1
|
Van Nguyen L, Nguyen GN. The results of femoral lengthening using domestic unilateral external fixation and then plating: the first case series in Vietnam. Ann Med Surg (Lond) 2024; 86:4344-4351. [PMID: 39118726 PMCID: PMC11305785 DOI: 10.1097/ms9.0000000000002172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/07/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction and importance This study aimed to assess the results of femoral lengthening using an external fixator and then plating. Case presentation This prospective case series study enrolled 11 patients who underwent femoral lengthening and then plating (LATP) between January 2019 and April 2023. The average age of patients was 14.45 ± 7.54 years. One patient with a femur was lengthened and plated, and one tibia was lengthened over a nail simultaneously. The average femoral lengthening was 8.41 ± 1.35 cm. Clinical discussion The femoral healing result was excellent in seven femurs and good in four femurs; the functional outcome was excellent in five patients and good in six patients. Pin-track infection occurred in all patients. A limited range of motion of knee flexion occurred in eight patients. Femoral varus and procurvatum deviation occurred during distraction in four and two patients. Femoral LATP was considered an attractive alternative to intramedullary lengthening nails in a low-income country. Conclusion Our research suggests that femoral LATP was an effective method. However, the most common complications were pin-site infection and extensive knee contracture. Further research should be done with a larger sample size and longer follow-up time. Level of evidence Level IV-prospective observational case series study.
Collapse
Affiliation(s)
- Luong Van Nguyen
- Institute of Trauma and Orthopaedics, 108 Central Military Hospital, Hanoi, Vietnam
| | | |
Collapse
|
2
|
Kunwar BB, Maheshwari V, Dhingra M, bhagat S, PV C, Vardhan S. Use of locked plates and mono-rail fixator in segmental tibial defects: A prospective interventional study. J Orthop 2023; 44:47-52. [PMID: 37664557 PMCID: PMC10471829 DOI: 10.1016/j.jor.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/05/2023] [Accepted: 08/13/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction The management of gap non-union is a major challenge to both the clinician and the patient as it is technically difficult, time-intensive, and physically arduous for the patient along with an unpredictable result. Gap non-union can arise from extrusion of bony fragment at the time of trauma or after debridement of unhealthy bone later. Moreover, Tibia because of its subcutaneous anatomy can easily undergo bone-loss and segmental defect. Among various methods available for managing gap non-union of tibia distraction osteogenesis using either ilizarov fixator or mono-rail fixator is the most popular one. Here we present functional and bony outcomes of combined use of locking plate and Limb Reconstruction System (LRS) in tibial gap non-union and assess whether it decreases fixator time and related complications. Patients and methods A prospective intervention study constituting 10 patients with Paley's type B1 tibial gap non-union over a period of 22months. In first stage, debridement was done; tibial locking plate and mono-rail fixator were applied along with corticomy at proximal tibia. Distraction was started 7-14 days later. At the end of distraction phase, fixator was removed and transported segment was fixed with screws with or without bone grafting at docking site. Patients were followed up every 6 weeks for radiological and clinical assessment. Functional assessment using Application for the Study and Application of the Method of Ilizarov (ASAMI) functional score, and Musculoskeletal Tumour Society (MSTS) functional score while bone outcome was assessed with ASAMI bone score. Quality of regenerate was assessed by Fernandez-Esteve grading. Detailed scoring was done at the time of index surgery, at the time of LRS removal and at the time of consolidation phase. Results All the 10 patients were male with mean age of 33 years. The mean defect size was 4.94 cm after debridement. Minimum duration of follow up was 30 weeks after removal of LRS. Mean duration between trauma and inclusion in the study was 17.7 months. The median external fixator index was 15.63 days/cm. The complication rate was 1.3/patient. According to Paley's classification, there were eleven problems and two obstacles, and no true complications. Both ASAMI bone score and functional scores were excellent in three and good in six patients. The median MSTS composite score was 76.66%. Conclusion The integrated fixation is an effective and satisfactory method enabling early external fixator removal with low rate of complication. So, this technique can be recommended for the management of segmental tibial defects. Level of evidence II.
Collapse
Affiliation(s)
- Bom Bahadur Kunwar
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Vikas Maheshwari
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Mohit Dhingra
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Saroj bhagat
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Chanakya PV
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Sunit Vardhan
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| |
Collapse
|
3
|
Armagan R, Kucukkaya M, Ozdemir HM. The Use of Ilizarov Method at the Lower Extremity Deformity Management. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:263-271. [PMID: 37899808 PMCID: PMC10600634 DOI: 10.14744/semb.2023.03185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 10/31/2023]
Abstract
Objectives Complications are common in the treatment of lower extremity congenital or acquired deformities by Ilizarov method. The results to be obtained vary in specific patient groups. In this study, deformities who developed before the age of 16 were compared with those developed after this age regardless of the type of aetiology, in terms of results obtained, treatment durations and complications encountered. Methods 53 bone deformities with an average of 9.5 (7.5-18) years of follow-up treated by the same surgeon were divided into 2 groups according to the age of deformity onset. Demographics and deformity characteristics of patients were defined, treatment times, bone healing indexes, consolidation/correction rates, problems encountered and results obtained were compared retrospectively. The results were compared with ASAMI functional and bone scoring. Complications were rated according to Paley and relative risk increases between groups were calculated. Results 26 of the patients were men and 22 were women. The average age was 26.47 (7-57). The mean deformity was 23.98° (7-60) and the mean shortness in 39 patients was 38.65 (10-110)mm. Mechanical axis deviation was corrected in 83% of patients. The Lengthening index was 54.13days/cm in the development group and 63.69 days/cm in adults. Consolidation/correction rate was 2.54 in developmental age and 2.4 (p=0.698) in adults. The risk increased by 1.02 times in terms of problems encountered, 2 for obstacles, 3 times in complications and 1.34 times in total difficulties per case, according to Paley. The duration of stay in the fixator was higher in developmental group (p=0.023). ASAMİ functional (p=0.000148) and anatomical (p=0.000242) scores were better in the adult group. Conclusion Congenital or acquired deformities in the lower extremity can be treated with satisfactory results by Ilizarov method. The development of deformity at an early age makes treatment difficult. Although the bone healing index is lower in this group of patients, which usually has a higher amount of shortness, the treatment is usually longer than that of adult deformities; complications are more frequent and serious. Functional and anatomical results are more unsuccessful.
Collapse
Affiliation(s)
- Raffi Armagan
- Department of Orthopedics and Traumatology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Metin Kucukkaya
- Department of Orthopedics and Traumatology, Florence Nightingale Hospital, Istanbul, Türkiye
| | - Haci Mustafa Ozdemir
- Department of Orthopedics and Traumatology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| |
Collapse
|
4
|
Van Nguyen L. Treatment of 18 cm lower limb length discrepancy using lengthening over nail technique in tibia and lengthening and plating in femur - A case report. Int J Surg Case Rep 2023; 104:107961. [PMID: 36893702 PMCID: PMC10018547 DOI: 10.1016/j.ijscr.2023.107961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/23/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The management of extreme limb-length discrepancy remains a challenge for surgeons. Limb lengthening using an external fixator is a popular method for managing limb-length discrepancy; however, it had many complications. Other techniques using external fixators have been described, such as lengthening over a nail (LON) technique and lengthening and then plating (LATP), which decrease external fixator duration, equinus contracture, pin-site infection, bone alignment, and bone fracture. Only a few cases of management of extreme limb-length discrepancy due to hip dysplasia using LATP and LON techniques are reported in the literature. CASE PRESENTATION We report a 24-year-old case of an 18 cm lower limb length discrepancy, who had tibial lengthening and Chiari pelvic osteotomy for treatment of congenital hip dislocation 12 years ago. The treatment for the patient was underwent the lengthening over nail technique in the tibia and lengthening and then plating in the femur. 9 months post-operative, the tibia and femur are union. The patient reported no pain and could walk and climb stairs without a crutch. CLINICAL DISCUSSION Following pelvic osteotomy, leg lengthening is a good treatment for limb-length discrepancy due to hip dysplasia. The LON technique or LATN in the tibia and in the femur is an alternative choice for the treatment of extreme limb-length discrepancy. Lengthening and then plating could be widely employed in patients who are not suitable for the LON technique. Although the patient had gained the 18 cm lengthening, the range of motion of the left knee joint and left ankle joint was unrestricted, and without neurovascular complication. CONCLUSION Following pelvic osteotomy, LON technique in the tibia and or LATP in the femur is considered an alternative choice for the treatment of extreme limb-length discrepancy due to hip dysplasia. LATP should be widely employed in patients who are not suitable for limb lengthening over a nail. LEVEL OF EVIDENCE A case report.
Collapse
Affiliation(s)
- Luong Van Nguyen
- Institute of Trauma and Orthopaedics, 108 Central Military Hospital, Hanoi, Viet Nam.
| |
Collapse
|
5
|
Mittal A, Allahabadi S, Jayaram R, Nalluri A, Callahan M, Sabharwal S. Trends and Practices in Limb Lengthening: An 11-year US Database Study. Strategies Trauma Limb Reconstr 2023; 18:21-31. [PMID: 38033925 PMCID: PMC10682549 DOI: 10.5005/jp-journals-10080-1574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/11/2023] [Indexed: 12/02/2023] Open
Abstract
Aim Over the past couple of decades, limb lengthening has evolved to encompass various implants and techniques. The purpose of this study was to (1) determine trends in the utilisation of various limb lengthening techniques for the femur and tibia in the United States, (2) determine trends in 1-year readmission rate following limb lengthening procedures and (3) to study the relationship of limb lengthening implant used and payment method used with the underlying diagnosis associated with limb shortening. Materials and methods Inpatient data were acquired using the Healthcare Cost and Utilisation Project (HCUP) database from 2005 to 2015 from seven states in the United States. Patients with an International Classification of Diseases (ICD)-9 code for limb lengthening of the femur or tibia were included. A total of 2,563 patients were included. Data were analysed using descriptive statistics, and chi-square test was used for comparison of subcategories. Linear regression analysis was used to examine trends over time. Results There was a strong linear trend towards increasing proportional use of internal lengthening of the femur from 2011 to 2015 (R2 = 0.99) with an increase of 10.2% per year. A similar trend towards increasing proportional use of internal lengthening of the tibia was seen from 2011 to 2015 (R2 = 0.87) with an increase of 4.9% per year. There was a moderate correlation showing a decrease in readmission rate of 1.07% per year from 2005 to 2015 (R2 = 0.55). Patients with short stature had increased use of internal lengthening and self-payment compared to patients with congenital, post-traumatic or other diagnoses. Conclusion There was increasing use of internal lengthening techniques from 2011 to 2015. Patients with short stature had higher use of internal lengthening technique and self-pay for payment method. Clinical significance Intramedullary devices have seen increasing use for limb lengthening procedures. Lengthening technique and payment method may differ by underlying diagnosis. How to cite this article Mittal A, Allahabadi S, Jayaram R, et al. Trends and Practices in Limb Lengthening: An 11-year US Database Study. Strategies Trauma Limb Reconstr 2023;18(1):21-31.
