Dislocation and subluxation during femoral lengthening

Femoral Lengthening in Children with Congenital Femoral Deficiency: A Systematic Review

BACKGROUND

Congenital femoral deficiency (CFD) presents a significant challenge in pediatric orthopaedics, characterized by a spectrum of congenital anomalies ranging from mild femoral shortening to complete absence of the proximal femur and hip joint. This review aims at reviewing the latest concepts of femoral limb lengthening modalities in treating CFD, to explore the efficacy, complications, and long-term outcomes of various surgical techniques.

METHODS

A comprehensive search of the literature was performed for clinical studies involving lengthening in patients with proximal focal femoral deficiency (PFFD) in several databases.

RESULTS

We analyze the evolution of limb lengthening procedures, from the Wagner and Ilizarov methods to the latest advancements in distraction osteogenesis, and assess their role in addressing the functional needs of patients. We also analyze the possible risk factors for the occurrence of complications with each method and alternatives to avoid them.

CONCLUSION

The review highlights the importance of individualized treatment plans, considering factors such as the degree of femoral deficiency and the potential for achieving a functional limb length; however, it requires a multidisciplinary approach and careful preoperative planning to optimize patient outcomes. The review underlines the need for ongoing research to refine surgical techniques and to compare them and improve the quality of life for individuals with PFFD.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Hip Joint Stability during and after Femoral Lengthening in Congenital Femoral Deficiency

BACKGROUND

Hip stability remains a major preoccupation during femoral lengthening in Congenital Femoral Deficiency (CFD). We aimed to review hip stability in Paley type 1a CFD patients undergoing femoral lengthening.

METHODS

A total of 33 patients with unilateral CFD, who were treated between 2014 and 2023, were retrospectively reviewed. In 20/33 cases (60.6%) the SUPERhip preparatory surgery was performed at a mean age of 4.3 years (range 2.7-8.1). The femoral lengthening using an external fixator was performed at a mean age of 7.8 years (range 4.3-14.3).

RESULTS

All patients presented with a stable hip joint after preparatory surgery and during femoral lengthening. Six cases of hip instability at a mean of 637 days after the external fixator removal were observed (range 127 to 1447 days). No significant differences between stable and unstable hips were noted for (1) Center-Edge Angle: 23.7 vs. 26.1 deg; (2) Acetabular Inclination: 12.8 vs. 11.7 deg; and (3) Ex-Fix Index: 35.6 days/cm vs. 42.4 days/cm; p > 0.05. Late hip instability was related to Coxa Vara and decreased femoral antetorsion before lengthening.

CONCLUSIONS

Late hip joint instability in Paley type 1a CFD patients may occur long after femoral lengthening despite hip morphology appearing to be normal on radiograms before and at the end of femoral lengthening. Coxa Vara, femoral torsional deformity, and posterior acetabular deficiency might be risk factors for hip instability.

SUPERhip Reconstruction Treatment in Patients with Congenital Femoral Deficiency of Paley's Classification Type 1b

BACKGROUND

Congenital femoral deficiency (CFD) is a challenging and complex condition that causes limb lengthening. We focused on the clinical and radiographic results of SUPERhip procedures in patients with congenital femoral deficiency type 1b, according to Paley's classification, prior to femoral lengthening.

METHODS

We reviewed all records and radiographs of patients who underwent this procedure between 2005 and 2020. We included 26 patients, with clinical and radiographic assessments performed during pre- and post-operative evaluations.

RESULTS

There were twenty-six patients (15 right vs. 11 left), with a mean age of 7 years (1-18). Most of the patients were female (17 patients; 65.4%). Twenty (76.9%) patients were undergoing their first procedure and six (23.1%) had already undergone a previous surgery. There was a significant improvement in all radiographic parameters, with the mean preoperative and postoperative Neck-Shaft Angle (NSA) being 72.3 ± 7.1° vs. 133.1 ± 12.7°, the Center-Edge Angle (CEA) 16.8 ± 9.8° vs. 33.5 ± 14.1°, and the Acetabular Index (AI) 27.8 ± 6.9° vs. 16.4 ± 6.8°, respectively. The complication rate was 15.4%, predominantly affecting patients under 5 years old.

CONCLUSIONS

The SUPERhip procedure is an effective and reproducible technique for clinical and radiographic correction to a significant degree in patients with Paley's type 1b CFD, in preparation for bone lengthening surgery.

