most important thing here. You have to put the wire central in the sagittal plane because if you put it entiere, that means that more growth will be posterior and that will give you a richer rhythm. And if you bought it slightly and steer it, grow more, and here that would be broken.
So make sure that the guidewire its center in the sagittal plane. And after that, you will put the plate and do both. This is two screws, or sometimes it's four screws, the paint depends and you should be parallel to each other. And so this is an X-ray and how you can differentiate between like if this aid plate it just applied or like applied one year ago or a few months ago. Usually you will find the screw is not parallel.
It start to diverge. That means that it grows to the other side and stop growing at this side. And the whole of the blade, if you have a look at the whole of the blade it allow, it allows the screws to divert. OK, so sometimes the examiner may in Survivor me start you with an X-ray like that and ask you just to comment so you will see from the X-ray.
So the screws in the medial side of the lower femur, it's not parallel. It's divergence. That means that it's old. It's not. It's not a new. So this surgery done maybe one year or more. And the patient becoming virus, so we'll ask you just to comment on the x-ray, so if you understand the mechanism of action of this plate, you know this is an old and this is a complication of the eight plate, which is the overgrowth like over the four, like the tuberosity and the deformity become more so.
It's converted from fungus to varus deformity now. And so it believed it should be like monitoring for it so that the patient should be follow up in the clinic and to monitor the growth and to avoid this complication. OK, so this is like a good example. You can see here, like the lens is well aligned and the screw is diversion, so that means it's not new.
And the lamp is, well aligned. No deformity, no, there is no Vargas. So now you can take it, take it out now and allow for normal growth. OK, so we'll take home message, so in the pediatric so we can start for show left if it leads to centimeter phase you judicious growth arrest if two to 5 centimeters if more than that, you will go for lengthening for the short limb.
And usually the same in the other two, you can use the Elisa roof and you can use the nail for lengthening, I usually I personally prefer the interim nail because most of the patients will not be happy with this result of two kept for about four or five months inside the lamp. And thank you. Planning for that very comprehensive lecture in terms of when you're monitoring eight plates.
Would you ask the patient to come and visit every year and do an X-ray or every month? Or do you leave it to the parents to watch for the week for the virus? No, actually, I will. I will not. I will not leave it to the parents. I have to see the patients and will do an X-ray and to measure how much like correction, because it's very always all the people will not behave the same.
OK and my second question is, in terms of timing of your surgery. That is why use application, usually my boss and all the pediatric specialists usually do use these applications. It's very handy. You just enter the patient date of birth, the gender and the like discrepancy in the lens, and you will let when to do the surgery.
And the aiming of the timing is everything. So my apologies. I misplaced that the aiming of the timing is so that the growth plate stops growing at the time. You yes, yes, yes, no, no, no, no, not forever. You have to take it out. Yeah, Yeah. I apologize, but I'm so.
OK, thank you very much. But thanks, honey, there's a couple of questions popped up. The first one is what about five steel bar excision? Actually, there is another option as well, but usually there is like a post-traumatic or like post infection. So something like physical power, so you have to do like a metaphysical window and we'll remove this power.
So yeah, it is one of the options one. OK, thank you. We've got a question from Melinda who says, please, can you explain how to square the pelvis? You adjust your hand. Just ask the patient to lie down and put your hand on the antero-supero-lateral iliac spines and make it square.
OK Muhammad has asked if we could write down the name of the app for him. Actually, just write multiplier in any like Apple store or anything. You'll find it. And in a way this like video will be like will be in the YouTube page. So actually, I can share I can share this picture from my presentation to the telegram group.
Hey, thanks, honey. We've also got some. When will we do permanent Odysseus for leg length discrepancy at any age? So if you like the remaining growth period, it just is a time to compensate the discrepancy. So you will keep it forever. You will do permanent, ok? And we got one from Adam who says in regards to less than 2 centimeters there is no compensation from the pelvis and spine.
I think that means, is there any compensation? That's really my two cents. If you don't, if you do like a short left can be compensated. So it's a very mild discrepancy here. I think the question is more will there be if you don't use this fine compensation? Well, yeah, yeah, Yeah. But it's better to if the patient is symptomatic just to give him a shot.
Yeah, it's also decreases the risk of spine problems as the patient gets older and/or more active. OK because a couple more questions. One just disappeared. How can we measure length, length, leg length in cases of flexion, contraction of the knee in knee arthritis and in case of trauma to medial malolos? OK, so will both the normal leg in the same deformity and the measures like that, and if it's a problem, is the medial measure in the lateral malleolus.
So any bony prominent but do the same to the other side. If there is a flexion deformity of the knee, both the same deformity of the normal side. Thanks, honey. And I think this is the last one. How regularly do you follow up when you put an 8 plate? Actually, between like every three to six months depends like depends on the surgeon preference, but almost about every six months, three to six months, it's OK.
OK and also, if the y if you use a wire knot screws to you, place the wire through the faces. Yes, we already do. We know that we like we have to start with the wire because the position is a trick in this surgery to put the plate in the center exactly in the center of suffices. So not anterior posterior, because that will do more like a deformity in the surgical plan.
So you have to survive first in the faces on the image. You have to take a lateral view in the X-ray. Make sure that it's central and after that you will put the plate. OK, thank you very much, Annie. Thank you, everyone, for your questions. So now we're going to stop the recording and we'll move on to the Viva sessions.
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