Collapse
Affiliation(s)
- Ashish Mittal
- Department of Orthopedic Surgery, St. Mary's Medical Center, San Francisco, California, United States of America
| | - Sachin Allahabadi
- Department of Orthopedic Surgery, University of California, San Francisco, California, United States of America
| | - Rishab Jayaram
- Department of Orthopedic Surgery, University of Rochester, Rochester, New York, United States of America
| | - Abhinav Nalluri
- Department of Orthopedic Surgery, St. Mary's Medical Center, San Francisco, California, United States of America
| | - Matt Callahan
- Department of Orthopedic Surgery, University of California, San Francisco, California, United States of America
| | - Sanjeev Sabharwal
- Department of Orthopedic Surgery, University of California, San Francisco; UCSF Benioff Children's Hospital, Oakland, California, United States of America
| |
Collapse
|
6
|
Plate fixation after lengthening with an external fixator in patients with achondroplasia : A comparative study between two centers. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:48-53. [PMID: 36280609 DOI: 10.1007/s00132-022-04306-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study compared internal fixation with a plate after lengthening (PAL) with an external fixator with the conventional method (CM) in terms of radiologic and clinical outcomes in the lower extremities of patients with achondroplasia. METHODS In this study 20 patients (50 lower extremity long bones) who underwent PAL or CM were divided into 2 cohort groups. The amount of lengthening, percentage lengthening, external fixator index (EFI), external fixator time, Li regeneration index, complication rate, and knee range of motion (ROM) were compared between the groups. RESULTS The median age was 9.4 years (range 6-16 years) in the PAL group and 12 years (range 9-16 years) in the CM group (p = 0.01). Males comprised 80% of the patients in the PAL group and 47% of the patients in the CM group (p = 0.02). The median amount of lengthening in the PAL and CM groups was 7.5 cm (range 5.5-9.5 cm) and 6.0 cm (range 5.5-9.0 cm), respectively (p < 0.01). The median percentage of lengthening in the PAL and CM groups was 44.6% (range 20.0-70.1%) and 43.0% (range 20.5-57.3%), respectively (p = 0.01). The median external fixator time in the PAL and CM groups was 127 days (range 94-185 days) and 180 days (range 105-355 days), respectively (p < 0.01). The median EFI in the PAL and CM groups was 21 days/cm (range 10-33 days/cm) and 27 days/cm (range 15-59 days/cm), respectively (p < 0.01). The Li regeneration index was 3 (interquartile range, IQR 2-4) in both groups (p = 0.2). The total complication rate was similar between the groups. CONCLUSION In patients with achondroplasia, after lengthening with an external fixator, internal fixation with a plate can be a reliable alternative to the conventional method. LEVEL OF EVIDENCE Level III therapeutic.
Collapse
|
7
|
Mittal A, Allahabadi S, Jayaram R, Nalluri A, Callahan M, Sabharwal S. What Factors Correlate With Length of Stay and Readmission After Limb Lengthening Procedures? A Large-database Study. Clin Orthop Relat Res 2022; 480:1754-1763. [PMID: 35353078 PMCID: PMC9384914 DOI: 10.1097/corr.0000000000002201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures. QUESTIONS/PURPOSES (1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission? METHODS Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses. RESULTS Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only. CONCLUSION When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Ashish Mittal
- Department of Orthopaedic Surgery, St. Mary’s Medical Center, San Francisco, CA, USA
| | - Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Abhinav Nalluri
- Department of Orthopaedic Surgery, St. Mary’s Medical Center, San Francisco, CA, USA
| | - Matt Callahan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Sanjeev Sabharwal
- Department of Orthopaedic Surgery, University of California, San Francisco. UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| |
Collapse
|
8
|
Functional outcomes and complications of tibial lengthening using unilateral external fixation and then plating. A prospective case series. Ann Med Surg (Lond) 2022; 74:103262. [PMID: 35127065 PMCID: PMC8792419 DOI: 10.1016/j.amsu.2022.103262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/09/2022] [Accepted: 01/13/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Material and methods Results Conclusion Level of evidence Patients with a narrow intramedullary cavity, joint contracture, pediatric patients are not suitable for LON or motorized nail. Tibial lengthening using external fixater then plating was safe and effective provided complications were kept in check. Equinus contracture, pin-site infection, and valgus alignment were the most common complications. Tibial lengthening then plating should be widely employed in patients who were not suitable for limb lengthening over a nail.
Collapse
|
9
|
Park KH, Oh CW, Kim JW, Oh JK, Yoon YC, Seo I, Ha SS, Chung SH. Matched Comparison of Bone Transport Using External Fixator Over a Nail Versus External Fixator Over a Plate for Segmental Tibial Bone Defects. J Orthop Trauma 2021; 35:e397-e404. [PMID: 33967227 DOI: 10.1097/bot.0000000000002084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the outcomes and complications of bone transport over a nail (BTON) with those of bone transport over a plate (BTOP) for segmental tibial bone defects. DESIGN Retrospective matched study design. SETTING A major metropolitan tertiary referral trauma center. PATIENTS Thirty-six patients with segmental tibial bone defects of >4 cm were included in this study. INTERVENTION Either BTON or BTOP was performed on 18 patients. MAIN OUTCOME MEASUREMENTS We compared the healing of the distraction process and of the docking site between the techniques. Distraction parameters including external fixator (EF) time, external fixation index, and healing index were compared. Bone and functional results were compared according to the Paley-Maar classification. Complications associated with each procedure were compared. RESULTS Both BTON and BTOP achieved similar rates of primary union (83% vs. 89%) at the distraction or docking site. Significantly less time wearing an EF was needed for BTOP than for BTON (2.8 vs. 5.4 months; P < 0.01). The external fixation index was significantly lower for BTOP than for BTON (0.45 vs. 0.94 mo/cm; P < 0.01), whereas the healing indexes were similar. The final outcomes and complication incidences were not significantly different. CONCLUSIONS The EF time was significantly shorter for BTOP than for BTON; however, the final outcomes were similar. Therefore, BTOP could be considered an attractive option for bone transport in patients with segmental tibial defects. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Kyeong-Hyeon Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Joon-Woo Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, School of Medicine, Korea University Guro Hospital, Seoul, Korea; and
| | - Yong-Cheol Yoon
- Orthopaedic Trauma Division, Trauma Center, Gachon University College of Medicine, Incheon, Korea
| | - Il Seo
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Sung-Soo Ha
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| | - Seung-Ho Chung
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Korea
| |
Collapse
|
10
|
Huang Q, Ren C, Li M, Xu Y, Li Z, Lin H, Zhang K, Ma T. Antibiotic calcium sulfate-loaded hybrid transport versus traditional Ilizarov bone transport in the treatment of large tibial defects after trauma. J Orthop Surg Res 2021; 16:568. [PMID: 34544458 PMCID: PMC8454113 DOI: 10.1186/s13018-021-02723-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/13/2021] [Indexed: 01/10/2023] Open
Abstract
Background The purpose of this study was to compare the clinical effects of antibiotic calcium sulfate-loaded hybrid transport (ACSLHT) and traditional Ilizarov bone transport (TIBT) in the treatment of large tibial defects after trauma. Methods Eighty-five patients with large tibial defects after trauma were selected for retrospective study. The range of tibial defects was 6–22 cm. After thorough debridement and infection controlled, bone transport technique was used to reconstruct tibial defects. Forty-four patients were treated with ACSLHT technique (the ACSLHT group), while the other 41 were treated with TIBT technique (the TIBT group). Time in external fixator was evaluated by EFI score. Enneking score was used to evaluate limb functions. SAS score was used to evaluate postoperative anxiety status. In addition, complication incidence was compared, including axis deviation, docking site nonunion, infection recurrence and so on. Results There was no significant difference in preoperative general data between ACSLHT and TIBT group. EFI score in ACSLHT and TIBT group was 0.6 ± 0.1 cm/month and 1.7 ± 0.3 cm/month, respectively (P < 0.05). Enneking score of ACSLHT and TIBT group was 86.5% and 75.1% (P < 0.05). SAS score of ACSLHT group was significantly lower than that of TIBT group (P < 0.05). Complication incidence in ACSLHT group was significantly lower than that in TIBT group (P < 0.05). Conclusions Compared with TIBT group, ACSLHT group had shorter time in external fixator, better limb functions, lower postoperative anxiety score and lower complication incidence which is worth of clinical promotion.
Collapse
Affiliation(s)
- Qiang Huang
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Cheng Ren
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Ming Li
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - YiBo Xu
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Zhong Li
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Hua Lin
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Kun Zhang
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China.
| | - Teng Ma
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China.
| |
Collapse
|
11
|
Management of post-traumatic femoral defects with a monorail external fixator over an intramedullary nail. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1119-1126. [PMID: 34363107 PMCID: PMC8345235 DOI: 10.1007/s00590-021-03082-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/26/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE The management of limb-length discrepancy secondary to traumatic femoral bone loss poses a unique challenge for surgeons. The Ilizarov technique is popular, but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail. METHODS Eight patients were included from October 2015 to May 2019 with post-traumatic femoral defects that underwent treatment with monorail fixator-assisted intramedullary nailing. Primary outcome was time to bone union and bone results according to ASAMI classification. Secondary outcomes were lengthening index, consolidation time and index, external fixator index (EFI), time to partial weight bearing(PWB) and full weight bearing (FWB), and complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores (OKS), and Oxford hip scores (OHS) were recorded after recovery. RESULTS Mean follow-up time was 227 weeks. Average bone defect size was 9.69 cm. Average consolidation time and index were 11.35 months and 1.24 months/cm, respectively. Mean lengthening and external fixator index were 20.2 days/cm and 23.88 days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, five patients had pin site infections, and two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p = 0.104, p = 0.238, respectively). Average OKS was 32.17 and OHS was 34.00. CONCLUSION Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time and returning patients' quality of life to a level comparable with the normal population.