Reconstruction with tibial lengthening for limb length discrepancy in Crowe Type IV developmental dysplasia of hip in adulthood

BACKGROUND

Persistence of hip dysplasia into adolescence and adulthood can lead to an abnormal gait, which would do harm to patients' physiological and psychological health. The aim of this study was to summarize our results of tibial lengthening for reconstruction of limb length discrepancy in Crowe Type IV developmental dysplasia of hip in adulthood.

METHODS

Between January 2000 and December 2002, 11 patients' limb length discrepancy in Crowe Type IV developmental dysplasia of hip was treated by tibial lengthening. There were 8 women and 3 men, aged from 18 to 25 years, averaged 21.2 years. The limb length discrepancy was 4.0-7.1 cm.

RESULTS

Eleven patients were followed up for a mean of 110 months. The limping was much improved from a moderate or severe degree to a mild degree in all patients. In the group of callus distraction with external fixation, the average external fixation index was 37.0 days/cm. In the group of callus distraction over an intramedullary nail, the average external fixation index was 16.6 days/cm, and the mean radiographic consolidation index was 34.4 days/cm. The extent of lengthening ranged from 4.0 to 7.0 cm.

CONCLUSIONS

Tibial lengthening may be a reliable treatment for untreated unilateral developmental dysplasia of hip in adolescents without pain but eager for improving limping.

Current concepts of leg lengthening

Any lower limb discrepancy may be equalised by conservative means (insoles, prosthesis and orthosis). However, their long-term acceptance is low in regard to function, costs, expenditure and appearance. Timely epiphysiodesis is the best option in uniplanar deformities with adequate remaining growth and for patients whose predicted final body height is above the 50th percentile. However, many patients present late or with multi-planar deformities, which warrant more sophisticated operative approaches. The history of surgical bone lengthening comprises 100 exciting years of struggling, development and ongoing learning. The initial strategy of acute or rapid incremental distraction had lasted almost half a century until Ilizarov recognised the benefits of biological periosteum-preserving osteotomies and incremental lengthening at slow rates (1 mm/day) at a 4 × 0.25-mm daily rhythm, well appreciated as callotasis. In parallel, ring and wire constructs made complex three-dimensional axial, translational and rotational bone moulding possible. Taylor Spatial Frames-built on hexapod strut-linked platform technology as known from flight simulators-took limb correction to a more reliable, more precise and aesthetical level, all the more that the whole process became web-based. It represents state-of-the-art methodology and technology for complex, multi-plane deformities. Due to the significant risk of secondary malalignment, indications for lengthening by unilateral fixation have shrunken to moderate amounts of length disparity and uni- to bi-planar deformities in patients with still open physes. Mechanical or motorised, minimally invasively placed nails prevent muscle fixation and, therefore, ease rehabilitation, increase patient comfort and potentially shorten the overall time of sick leave and refrain from sports activities. Hence, they offer a valuable alternative for low-grade complexity situations. It remains to be proved if the significantly higher implant costs are compensated by lower treatment costs. Overall, limb lengthening, particularly in combination with multi-planar deformity correction, can still be an arduous endeavour. In any case, wise judgement of the patient's deformity, medical and biological situation, psychosocial environment, selection of the appropriate method and hardware, as well as meticulous operating technique by an experienced surgeon are the cornerstones of successful outcomes.

Hip dislocation during lengthening of congenital short femur

Hip dislocation is a serious but rarely reported complication of femoral lengthening in congenital short femora. We report a retrospective series of three hip dislocations that occurred during lengthening, analyze the factors contributing to the dislocation, and discuss the treatment of this difficult problem. The average lengthening achieved was 9 cm. We found progressive acetabular dysplasia and decreasing center edge angle. Closed reduction failed. Treatment included soft tissue release, open reduction with femoral shortening, and acetabular procedures. At a mean follow-up of 4.4 years, two patients had a good modified Mckay score and a modified Severin score of 3. Excessive lengthening should be avoided.

Hip and knee dislocation during femoral lengthening in congenital short femur: a rare case report

Congenital short femur is a rare and complex deformity that is often associated with other anomalies. There are few reports of either hip or knee dislocations during femoral lengthening in congenital short femur predisposed by associated anomaly. However, there are probably no case reports of both hip and knee joint dislocation occurring in same case during femoral lengthening in congenital short femur. We have this case of congenital short femur, where both hip and knee dislocation occurs during femoral lengthening. We reviewed different article to understand the cause and avoid such unwanted complications in future.

Bone lengthening with extra-articular arthrodesis of the hip using external fixation

This is a case series of 11 children and adolescents who underwent femoral lengthening and percutaneous hip arthrodesis using a method of extra-articular joint compression in combination with callotasis. Clinical review indicated a significant improvement in physical function and psychological well-being. The average lengthening was 5.3 cm or 16% of the initial length. Complications were more frequent in patients older than 14 years (P = 0.034) as was a higher maturation index (P = 0.021). No additional operations were required to achieve the surgical objective.