Collapse
|
12
|
Abstract
OBJECTIVES To evaluate the results of the bone transport over an intramedullary nail (BTON) technique for the treatment of segmental bone defects. DESIGN Retrospective review of case series. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS We included 40 patients who underwent reconstruction of the lower limb with BTON technique between 2000 and 2018. The technique was performed in the tibial segments in 21 patients and in the femoral segments in 19 patients. INTERVENTION The surgical technique was performed in 2 stages for patients with infected nonunion. Infection was eradicated in all patients at the first stage. For the BTON at the second stage, monolateral external fixators and circular external fixators were used for femoral and tibial defects, respectively. In cases of defects without any infection, debridement with a single-stage BTON was performed. MAIN OUTCOME MEASUREMENTS Complications as well as radiological and clinical results were evaluated according to the criteria of Paley-Maar. RESULTS Minor complications occurred in 11 patients: pin site problems (9), cellulitis (1), and skin detachment due to Schanz screw (1). Major complications occurred in 8 patients: docking site nonunion (4), early consolidation and Schanz screw failure (1), knee flexion contracture (1), and ankle equinus contracture (2). Four patients had osteomyelitis as residual sequelae. Bone score was excellent in 27 patients. Excellent functional results were obtained in 31 patients. CONCLUSIONS The BTON technique is associated with low cost because of the short treatment period, low complication risk, and rapid rehabilitation and is not limited by the amount of bone transport. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
13
|
Integrated Limb Lengthening Is Superior to Classical Limb Lengthening: A Systematic Review and Meta-analysis of the Literature. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-20-00054. [PMID: 32656477 PMCID: PMC7322778 DOI: 10.5435/jaaosglobal-d-20-00054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Integrated limb lengthening combines both internal and external fixation methods. It has been introduced to improve time to union, patient time in frame, risk of regenerate refracture, and patient function. We systematically review studies to assess whether integrated limb lengthening methods are superior to classic limb lengthening. Methods A total of 457 patients had classic limb lengthening, whereas 488 underwent integrated limb lengthening. The primary outcome measures were total length achieved (cm), external fixator index (month/cm) and bone healing index (month/cm). Problems, obstacles, and sequelae were compared using random effects meta-analyses of all available cases. Kaplan-Meier curves were generated to compare the time spent in frame. Results Integrated limb lengthening demonstrated a superior external fixator index (P = 0.0001) and bone healing index (P = 0.0146). The mean time spent in frame for integrated lengthening was significantly shorter (P = 0.0015). Significantly fewer problems (P = 0.000) and sequelae (P = 0.001) were observed with integrated lengthening. Deep infections were more common in the integrated cohort. The lengthening over a nail deep infection rate was significantly higher than with the lengthening and then nailing and lengthening and then plating techniques (P = 0.005). Conclusions Integrated methods of limb lengthening are superior to classic methods. We suggest the integration of plates and nails with circular frames to improve outcomes in patients undergoing limb lengthening procedures.
Collapse
|
14
|
Munajat I, Sulaiman AR, Mohd EF, Zawawi M. Submuscular Plate Stabilisation After Lengthening: Standard and Modified Techniques. Malays Orthop J 2020; 14:49-54. [PMID: 32296482 PMCID: PMC7156169 DOI: 10.5704/moj.2003.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Submuscular plating after lengthening shortened the period of external fixation in distraction osteogenesis of the femur. In the femur, where monolateral or ring fixators had been used for the distraction, plates, could be inserted laterally, anteriorly or medially. Specific technical modification of the plate insertion, however, would be necessary to accommodate the femoral varus angular correction created at the end of the distraction, in the pelvic support osteotomy lengthening. Material and Methods: We reviewed a series of eight cases with standard and modified techniques of plating after lengthening. The amount of lengthening, the period of distraction, the external fixator index and the associated complications were assessed. Results: The mean lengthening was 5cm, with a range of 3cm to 9cm. The external fixation index, the period of external fixators in days in relation to the length of distraction in cm, was between 18 days/cm to 58 days/cm. One patient with quadriceps contracture, underwent quadriceplasty to improve knee flexion. Three patients with transient knee stiffness had resolution with aggressive physiotherapy. One patient with transient hypoesthesia recovered spontaneously. None of the patients developed joint subluxation, deep infection, re-fracture or implant failures. Conclusion: Standard and modified techniques of plating after lengthening were safe and required only a short period of external fixation. The modified technique offered an easier way of plate insertion in a deformed bone.
Collapse
Affiliation(s)
- I Munajat
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - A R Sulaiman
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - E F Mohd
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Msf Zawawi
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| |
Collapse
|
15
|
Barakat AH, Sayani J, O'Dowd-Booth C, Guryel E. Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications. Strategies Trauma Limb Reconstr 2020; 15:54-61. [PMID: 33363643 PMCID: PMC7744668 DOI: 10.5005/jp-journals-10080-1451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Circular frames have been the gold standard of treatment for complex deformity corrections and bone loss. However, despite the success of frames, patient satisfaction has been low, and complications are frequent. Most recently, lengthening nails have been used to correct leg length discrepancies. In this article, we review the current trends in deformity correction with emphasis on bone lengthening and present our case examples on the use of lengthening nails for management of complex malunions, non-unions, and a novel use in bone transport. MATERIALS AND METHODS A nonsystematic literature review on the topic was performed. Four case examples from our institute, Brighton and Sussex University Hospitals, East Sussex, England, UK, were included. RESULTS New techniques based on intramedullary bone lengthening and deformity correction are replacing the conventional external frames. Introduction of lengthening and then nailing and lengthening over a nail techniques paved the way for popularization of the more recent lengthening nails. Lengthening nails have gone through evolution from the first mechanical nails to motorized nails and more recently the magnetic lengthening nails. Two case examples demonstrate successful use of lengthening nails for management of malunion, and two case examples describe novel use in management of non-unions, including the first report in the literature of plate-assisted bone segment transport for the longest defect successfully treated using this novel technique. CONCLUSION With the significant advancement of intramedullary lengthening devices with lower complications rates and higher patient satisfaction, the era of the circular frame may be over. HOW TO CITE THIS ARTICLE Barakat AH, Sayani J, O'Dowd-Booth C, et al. Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications. Strategies Trauma Limb Reconstr 2020;15(1):54-61.
Collapse
Affiliation(s)
- Ahmed H Barakat
- Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, East Sussex, England, UK
| | - Junaid Sayani
- Department of Trauma and Orthopaedics, Maidstone and Tunbridge Wells NHS Trust, UK
| | - Christopher O'Dowd-Booth
- Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, East Sussex, England, UK
| | - Enis Guryel
- Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, East Sussex, England, UK
| |
Collapse
|
16
|
Kähler Olesen U. [Plate-assisted segmental bone transport with a lengthening nail and a plate : A new technique for treatment of tibial and femoral bone defects]. Unfallchirurg 2019; 121:874-883. [PMID: 30242443 DOI: 10.1007/s00113-018-0546-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Distraction osteogenesis represents an effective procedure for treatment of bone defects from various causes (e.g. trauma, malignancy, congenital and infection). In the past the available procedures were practically exclusively external. PRINCIPLES In the plate-assisted segmental bone transport (PABST) procedure a commercially available motorized intramedullary lengthening nail is used for segment transport. The transport segment is transported along a bone plate, which is responsible for maintaining the position of the proximal and distal main fragments. SURGICAL TECHNIQUE In staged sequences, a plate spanning the defect is placed. A lengthening nail is inserted in an antegrade or retrograde direction and a vascularized transport segment is created with an osteotomy. Bone transport is initiated at 1.0 mm a day. The transport segment is pulled or pushed into place, depending on the location of the bone void. In due time, a docking procedure is performed and full weight bearing is allowed. Supplementary lengthening can be initiated at docking or in a separate procedure. In smaller defects the gap is closed immediately over the plate and the bone is lengthened by the nail in the opposite end of the defect. CONCLUSION The presented method is a valuable addition to the armamentarium for treatment of bone defects. The main advantages are the avoidance of external fixation (fixation wires, Schanz screws) and the creation of physiological bone substitute. Vital soft tissues are essential for a good outcome. With appropriate management (systematic debridement, local and systemic administration of antibiotics and free soft tissue flaps), this method can be a solution to even complex reconstructive problems.
Collapse
Affiliation(s)
- Ulrik Kähler Olesen
- Abteilung für Orthopädische Chirurgie, Copenhagen Limb Lengthening and Bone Reconstruction Unit, Rigshospitalet, Blegdamsvej 9, 2100, Kopenhagen, Dänemark.
| |
Collapse
|
17
|
Relevant advances in bone lengthening research: a bibliometric analysis of the 100 most-cited articles published from 2001 to 2017. J Pediatr Orthop B 2019; 28:495-504. [PMID: 30312248 DOI: 10.1097/bpb.0000000000000557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This study aimed to assess the scientific production of bone lengthening research by identifying the most-cited papers. All articles including the term 'bone lengthening' published between 2001 and 2017 were retrieved through the Web of Science database. The 100 most-cited articles on bone lengthening included a total of 4244 citations, with 414 (9.7%) citations in 2017. There was an average of 249.6 citations per year. The articles predominantly addressed biomechanics and bone formation (38). Different surgical techniques, including intramedullary nail (14), Ilizarov (nine), intramedullary skeletal kinetic distractor (ISKD) (six), Taylor spatial frame (6), the PRECICE device (three), and lengthening and submuscular locking plate (three), were the second most-studied topic. Most studies were therapeutic (58), whereas 30 studies were experimental investigations using animal models. Among the clinical studies, case series were predominant (level of evidence IV) (57). This study presents the first bibliometric analysis of the most relevant articles on bone lengthening. The list is relatively comprehensive in terms of identifying the top issues in this field. However, the most influential clinical studies have a poor level of evidence, although a slight tendency toward a better level of evidence has been observed in more recent years.
Collapse
|
18
|
Horn J, Hvid I, Huhnstock S, Breen AB, Steen H. Limb lengthening and deformity correction with externally controlled motorized intramedullary nails: evaluation of 50 consecutive lengthenings. Acta Orthop 2019; 90:81-87. [PMID: 30371122 PMCID: PMC6366464 DOI: 10.1080/17453674.2018.1534321] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Limb lengthening with an intramedullary motorized nail is a relatively new method. We investigated if lengthening nails are reliable constructs for limb lengthening and deformity correction in the femur and the tibia. Patients and methods - 50 lengthenings (34 Precice and 16 Fitbone devices) in 47 patients (mean age 23 years [11-61]) with ≥12 months follow-up are included in this study. 30 lengthenings were done due to congenital and 20 because of posttraumatic deformity (21 antegrade femora, 23 retrograde femora, 6 tibiae). Initial deformities included a mean shortening of 42 mm (25-90). In 15 patients, simultaneous axial correction was done using the retrograde nailing technique. Results - The planned amount of lengthening was achieved in all but 2 patients. 5 patients who underwent simultaneous axial correction showed minor residual deformity; unintentionally induced minor deformities were found in the frontal and sagittal plane. The consolidation index was 1.2 months/cm (0.6-2.5) in the femur and 2.5 months/cm (1.6-4.0) in the tibia. 2 femoral fractures occurred in retrograde femoral lengthenings after consolidation due to substantial trauma. There were 8 complications, all of which were correctable by surgery, with no permanent sequelae. Interpretation - Controlled acute axial correction of angular deformities and limb lengthening can be achieved by a motorized intramedullary nail. A thorough preoperative planning and intraoperative control of alignment are required to avoid residual and unintentionally induced deformity. In the femur relatively fast consolidation could be observed, whereas healing was slower in the tibia.
Collapse
Affiliation(s)
- Joachim Horn
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital;; ,Correspondence:
| | - Ivan Hvid
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital;;
| | - Stefan Huhnstock
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital;;
| | - Anne B Breen
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital;;
| | - Harald Steen
- Biomechanics Lab, Division of Orthopaedic Surgery, Oslo University Hospital, Norway
| |
Collapse
|
19
|
Tomczak C, Beaman D, Perkins S. Combined Intramedullary Nail Coated With Antibiotic-Containing Cement and Ring Fixation for Limb Salvage in the Severely Deformed, Infected, Neuroarthropathic Ankle. Foot Ankle Int 2019; 40:48-55. [PMID: 30264587 DOI: 10.1177/1071100718800836] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: The severely deformed, infected, and unstable neuroarthropathic ankle is challenging to treat. We evaluated our preliminary experience and results of combined internal and external ring fixation for a complex neuropathic population. METHODS: We retrospectively reviewed medical records and radiographs for 8 patients with unilateral severely deformed ankle neuroarthropathy associated with infection and ulceration. Treatment included single-stage reconstruction arthrodesis with an interlocked intramedullary nail coated with antibiotic-containing cement combined with ring fixation. Taylor Spatial Frame™ technology was used when the deformity was not amenable to acute correction (5 patients). Protected postoperative weightbearing was permitted. Their mean age averaged 55.6 (range, 42-66) years with an average body mass index of 38.4 (range, 28.7-49.6) kg/m2. RESULTS: Seven patients achieved limb preservation. Average time for fusion healing was 15.2 (range, 12.2-22.2) weeks, frame time was 17.7 (range, 12.2-23.0) weeks, and follow-up was 34.1 (range, 24.1-68.8) months. All presenting wounds and infection successfully resolved. Reinker and Carpenter scale was excellent for 2 patients, good for 2 patients, and fair for 3 patients. Foot and Ankle Ability Measure averaged 59.0% (range, 39.3%-87.5%). One patient developed a recalcitrant calcaneal ulcer with osteomyelitis that required a transtibial amputation 17 months after successful ankle arthrodesis. CONCLUSIONS: Combined use of interlocked intramedullary nail and ring external fixation for neuroarthropathic ankle arthrodesis achieved a functional and clinically stable salvaged lower limb for most patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.
Collapse
Affiliation(s)
| | | | - Serene Perkins
- 2 Legacy Institute for Surgical Education & Innovation, Legacy Research Institute, Portland, OR, USA
| |
Collapse
|
20
|
Demir B, Ozkul B, Lapcin O, Beng K, Arikan Y, Yalcinkaya M. A Modification of Internal Bone Transport Method for Reconstruction of Nonunion of Forearm. Indian J Orthop 2019; 53:196-203. [PMID: 30906002 PMCID: PMC6394197 DOI: 10.4103/ortho.ijortho_52_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Defects of bone and soft tissue occur frequently after high-energy trauma, infections, and tumor resection. Treatment options are limited and outcomes are controversial in nonunion. Classical reconstruction methods are challenging. We describe a method of internal bone transport for treatment of complicated nonunion of the forearm. This method permits axial and internal bone transport without harming the distorted and complex neurovascular anatomy or soft-tissue envelope. MATERIALS AND METHODS Five patients (mean age, 27 years) with defect nonunion (3 ulna, 2 radius) were treated. Mean preoperative defect size was 36 mm, mean shortening was 14 (0-30) mm, and the extent of surgical resection was 24 (20-40) mm. Total bone loss due to defect, resection, or shortening was 74 mm. According to Paley classification, two of the patients had B1, and three had B3 defect nonunion. This study treats defect nonunion of the forearm using an internal bone-transport method. Our method involved cannulated screws, a cerclage wire, and a circular fixator being used in combination. When transportation was completed, internal fixation of the docking site with a plate and screws was done, with bone grafting after fixator removal. Bone healing and functional outcomes were assessed with radiographs and disabilities of the arm, shoulder, and hand (DASH) scores, respectively. RESULTS Mean followup was 67.6 months. Solid osseous union and functional improvement were achieved in all cases. Mean bone loss was 66 mm, mean fixator time was 131.8 days, the lengthening index was 1.3 days/mm, and the fixator index was 2.1 days/mm. DASH score was 82.2 before treatment and 15.36 after treatment. CONCLUSIONS Using our method, internal bone transport and progressive axial docking of defects can be done with minimal effects on surrounding neurovascular arrangements and soft tissues. Size of fixators can be decreased and formation of painful scar tissue can be avoided.
Collapse
Affiliation(s)
- Bilal Demir
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Baris Ozkul
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey,Address for correspondence: Dr. Baris Ozkul, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital. Rumeli Hisari Street. No: 62, 34470, Baltalimani, Sariyer, Istanbul, Turkey.” E-mail:
| | - Osman Lapcin
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Kubilay Beng
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Yavuz Arikan
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Merter Yalcinkaya
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
21
|
Chavoshnejad P, Ayati M, Abbasspour A, Karimpur M, George D, Rémond Y, Heidary Rouchi A, Baniassadi M. Optimization of Taylor spatial frame half-pins diameter for bone deformity correction: Application to femur. Proc Inst Mech Eng H 2018; 232:673-681. [PMID: 29962324 DOI: 10.1177/0954411918783782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Using external fixtures for bone deformity correction takes advantages of less soft tissue injury, better bone alignment and enhances strain development for bone formation on cutting section, which cause shorter healing time. Among these fixtures, Taylor spatial frame is widely used and includes two rings and six adjustable struts developing 6 degrees of freedom, making them very flexible for this type of application. The current study describes a method to optimize Taylor spatial frame pin-sizes currently chosen from the surgeon's experiences. A three-dimensional model of femur was created from computed tomography images; segmentation of the medical images was made based on the Hounsfield unit (gray scale) in order to allocate adequate mechanical properties into cortical and trabecular bone sections. Both the cortical and trabecular sections were assumed to be isotropic and homogeneous. The diameter optimization of Taylor spatial frame's half-pins was carried out by coupling genetic algorithm and finite element analysis. The finite element analysis was based on a static mechanical load corresponding to a standing person's body weight. Finite element analysis results were validated with experimentally measured strains obtained from bone compression tests. A cost function, based on the developed bone stresses, was defined close to the Taylor spatial frame's half-pins. The calculated cost function showed a decrease of over 33% from the initial half-pin selection by the surgeon and the genetic algorithm optimization. Consequently, the maximum stresses experienced by the bone in the connected location of the half-pins decreased from 121.4 MPa in the surgeon's selection to 73.07 MPa as a result of the optimization process.