[Lengthening of proximal femoral focal deficiency using a hybrid fixation with inclusion of the knee joint]

BACKGROUND

A major problem in lengthening a short femur in proximal focal deficiency of the femur (PFFD) is the development of contractures and dislocation of the hip and knee joint. The knee joint is particularly prone to dislocation because of the cruciate ligament insufficiency associated with PFFD. Axis deviations also need specific attention.

PATIENTS AND METHODS

In four patients (age 2.5-11 years) with PFFD (PAPPAS class III in one patient and VII in three patients), five femoral lengthenings with mechanical axis corrections were performed by the callotasis technique using a hybrid fixation system (Monotube/Triax) connecting the femur and the tibia with a fixed hinged knee joint to protect the knee against contracture and dislocation.

RESULTS

All patients retained their hip and knee function. Hip flexion contracture during lengthening may make inclusion of the hip joint into the fixation system necessary, but was not carried out in the four patients presented.

CONCLUSION

Four consecutive lengthenings of the femur with focal deficiency were carried out under protection by a hinged knee bridging external fixator. A dislocation could be prevented in all patients. We consider that such a system could be used during these lengthening procedures.

Use of the Ilizarov method to correct lower limb deformities in children and adolescents

The introduction to the West in the early 1980s of the Ilizarov circular external fixator and method resulted in rapid advances in limb lengthening, deformity correction, and segmental long-bone defect reconstruction. The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov's contribution. The most common indications for children and adolescents are limb lengthening and angular deformity correction. Surgical application and postoperative management of the device require diligent attention to detail by both patient and surgeon. Also required of the surgeon is a thorough appreciation of the basic principles of the apparatus, mechanical axial realignment, potential complications, and biologic response to stretching.

Mandibular distraction osteogenesis using an intraoral device and bite plate for a case of hemifacial microsomia

OBJECTIVE

To present orthodontic treatment combined with mandibular distraction osteogenesis using an intraoral device and a bite plate in a patient with hemifacial microsomia, severe facial asymmetry, and unilateral mandibular hypoplasia.

PATIENT

An 8-year-old girl exhibited mandibular deviation resulting from hypoplasia of the mandibular condyle and ramus on the left side. The patient was treated with an intraoral device for mandibular distraction osteogenesis, bite plate, and hybrid-type functional appliance. Facial asymmetry was improved, and the mandibular ramus was elongated in an anterior and primarily posterior direction with slightly posterior and superior displacement of the proximal segment. Postdistraction treatment results have been stable for 1 year. At the 1-year follow-up, the volume of the lateral and medial pterygoid muscles on the left side had increased. The condyle and disc on the right temporomandibular joint moved well and in harmony at open mouth position, and a rotational movement of the left temporomandibular joint was observed.

Bilateral humeral lengthening in achondroplasia

Twenty humeral lengthenings were done on 10 achondroplastic dwarfs using the Ilizarov circular fixator. There were five female and five male patients from 6 years 11 months to 17 years 8 months of age (mean, 12 years 10 months) at the time of the operation. Mean length obtained was 7.8 cm (range, 3.5 cm-10 cm). External fixation time ranged from 105 days to 368 days (mean, 221 days). Healing index averaged 30 days/cm (27 days/cm when two patients with radial nerve palsy were excluded). Two half pins in one patient required replacement. Two humeral fractures occurred, one while in the fixator and the other after removal of the apparatus. Transient radial nerve palsy developed during lengthening in two patients, and lengthening was discontinued. Symptoms of radial nerve palsy resolved completely in both patients, but one patient required an additional surgery to explore the radial nerve for persistent paresthesia of the forearm. Although preexisting loose shoulders deteriorate during lengthening and sometimes cause pain and discomfort, they always resolve spontaneously as lengthening proceeds. Bilateral humeral lengthening was very effective for improving function and overall proportion in patients with achondroplasia.