Collapse
Affiliation(s)
- Pooria Chavoshnejad
- 1 School of Mechanical Engineering, Faculty of Engineering, University of Tehran, Tehran, Iran
| | - Moosa Ayati
- 1 School of Mechanical Engineering, Faculty of Engineering, University of Tehran, Tehran, Iran
| | - Aziz Abbasspour
- 2 Department of Orthopedics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Morad Karimpur
- 1 School of Mechanical Engineering, Faculty of Engineering, University of Tehran, Tehran, Iran
| | - Daniel George
- 3 ICube Laboratory, CNRS, University of Strasbourg, Strasbourg, France
| | - Yves Rémond
- 3 ICube Laboratory, CNRS, University of Strasbourg, Strasbourg, France
| | - Alireza Heidary Rouchi
- 4 Iranian Tissue Bank & Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Baniassadi
- 1 School of Mechanical Engineering, Faculty of Engineering, University of Tehran, Tehran, Iran.,3 ICube Laboratory, CNRS, University of Strasbourg, Strasbourg, France
| |
Collapse
|
22
|
Awad F, Jennison T, Hughes A. Radiolucent triangle and U-bolster for lower leg positioning for circular frame application. Ann R Coll Surg Engl 2018; 101:76. [PMID: 30112940 DOI: 10.1308/rcsann.2018.0122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- F Awad
- Royal Devon and Exeter Hospital , Exeter , UK
| | - T Jennison
- Royal Devon and Exeter Hospital , Exeter , UK
| | - A Hughes
- Royal Devon and Exeter Hospital , Exeter , UK
| |
Collapse
|
23
|
Gupta S, Malhotra A, Mittal N, Garg SK, Jindal R, Kansay R. The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate. Bone Joint J 2018; 100-B:1094-1099. [PMID: 30062945 DOI: 10.1302/0301-620x.100b8.bjj-2017-1442.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aims The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria. Patients and Methods Between January 2012 and January 2015, 14 consecutive patients were treated for an infected nonunion of the tibia with a gap and were included in the study. During stage one, a radical debridement of bone and soft tissue was undertaken with the introduction of an antibiotic-loaded cement spacer. At the second stage, the tibia was stabilized using a long lateral locked plate and a six-pin monorail fixator on its anteromedial surface. A corticotomy was performed at the appropriate level. During the third stage, i.e. at the end of the distraction phase, the transported fragment was aligned and fixed to the plate with two to four screws. An iliac crest autograft was added to the docking site and the fixator was removed. Functional outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. Patient-reported outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score. Results The mean age of patients was 38.1 years (sd 12.7). There were 13 men and one woman. The mean size of the defect was 6.4 cm (sd 1.3). the mean follow-up was 33.2 months (24 to 50). The mean external fixator index was 21.2 days/cm (sd 1.5). The complication rate was 0.5 (7/14) per patient. According to the classification of Paley, there were five problems and two obstacles but no true complications. The ASAMI bone score was excellent in all patients. The functional ASAMI scores were excellent in eight and good in six patients. The mean MSTS composite score was 83.9% (sd 7.1), with an MSTS emotional acceptance score of 4.9 (sd 0.5; maximum possible 5). Conclusion Composite fixation (rail-plate) decreases fixator time and the associated complications, in the treatment of patients of infected nonunion tibia with a segmental defect. It also provides good anatomical and functional results with high emotional acceptance. Cite this article: Bone Joint J 2018;100-B:1094-9.
Collapse
Affiliation(s)
- S Gupta
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - A Malhotra
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - N Mittal
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - S K Garg
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - R Jindal
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - R Kansay
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| |
Collapse
|
24
|
Fragomen AT, Kurtz AM, Barclay JR, Nguyen J, Rozbruch SR. A Comparison of Femoral Lengthening Methods Favors the Magnetic Internal Lengthening Nail When Compared with Lengthening Over a Nail. HSS J 2018; 14:166-176. [PMID: 29983659 PMCID: PMC6031532 DOI: 10.1007/s11420-017-9596-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 11/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bone lengthening with an internal lengthening nail (ILN) avoids the need for external fixation and requires one less surgical procedure than lengthening over a nail (LON). However, LON has been shown to be superior to femoral internal lengthening using a mechanical nail. The magnetic ILN, a remote-controlled and magnet-driven device, may have overcome the weaknesses of earlier internal lengthening technology and may be superior to LON. QUESTIONS/PURPOSES (1) Is the magnetic ILN more accurate than LON for femoral lengthening? (2) Does the magnetic ILN demonstrate more precise distraction rate control than LON? (3) Does the magnetic ILN result in faster regenerate site healing, with more robust callus, than LON? (4) Does the magnetic ILN result in fewer complications, including impediments to knee motion, than LON? METHODS We conducted a retrospective comparison of the records and radiographs of 21 consecutive patients with 22 femoral lengthenings using LONs and 35 consecutive patients with 40 femoral lengthenings using remote-controlled magnetic ILNs. Primary outcomes measured included accuracy, distraction rate precision, time to bony union, final knee range of motion, regenerate quality, and complications. The minimum follow-up times for the LON and ILN cohorts were 13 and 21 months, respectively. RESULTS Patients treated with ILN had a lower post-treatment residual limb-length discrepancy (0.3 mm) than those treated with LON (3.6 mm). The rate of distraction was closer to the goal of 1 mm/day and more tightly controlled for the ILN cohort (1 mm/day) than that for the LON group (0.8 mm/day; SD, 0.2). Regenerate quality was not significantly different between the cohorts. Bone healing index for ILN was not statistically significant. Time to union was shorter in the ILN group (3.3 months) than that in the LON group (4.5 months). A lower percentage of patients experienced a complication in the ILN group (18%) than in the LON group (45%). Knee flexion at the end of distraction was greater for ILN patients (105°) than that for LON patients (88.8°), but this difference was no longer observed after 1 year. CONCLUSIONS Femoral lengthening with magnetic ILN was more accurate than with LON. The magnetic ILN comports the additional advantage of greater precision with distraction rate control and fewer complications. Both techniques afford reliable healing and do not significantly affect knee motion at the final follow-up. The magnetic ILN method showed no superiority in regenerate quality and healing rate.
Collapse
Affiliation(s)
- Austin T. Fragomen
- Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021 USA
| | | | | | - Joseph Nguyen
- Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021 USA
| | - S. Robert Rozbruch
- Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021 USA
| |
Collapse
|
25
|
Wright J, Hill RA, Eastwood DM, Hashemi-Nejad A, Calder P, Tennant S. Posteromedial bowing of the tibia: a benign condition or a case for limb reconstruction? J Child Orthop 2018; 12:187-196. [PMID: 29707059 PMCID: PMC5902754 DOI: 10.1302/1863-2548.12.170211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To review the initial deformity and subsequent remodelling in posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition. PATIENTS AND METHODS In all, 38 patients with posteromedial bowing of the tibia presenting between 2000 and 2016 were identified. Mean follow-up from presentation was 78 months. A total of 17 patients underwent lengthening and deformity correction surgery, whilst three further patients are awaiting lengthening and deformity correction procedures. RESULTS The greatest correction of deformity occurred in the first year of life, but after the age of four years, remodelling was limited. The absolute leg-length discrepancy (LLD) increased throughout growth with a mean 14.3% discrepancy in tibial length. In the lengthening group, mean length gained per episode was 45 mm (35 to 60). Mean duration in frame was 192 days, with a mean healing index of 42.4 days/cm. Significantly higher rates of recurrence in LLD were seen in those undergoing lengthening under the age of ten years (p = 0.046). Four contralateral epiphysiodeses were also performed. CONCLUSION Posteromedial bowing of the tibia improves spontaneously during the first years of life, but in 20/38 (53%) patients, limb reconstruction was indicated for significant residual deformity and/or worsening LLD. For larger discrepancies and persistent deformity, limb reconstruction with a hexapod external fixator should be considered as part of the treatment options. LEVEL OF EVIDENCE Level IV (Case series).
Collapse
Affiliation(s)
- J. Wright
- Department of Orthopaedics, Great Ormond Street Hospital for Children, London, UK,Catterall Unit, Royal National Orthopaedic Hospital, Stanmore, UK, Correspondence should be sent to J. Wright, Catterall Unit, Royal National Orthopaedic Hospital, Stanmore, UK. E-mail:
| | - R. A. Hill
- Department of Orthopaedics, Great Ormond Street Hospital for Children, London, UK
| | - D. M. Eastwood
- Department of Orthopaedics, Great Ormond Street Hospital for Children, London, UK,Catterall Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - A. Hashemi-Nejad
- Catterall Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - P. Calder
- Catterall Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - S. Tennant
- Catterall Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| |
Collapse
|
26
|
Resection arthrodesis using distraction osteogenesis then plating as a hybrid surgical technique for the management of bone sarcomas of the distal tibia. INTERNATIONAL ORTHOPAEDICS 2018; 42:705-711. [DOI: 10.1007/s00264-018-3811-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
|
27
|
Abstract
BACKGROUND Limb lengthening over a percutaneous plate can be used during pediatric distraction osteogenesis to decrease the time of external fixation. METHODS A retrospective, consecutive 2-surgeon experience of pediatric femoral and tibial lengthenings with a plate-assisted lengthening (PAL) technique was performed. The plate was placed at the time of index corticotomy. The primary outcome measures of external fixation index, consolidation index, and complications were assessed for each lengthening. RESULTS From 2005 to 2012, 38 lengthenings (23 femur, 15 tibia) in 30 patients were performed by a PAL technique. All patients experienced successful distraction and consolidation. The average achieved lengthening was 3.80±0.98 cm (range, 2.2 to 6.4) with an average consolidation index of 27 days/cm and a mean external fixation index of 13.1±4.29 days/cm (range, 7.8 to 30). Patients returned to full weight-bearing activity after an average of 98.3±28.5 days. There were an average of 1.08±1.05 total complications and 0.39±0.75 severe complications per lengthening. Complications were encountered most commonly during femoral lengthening, including procurvatum and varus deformity through the regenerate. These deformities were usually corrected by frame adjustment before removal. CONCLUSIONS PAL is a safe technique that minimizes time of external fixation, accelerates rehabilitation and weight-bearing, and can be successfully used on the femur or tibia. The most common complications are angular deformities of the regenerate that can be treated with adjustment before or at the time of plate locking. LEVEL OF EVIDENCE Level IV-retrospective case series.
Collapse
|
28
|
Yoshida T, Kim WC, Oka Y, Nakase M, Nishida A, Fujiwara H, Kubo T. Monitoring of Callus Maturation and Measurement of Resistance Rates Using Bioelectrical Impedance for Patients Treated With an External Fixator. Orthopedics 2018; 41:54-58. [PMID: 29257188 DOI: 10.3928/01477447-20171213-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/31/2017] [Indexed: 02/03/2023]
Abstract
Evaluation of callus maturation and the decision to remove an external fixator depend on radiographic and clinical findings, which are subjective. Callus fracture or recurrent deformity may occur after premature removal of a fixator. The authors applied a technique to measure bioelectrical impedance to assess callus maturation. This study included 27 limbs that underwent deformity correction or callus distraction using a fixator. Mean patient age at the time of surgery was 17.2 years. Overall impedance during callus maturation was measured from after completion of correction or distraction to removal of the fixator. Temporal changes in impedance values were measured, and maximum and final values were compared with initial values. The resistance rates were compared by age (<15 or ≥15 years), correction site (femur or tibia), and treatment method (noncontact or contact). Mean overall impedance increased gradually. Compared with initial values, maximum and final impedance values were 1.21 times and 1.15 times higher, respectively. Resistance rates by age, correction site, and treatment method were significantly higher in patients 15 years and older, in the tibia, and in the contact group, respectively. Overall impedance tended to increase during callus maturation but varied among patients. Therefore, resistance rates were calculated to classify differences for individual patients. Age and treatment method were important predictors of resistance rates. These data by age, correction site, and treatment method, which assume overall impedance from after completion of correction or distraction, can serve as a useful index to determine when a fixator should be removed. [Orthopedics. 2018; 41(1):54-58.].
Collapse
|
29
|
Živanović D, Slavković A, Marjanović Z, Djordjević I, Bojović N, Petrović M. Congenital Posteromedial Bowing of the Tibia: A Single Center Experience. ACTA FACULTATIS MEDICAE NAISSENSIS 2017. [DOI: 10.1515/afmnai-2017-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Summary
Congenital posteromedial bowing of the tibia (CPMBT) is a rare congenital anomaly of the lower limbs. The aim of the present study was to analyze our experience in the treatment of CPMBT.
A retrospective study of patients treated for CPMBT in the period January 2000 – June 2016 was performed. In the observed period, six patients were treated (five girls and one boy), with predominance of the right tibia involvement (5:1).
The initial treatment included a series of corrective casts (4-9) applied in all patients, followed by removable splints and physiotherapy. Four children with residual angulation of tibia after walking age were prescribed ankle-foot orthosis (AFO) as a prevention of pathological fractures. Both posterior and medial angulation correct over time. Mean initial shortening was 11 mm. At the last follow-up visit, mean shortening was 23.33mm. Three patients had lower limb shortening of more than 2 cm. In two of them, with shortening of 27 mm and 35 mm, Ilizarov lengthening was performed. In one girl, we performed lengthening over titanium elastic nails. In the other girl, after lengthening, circular frame was exchanged with a locking plate to reduce fixator wearing time. There were no major complications of treatment. Patients were followed up for 2-12 years (mean 6.83 years). None of them reached skeletal maturity yet.
Primary manifestation of CPMBT – angulation of tibia and fibula as well as calcaneovalgus deformity usually correct spontaneously or with conservative measures. However, limb length inequality, as a consequence of CPMBT, progresses with growth and may require surgical correction in some children. Therefore, all children with CPMBT should be followed up until skeletal maturity.
Collapse
|
30
|
Distal femoral flexion deformity from growth disturbance treated with a two-level osteotomy and internal lengthening nail. Strategies Trauma Limb Reconstr 2017; 12:159-167. [PMID: 29039128 PMCID: PMC5653604 DOI: 10.1007/s11751-017-0298-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 10/04/2017] [Indexed: 10/27/2022] Open
Abstract
Salter Harris fractures of the distal femur can lead to growth disturbance with resulting leg length inequality and knee deformity. We have looked at a case series (3) of patients who presented with a distal femur flexion malunion and shortening treated with a distal femoral osteotomy and plating and a proximal femoral osteotomy with a magnetic internal lengthening nail. Does a two-level osteotomy and internal fixation approach provide a reliable result both radiographically and functionally? The average knee extension loss was 12°, LLD 47 mm, PDFA 65°, MAD 2 mm. The patients were treated with an acute, posterior, opening wedge osteotomy of the distal femur stabilized with a lateral plate and screws and grafted with cancellous chips and putty. A second osteotomy was made proximally in the femur percutaneously, and the internal lengthening nail was inserted. Lengthening was done at approximately 1 mm/day. The average extension gain was 12°; amount of lengthening at the proximal site was 40 mm, LLD was 3 mm. The average PDFA was 81°, and MAD 3 mm. There were no complications. Functional results were excellent. Bone healing index was 24 days/cm. The average distance from the distal osteotomy to the joint line was 57 mm. The technique of two-level femur osteotomy stabilized with a plate and lengthening nail yielded excellent results with acceptable correction of deformity, full knee extension, and improved function. There were no complications including implant failure, infection, need for blood transfusion, knee stiffness, nonunion, compartment syndrome, or malunion.
Collapse
|
31
|
Abstract
Ring fixation is a powerful tool in the treatment of bone defects. The ability to create high-quality, biologically normal new bone of even massive proportions using distraction osteogenesis is a major reason for its success. In addition, ring fixation provides the ability to limit the risk of deep infection, improves flexibility in limb length control and alignment, and increases soft tissue coverage options. The drawbacks of ring fixation include long frame times, pin problems, risk of joint contractures, and difficult usage in areas with a large soft tissue envelope such as the thigh. Significant advancements such as hydroxyapatite coated pins, internal cable transport, multifocal transport, and combined techniques with internal fixation have helped increase the effectiveness of ring fixator use by minimizing many of the drawbacks. At present, ring fixation provides the most effective means of treatment for large bone defects in many clinic situations.
Collapse
|
32
|
Abstract
Distraction osteogenesis has proven effective in the management of tibial bone loss from severe trauma and infection. Unfortunately, pain and scarring from wires and half pins dragging through the skin and the required prolonged time in the external fixator make treatment difficult. Cable bone transport has been shown to improve cosmesis and decrease pain during transport. However, the published methods have limitations in that they have poor control of transport segment alignment, do not allow for lengthening of the limb, and do not permit weight bearing during the treatment process. We describe a novel method of cable bone transport that addresses each of these limitations with excellent control of alignment including the transport segment, easy conversion to allow limb lengthening, and full weight bearing throughout the treatment process. In addition, the method facilitates multifocal transport and safe conversion to intramedullary nail fixation, both of which can be used to substantially shorten the time of reconstruction.
Collapse
|
33
|
Abstract
A new generation of internal lengthening nail is now available that has reliable remote-controlled mechanisms. This allows accurate and well-controlled distraction rate and rhythm, and early clinical results have been very positive. In this article, 2 posttraumatic cases are presented that illustrate deformity correction and lengthening using the internal lengthening nail. Surgical planning and adjuvant techniques of fixator-assisted nailing and the use of blocking screws are discussed.
Collapse
|
34
|
Tosun HB, Agir I, Gumustas S, Serbest S, Uludag A, Celik S. Tibial Lengthening Using a Fixator-Assisted Lengthening Plate: A New Technique. Trauma Mon 2017; 21:e25340. [PMID: 28184364 PMCID: PMC5292023 DOI: 10.5812/traumamon.25340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 12/24/2014] [Accepted: 01/06/2015] [Indexed: 11/17/2022] Open
Abstract
Background There are many techniques that are used for limb lengthening. Lengthening a limb over a plate is an alternative choice used in children or when using an intramedullary nail is difficult. Objectives In this study, we presented a new technique for tibial lengthening using a monolateral external fixator over a lengthening plate. Materials and Methods For tibial lengthening, a monolateral external fixator was attached to the composite bone model medially. After a corticotomy was performed, the lengthening plate was placed laterally. Three locking screws were inserted proximally, and two cortical screws were inserted into a lengthening hole that was 1 cm below the osteotomy site. We avoided contact between the screws of the lengthening plate and the pins of the external fixator. During bone lengthening with the monolateral external fixator, the screws at the lengthening hole were able to slide distally with the distal segment of the tibia to allow for tibial elongation. Two locking screws were fixed at the distal locking holes of the plate when the bone elongation was complete. The external fixator was then removed. Results The fixator-assisted lengthening plate allowed bone lengthening without malalignment. There were no mechanical problems associated with the external fixator during the lengthening process. Plate osteosynthesis was stable after the fixator was removed. There was no contact between the screws of plate and the Schanz pins of the external fixator under C-arm fluoroscopy. Conclusions The fixator-assisted lengthening plate technique helps to maintain the stability and alignment at both sides of an osteotomy during tibial elongation. It allows the early removal of the external fixator immediately after lengthening is completed. This technique can be applied in children with open physes and in patients with a narrow medullary canal who are unsuitable for limb lengthening over an intramedullary nail.
Collapse
Affiliation(s)
- Haci Bayram Tosun
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey
- Corresponding author: Haci Bayram Tosun, Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey. Tel: +90-5334497699, Fax: +90-4162231693, E-mail:
| | - Ismail Agir
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey
| | - Seyitali Gumustas
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey
| | - Sancar Serbest
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey
| | - Abuzer Uludag
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey
| | - Suat Celik
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey
| |
Collapse
|
35
|
78495111110.1016/j.otsr.2016.05.020" />
|
36
|
Femoral lengthening in children and adolescents. Orthop Traumatol Surg Res 2017; 103:S143-S149. [PMID: 28110891 DOI: 10.1016/j.otsr.2016.05.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/17/2016] [Accepted: 05/26/2016] [Indexed: 02/02/2023]
Abstract
Current lengthening techniques are still based on the Ilizarov method and the concept of callotasis. Research and progress in medical devices have led to constant improvement in results. Hexapod fixators allow more precise correction of complex deformities, with shorter learning curve. Associating lengthening by external fixation (EF) to internal fixation (K-wire, intramedullary nail or locking plate) has reduced EF times and complications rates, while improving anatomic and functional results. Lengthening nails provides faster recovery of range of motion and return to activity during lengthening and consolidation, with better psychological tolerance. Lengthening with deformity correction by retrograde nailing has no impact on consolidation. Monolateral EF is a reliable and easy-to-implement technique that is well tolerated by patients. Association to internal fixation gives promising results. Bone healing solidity assessment on plain X-ray is highly subjective, with wide inter- and intra-observer variation; bone mineralization is better assessed in terms of pixel-value ratio (PVR: ratio of pixel value of regenerate to adjacent bone) on picture archiving and communication system (PACS) digitized radiographs, providing objective assessment of callus solidity.
Collapse
|
37
|
Persico F, Fletscher G, Zuluaga M. Submuscular plating of the femur through an anterior approach after bone distraction. Strategies Trauma Limb Reconstr 2017; 12:53-58. [PMID: 28063081 PMCID: PMC5360673 DOI: 10.1007/s11751-016-0274-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 12/27/2016] [Indexed: 11/24/2022] Open
Abstract
The method of osteogenesis by distraction is a known technique in orthopaedics for the management of bone defects secondary to trauma, infections or tumours. New strategies have been developed for decreasing the external fixator time. The use of the minimally invasive plate osteosynthesis technique is a secure approach through a percutaneous fixation technique in the anterior aspect of the femur that permits minimal dissection of the soft tissues while preventing cross-contamination with the pin tracts of the external fixators. The goal of this article is to show that a new surgical technique, to preserve the benefits related to the internal fixation and at the same time decrease the risk of infection, can be used to perform femoral plating after bone distraction with a low contact plate through an anterior approach to the femur while still taking adequate care of the soft tissues.