Factors leading to hip subluxation and dislocation in femoral lengthening of unilateral congenital short femur

Congenital short femur is a rare and complex deformity. For it to be treated in the most accurate way, we must know of every possible complication. The purpose of this study was to determine the factors leading to hip subluxation or dislocation in patients with an unilateral congenital short femur who underwent a femoral lengthening procedure. Forty-four patients with congenital unilateral short femora types I, II, and IIIA were seen between 1981 and 1993 at Alfred I. duPont Hospital for Children. Seventeen patients had type I, 9 patients had type II, and 18 patients had type IIIA. Twenty patients underwent simultaneous lengthening of the femur and tibia, and 24 patients had primary lengthening of the femur. Eleven patients had an epiphysiodesis of the contralateral femur for residual leg length discrepancies of <6 cm. We observed that in patients with type IIIA, the acetabular dysplasia is severe, as well as the coxa vara deformity, and is associated with progressive subluxation and dislocation of the hip with lengthening. We believe that the combined abnormality of coxa vara and bow of the femoral shaft contributes to hip subluxation and dislocation in congenital short femur in association with an acetabular dysplasia prior to the lengthening. We recommend correction of the varus bow of the femur and the neck-shaft angle to 120 degrees and the acetabular index to <25 degrees prior to lengthening of type IIIA femora.

Distraction osteogenesis of the lower extremity with use of monolateral external fixation. A study of two hundred and sixty-one femora and tibiae

We reviewed the results of distraction osteogenesis of 114 femora and 147 tibiae that had been lengthened to treat a variety of diagnoses. The femora had been lengthened an average of eleven centimeters (range, 3.5 to 17.0 centimeters), or 48 per cent (range, 8 to 86 per cent) of the original femoral length. The average total time for the treatment of the femora (use of the fixator and any subsequent immobilization) was 257 days (range, 105 to 420 days). There were 114 complications related to the femoral lengthenings, which led to eighty-seven additional operations. The tibiae were lengthened an average of nine centimeters (range, 3.0 to 15.6 centimeters), or 41 per cent (range, 9 to 100 per cent) of the original tibial length. The average total time for the treatment of the tibiae was 268 days (range, 110 to 497 days). There were 196 complications related to the tibial lengthenings, which led to 219 additional operations. The Achilles tendon was lengthened during or after seventy-three (50 per cent) of the tibial lengthenings. The femoral lengthenings that were performed to treat a limb-length discrepancy were associated with significantly higher rates of complications overall (p = 0.010) and additional operations (p = 0.023) for each percentage of length gained than those that were performed to treat achondroplasia or another skeletal dysplasia. The femoral lengthenings that were performed to treat short stature (of an endocrine or idiopathic etiology) were also associated with higher rates of complications overall and additional operations than those performed to treat skeletal dysplasias, but the rates were lower than those for lengthenings performed to treat limb-length discrepancy. The rate of complications overall associated with femoral lengthening in patients who were fourteen years old or more was significantly higher than that associated with lengthening in patients who were less than fourteen years old (p = 0.047). Femoral lengthening through the metaphysis was associated with significantly higher rates of complications overall (p = 0.031) and additional operations (p = 0.042) for each percentage of length gained than femoral lengthening through the diaphysis. The tibial lengthenings that were performed to treat Turner syndrome and idiopathic short stature were associated with significantly higher rates of complications overall (p = 0.026) and additional operations (p = 0.003) for each percentage of length gained than those performed to treat skeletal dysplasias. The rate of joint-related problems (p = 0.044) and that of additional operations (p = 0.053) after tibial lengthening in patients who were fourteen years old or more were significantly higher than those rates after tibial lengthening in patients who were less than fourteen years old. The site of the tibial osteotomy did not affect the rate of complications or additional operations. The femoral healing indices (in terms of both days per centimeter [p = 0.002] and days for each percentage of length gained [p = 0.019]) were significantly higher in the patients who were fourteen years old or more than in those who were less the fourteen years old. These values could not be used to predict an increase in the complications because of poor bone formation. The results of the present review suggest that the use of healing indices to gauge the final outcome of distraction osteogenesis is questionable; we were unable to discern significance or clinical importance from appropriately adjusted values.

Femoral lengthening after type IVB septic arthritis of the hip in children

Septic arthritis of the hip in the newborn baby can result in severe long-term sequelae in the form of dislocation of the hip, loss of movement, and growth disturbance with leg-length discrepancy. For more severe discrepancies often with concomitant hip dislocation, no good solutions are readily available. This series comprised four patients with Choi's type IVB septic hip sequelae. They all had associated multiple-joint sepsis and resultant major leg-length discrepancies ranging from 6.9 to 14 cm. All underwent distraction lengthening with simultaneous correction of angulation and other deformities of the femur, three with the Ilizarov and one with the Orthofix system. The age at operation ranged from 9 to 13 years, with an average follow-up of 3 years. The overall lengthening achieved ranged from 4.5, 6.8, 12, to 13 cm, with the lengthening index from 24 to 51 days/cm. All hips remained stable, and the loss of range of hip and knee motion was not significant. Other complications included one deep pin-tract infection and one fracture of the callus.