Collapse
Affiliation(s)
- Federico Persico
- Osteoarticular Diseases Institute, Imbanaco Medical Center, Cali, Colombia
| | - Gabriel Fletscher
- Osteoarticular Diseases Institute, Imbanaco Medical Center, Cali, Colombia.
| | - Mauricio Zuluaga
- Osteoarticular Diseases Institute, Imbanaco Medical Center, Cali, Colombia
| |
Collapse
|
38
|
Tosun HB, Serbest S, Uludag A, Gumustas S, Celik S. Fixator-assisted tibial lengthening over a plate in a patient with sequelae of poliomyelitis. Medicine (Baltimore) 2016; 95:e5252. [PMID: 27858886 PMCID: PMC5591134 DOI: 10.1097/md.0000000000005252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
There are many techniques for limb lengthening. Lengthening over a plate is an alternative choice of fixation in children or when nailing is difficult. We present a new technique for tibial lengthening with using a monolateral external fixator over a lengthening plate.Lengthening over an intramedullary nail is a commonly used method in patients with short stature or limb-length discrepancy. However, in patients with a narrow and excessively sclerotic intramedullary cavity in the pediatric age group where the skeletal system has not yet fully developed, difficulties have been observed in lengthening methods with nailing.Therefore, in these cases, the use of lengthening techniques over a plate is an alternative treatment option. Nevertheless, in lengthening techniques over a plate, if one side of the osteotomy area cannot be fixed, associated mechanical axis problems have been reported.We applied tibia lengthening with external fixator assistance over a custom-made lengthening plate in a patient with sequelae of poliomyelitis. This new lengthening technique applied over a plate could be the solution to the problems observed in other lengthening techniques over a plate.
Collapse
Affiliation(s)
- Haci Bayram Tosun
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman
| | - Sancar Serbest
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Kırıkkale University, Kırıkkale, Turkey
- Correspondence: Sancar Serbest, Department of Orthopaedics and Traumatology, Faculty of Medicine, Kırıkkale University, 71100 Kırıkkale, Turkey (e-mail: )
| | - Abuzer Uludag
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman
| | - Seyitali Gumustas
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman
| | - Suat Celik
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman
| |
Collapse
|
39
|
Laubscher M, Mitchell C, Timms A, Goodier D, Calder P. Outcomes following femoral lengthening. Bone Joint J 2016; 98-B:1382-1388. [DOI: 10.1302/0301-620x.98b10.36643] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/03/2016] [Indexed: 01/20/2023]
Abstract
Aims Patients undergoing femoral lengthening by external fixation tolerate treatment less well when compared to tibial lengthening. Lengthening of the femur with an intramedullary device may have advantages. Patients and Methods We reviewed all cases of simple femoral lengthening performed at our unit from 2009 to 2014. Cases of nonunions, concurrent deformities, congenital limb deficiencies and lengthening with an unstable hip were excluded, leaving 33 cases (in 22 patients; 11 patients had bilateral procedures) for review. Healing index, implant tolerance and complications were compared. Results In 20 cases (15 patients) the Precice lengthening nail was used and in 13 cases (seven patients) the LRS external fixator system. The desired length was achieved in all cases in the Precice group and in 12 of 13 cases in the LRS group. The mean healing index was 31.3 days/cm in the Precice and 47.1 days/cm in the LRS group (p < 0.001). This was associated with an earlier ability to bear full weight without aids in the Precice group. There were more complications with LRS lengthening, including pin site infections and regenerate deformity. Implant tolerance and the patients’ perception of the cosmetic result were better with the Precice treatment. Conclusion Femoral lengthening with the Precice femoral nail achieved excellent functional results with fewer complications and greater patient satisfaction when compared with the LRS system in our patients. Cite this article: Bone Joint J 2016;98-B:1382–8.
Collapse
Affiliation(s)
- M. Laubscher
- H49 OMB Groote Schuur Hospital, University
of Cape Town, Cape Town, 7925, South Africa
| | - C. Mitchell
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - A. Timms
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - D. Goodier
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - P. Calder
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex, HA7 4LP, UK
| |
Collapse
|
40
|
Does Integrated Fixation Provide Benefit in the Reconstruction of Posttraumatic Tibial Bone Defects? Clin Orthop Relat Res 2015; 473:3143-53. [PMID: 25940337 PMCID: PMC4562932 DOI: 10.1007/s11999-015-4326-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limb salvage in the presence of posttraumatic tibial bone loss can be accomplished using the traditional Ilizarov method of distraction osteogenesis with circular external fixation. Internal fixation placed at the beginning of the consolidation phase, so-called integrated fixation, may allow for earlier removal of the external fixator but introduces concerns about cross-contamination from the additional open procedure and maintenance of bone regenerate stability. QUESTIONS/PURPOSES Among patients deemed eligible for integrated fixation, we sought to determine: (1) Does integrated fixation decrease the time in the external fixator? (2) Is there a difference in the rate of complications between the two groups? (3) Are there differences in functional and radiographic results between integrated fixation and the traditional Ilizarov approach of external fixation alone? METHODS Between January 2006 and December 2012, we treated 58 patients (58 tibiae) with posttraumatic tibial bone loss using the Ilizarov method. Of those, 30 patients (52%) were treated with the "classic technique" (external fixator alone) and 28 (48%) were treated with the "integrated technique" (a combination of an external fixator and plating or insertion of an intramedullary nail). During that period, the general indications for use of the integrated technique were closed physes, no active infection, and a healed soft tissue envelope located at the intended internal fixation site; the remainder of the patients were treated with the classic technique. Followup on 30 (100%) and 28 (100%) patients in the classic and integrated techniques, respectively, was achieved at a minimum of 1 year (mean, 3 years; range, 1-8 years). Adverse events were reported as problems, obstacles, and complications according to the publication by Paley. Problems and obstacles are managed by nonoperative and operative means, respectively; in addition, they resolve completely with treatment. Complications, according to the Paley classification, result in permanent sequelae. Functional and radiographic results were reported using the Association for the Study and Application of Methods of Ilizarov scoring system. RESULTS Overall, there was a mean of four (range, 2-5) surgical procedures to complete the tibial reconstruction with a similar incidence of unplanned surgical procedures (obstacles) between the two groups (p = 0.87). Patients treated with integrated fixation spent less time in the external fixator, 7 months (range, 5-20 months) versus 11 months (range, 1-15 months; p < 0.001). There were seven problems, 15 obstacles, and zero complications in the classic group. Ten problems, 15 obstacles, and one complication occurred in the integrated fixation group. There was no difference in the severity (p = 0.87) or number (p = 0.40) of complications between both groups. Good to excellent Association for the Study and Application of Methods of Ilizarov function and bone scores were obtained in 100% and 98% of patients, respectively. CONCLUSIONS The integrated fixation method allows for a more efficient limb salvage surgical reconstruction in patients carefully selected for that approach, whereas the frequency of adverse events and ability to restore limb lengths was not different between the groups with the numbers available. Careful placement of external fixation pins is critical to decrease cross-contamination with planned internal fixation constructs. In this study of posttraumatic tibial bone defect reconstruction, good/excellent results were found in all patients after a mean of four surgical procedures; however, a larger multicenter prospective study would allow for more robust and generalizable conclusions. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
41
|
Abstract
Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients' outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.
Collapse
Affiliation(s)
- Remy V Rabinovich
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
| | - Amgad M Haleem
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
| | - S Robert Rozbruch
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
| |
Collapse
|
42
|
Rabinovich RV, Haleem AM, Rozbruch SR. Complex ankle arthrodesis: Review of the literature. World J Orthop 2015; 6:602-613. [PMID: 26396936 PMCID: PMC4573504 DOI: 10.5312/wjo.v6.i8.602] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 06/22/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023] Open
Abstract
Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients’ outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.
Collapse
|
43
|
Callus massage after distraction osteogenesis using the concept of lengthening then dynamic plating. Strategies Trauma Limb Reconstr 2015; 10:129-35. [PMID: 26338093 PMCID: PMC4570884 DOI: 10.1007/s11751-015-0233-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 08/23/2015] [Indexed: 10/28/2022] Open
Abstract
Correction of complex deformities is a challenging procedure. Long-term wearing of a fixator after correction and lengthening are inconvenient and has a high rate of complication. The goals of the surgical treatment in the presented case were: (1) correction of the deformity and lengthening of the left leg by the Taylor spatial frame (TSF, Smith and Nephew, Marl, Germany); (2) reduction in the time the patient wears the TSF by changing the fixation system to a plate (lengthening then plating-LTP) and using a locking compression plate in conjunction with the 5.0 dynamic locking screws in order to accelerate bone healing.
Collapse
|
44
|
Abstract
PURPOSE We assessed whether an intramedullary lengthening device would reduce the problems normally associated with the external fixation technique. We also wanted to determine whether it is a reliable construct for limb lengthening and deformity correction in the femur. PATIENTS AND METHODS We conducted a matched-pair comparison of 30 femoral lengthenings, 15 with a motorized intramedullary nail (the nail group) and 15 lengthenings with an external ring fixator (the fixator group). The patients were matched based on age, sex, amount of lengthening, and the etiology of leg length discrepancy. Mean lengthening was 35 (25-55) mm in the nail group and 38 (15-75) mm in the fixator group. Outcome measures were: lengthening and alignment achieved, consolidation index, knee range of motion (ROM), and complications. RESULTS The pairs in this matched-pair study were similar in terms of age, sex, diagnosis, and amount of lengthening. The planned amount of lengthening was achieved in all patients in both groups and axis correction was considered sufficient. The mean radiographic consolidation index in the nail group, at 1.5 (0.9-3.0) months/cm, was better than the mean value for the fixator group (1.9 (0.9-3.4) months/cm) (p = 0.01). Knee ROM was better in the nail group during the lengthening, 6 weeks after lengthening was completed, and 6 months after lengthening was completed (p < 0.001). A larger number of complications were observed in the fixator group than in the nail group. INTERPRETATION A lengthening nail may be superior to external fixation in femoral lengthening, when the anatomical conditions and the complexity of the deformity allow the use of an intramedullary nail.
Collapse
Affiliation(s)
- Joachim Horn
- Departments of Children’s Orthopaedics and Reconstructive Surgery
| | | | | | - Stefan Huhnstock
- Departments of Children’s Orthopaedics and Reconstructive Surgery
| | - Harald Steen
- Biomechanics Laboratory, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| |
Collapse
|
45
|
Abstract
BACKGROUND Previous designs of internal bone lengthening devices have been fraught with imprecise distraction, resulting in nerve injuries, joint contractures, nonunions, and other complications. Recently, a magnet-operated PRECICE nail (Ellipse Technologies, Inc, Irvine, CA, USA) was approved by the FDA; however, its clinical efficacy is unknown. QUESTIONS/PURPOSES We evaluated this nail in terms of (1) accuracy and precision of distraction, (2) effects on bone alignment, (3) effects on adjacent-joint ROM, and (4) frequency of implant-related and non-implant-related complications. METHODS We reviewed medical and radiographic records of 24 patients who underwent femoral and/or tibial lengthening procedures using the PRECICE nail from August 2012 to July 2013 for conditions of varied etiology, the most common being congenital limb length discrepancy, posttraumatic growth arrest, and fracture malunion. This group represented 29% of patients (24 of 82) who underwent a limb lengthening procedure for a similar diagnosis during the review period. At each postoperative visit, the accuracy and precision of distraction, bone alignment, joint ROM, and any complications were recorded by the senior surgeon (SRR). Accuracy reflected how close the measured lengthening was to the prescribed distraction at each postoperative visit, while precision reflected how close the repeated measurements were to each other over the course of total lengthening period. No patients were lost to followup. Minimum followup from surgery was 3 weeks (mean, 14 weeks; range, 3-29 weeks). RESULTS Mean total lengthening was 35 mm (range, 14-65 mm), with an accuracy of 96% and precision of 86%. All patients achieved target lengthening with minimal unintentional effects on bone alignment. The knee and ankle ROM were minimally affected. Of the complications requiring return to the operating room for an additional surgical procedure, there was one (4%) implant failure caused by a nonfunctional distraction mechanism and six (24%) non-implant-related complications, including premature consolidation in one patient (4%), delayed bone healing in two (8%), delayed equinus contracture in two (8%), and toe clawing in one (4%). CONCLUSIONS We conclude that this internal lengthening nail is a valid option to achieve accurate and precise limb lengthening to treat a variety of conditions with limb shortening or length discrepancy. Randomized, larger-sample, long-term studies are required to further confirm clinical efficacy of these devices, monitor for any late failures and complications, and compare with other internal lengthening devices with different mechanisms of operation. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Yatin M. Kirane
- />Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY 10021 USA
| | - Austin T. Fragomen
- />Weill Cornell Medical College, Cornell University, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10021 USA
| | - S. Robert Rozbruch
- />Weill Cornell Medical College, Cornell University, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10021 USA
| |
Collapse
|
46
|
Oh CW, Apivatthakakul T, Oh JK, Kim JW, Lee HJ, Kyung HS, Baek SG, Jung GH. Bone transport with an external fixator and a locking plate for segmental tibial defects. Bone Joint J 2014; 95-B:1667-72. [PMID: 24293598 DOI: 10.1302/0301-620x.95b12.31507] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although gradual bone transport may permit the restoration of large-diameter bones, complications are common owing to the long duration of external fixation. In order to reduce such complications, a new technique of bone transport involving the use of an external fixator and a locking plate was devised for segmental tibial bone defects. A total of ten patients (nine men, one woman) with a mean age at operation of 40.4 years (16 to 64) underwent distraction osteogenesis with a locking plate to treat previously infected post-traumatic segmental tibial defects. The locking plate was fixed percutaneously to bridge proximal and distal segments, and was followed by external fixation. After docking, percutaneous screws were fixed at the transported segment through plate holes. At the same time, bone grafting was performed at the docking site with the external fixator removed. The mean defect size was 5.9 cm (3.8 to 9.3) and mean external fixation index was 13.4 days/cm (11.8 to 19.5). In all cases, primary union of the docking site and distraction callus was achieved, with an excellent bony result. There was no recurrence of deep infection or osteomyelitis, and with the exception of one patient with a pre-existing peroneal nerve injury, all achieved an excellent or good functional result. With short external fixation times and low complication rates, bone transport with a locking plate could be recommended for patients with segmental tibial defects.
Collapse
Affiliation(s)
- C-W Oh
- Kyungpook National University Hospital, Department of Orthopaedic Surgery, 50 Samdok 2-Ga, Jung-gu, Daegu, 700-721, South Korea
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
Limb lengthening and deformity correction with fully implantable systems is becoming more and more widespread. Different actuation techniques are known and every system has its specific limitations in distraction control and/or stability. A new system with magnetic actuation offers outstanding options. The mechanism of the Phenix M2(®) bone lengthening nail (Phenix Medical, France) is driven by a strong external magnet. The device can provide lengthening, shortening and bone transport. Between December 2011 and November 2012 we applied the nail in 10 patients with an average age of 25 years (range 15-40 years). There were 6 femoral and 4 tibial procedures. The intended distraction goal was achieved in 8 of 10 patients. In three cases we simultaneously corrected malalignment. Average lengthening was 4.6 cm (range 1.3-7.6 cm). Average distraction index was 0.85 mm/day (range 0.6-1.3mm/day). Average weight bearing index was 27 days/cm (range 16-37 days/cm). Three patients had revisions due to early distraction arrest. The early results are comparable to those of other intramedullary systems in the literature like the ISKD(®), the Albizzia(®) or the Fitbone(®) system. All intramedullary procedures require accurate analysis and planning, advanced operative technique and close follow-up. The custom made design of the Phenix nail with unique options for size, stroke and locking provides new options for small bones and improved stability. The shortening option may be helpful for soft tissue problems, joint subluxation and additional stimulation of bone formation. Magnetic forces have to be considered and too much soft tissue around the nail might be a limiting factor. The magnetically actuated Phenix nail offers new therapeutic options in limb lengthening.
Collapse
|
48
|
Sabharwal S, Fragomen A, Iobst C. What's new in limb lengthening and deformity correction. J Bone Joint Surg Am 2013; 95:1527-34. [PMID: 23965706 DOI: 10.2106/jbjs.m.00599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sanjeev Sabharwal
- Department of Orthopedics, UMDNJ-New Jersey Medical School, Newark, NJ 07103, USA.
| | | | | |
Collapse
|
49
|
The Ilizarov paradigm: thirty years with the Ilizarov method, current concerns and future research. INTERNATIONAL ORTHOPAEDICS 2013; 37:1533-9. [PMID: 23712212 DOI: 10.1007/s00264-013-1935-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/07/2013] [Indexed: 02/06/2023]
Abstract
The Ilizarov method of bone lengthening, reconstruction and osteosynthesis has developed immensely since its introduction by G.A. Ilizarov in the Soviet Union in the 1960s and in the Western countries in the early 1980s. It has become an integral part of the arsenal used by the orthopaedic community worldwide. The evolutionary development of the method and its current role has considerably improved the quality of life for millions of people around the whole world. Despite the great versatility of its possible applications for bone injuries and diseases, the Ilizarov method could not and cannot be the alternative to a range of other methods that are applied for some specific bone conditions, but rather is a method of choice. Its combination with the current methods of internal fixation or the means of internal fixation that use the biological principles that were laid down by G.A. Ilizarov have demonstrated the importance of tension stress, blood supply, functional loading, and fragment control during bone treatment. The objective of this study was to present an overview of the current state and concerns in the application of the Ilizarov method and define the prospective research trends aimed at regeneration stimulation, better control of treatment, infection barriers and patient comfort.
Collapse
|
50
|
Monni T, Birkholtz FF, de Lange P, Snyckers CH. Conversion of external fixation to internal fixation in a non-acute, reconstructive setting: a case series. Strategies Trauma Limb Reconstr 2013; 8:25-30. [PMID: 23475382 PMCID: PMC3623921 DOI: 10.1007/s11751-013-0157-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Accepted: 02/24/2013] [Indexed: 12/01/2022] Open
Abstract
The aim of the study is to determine the outcomes in patients who underwent conversion from an external fixator to an internal fixation device. This is a retrospective review of 18 patients (24 limbs) who underwent conversion from external to internal fixation. The patients had external fixators applied for traumatic bone defects or congenital deformities. Conversion to internal fixation was performed for reasons of patient dissatisfaction with external fixation, pin track sepsis, persistent non-union or refracture. The complexity of cases was graded using Paley's level of difficulty score. Patients were either converted acutely or delayed. Internal fixation devices were either intramedullary nails or plate and screws. Outcome was regarded as excellent if the patients were fully weight-bearing and pain-free on a mechanically well-aligned limb and without need for further surgery: good if the patient required subsequent surgery to achieve union and poor if irreversible complications occurred. Acute conversions (fixator removal and introduction of internal fixation device at same surgery) were done in 19 limbs and delayed conversion (interval between fixator removal and internal fixation) in 5. In the acute group, 17 limbs (89.4 %) had at least a good outcome, 16 of these limbs had an excellent result. Two limbs (10.6 %) had a poor result and required amputation. Both cases were after acute conversion to intramedullary nails; the original presenting diagnosis was of an infected non-union of the tibia and both had Paley scores above 7. In the delayed conversion group, all limbs (100 %) had at least a good outcome, with 4 limbs (80 %) having an excellent result. The mean external fixator time was 185 days (61-370). Both the cases with poor outcomes had longer external fixation times. This series supports the practice of conversion of external fixation to internal fixation with the majority of patients attaining good results. It identifies that plate devices appear to produce fewer deep sepsis complications, as compared to intramedullary nails, particularly when the original presenting diagnosis is a septic non-union.
Collapse
Affiliation(s)
- T Monni
- Steve Biko Academic Hospital, Pretoria, Gauteng, South Africa,
| | | | | | | |
Collapse
|