Limb lengthening history, evolution, complications and current concepts

Stature seekers: Cosmetic limb lengthening in medical tourism a case report

This case report details orthopaedic cosmetic surgery tourism, an emerging trend where individuals seek orthopaedic cosmetic procedures abroad. While this practice is increasingly common, it lacks regulation, potentially endangering patients. Factors driving this trend include rising healthcare costs and lengthy waitlists in public healthcare systems. Patients often pursue surgery abroad to save costs, or access specialised procedures not available domestically. However, complications can arise, necessitating costly management back home. Surgeons may face challenges due to unfamiliarity with overseas care, while patients encounter language barriers and variations in medical standards. This case report highlights a 28-year-old male who underwent bilateral limb lengthening surgery in Turkey, experiencing serious complications. While existing data on cosmetic tourism mainly focuses on plastic and bariatric surgeries, documentation specific to orthopaedic cases is limited. This report underscores the need for further research and regulation in this rapidly growing field, to ensure patient safety and optimal outcomes.

Meeting report from the 3rd ISCBH-ERN BOND Achondroplasia Workshop on Long Bone Pathology in Children with Achondroplasia, Salzburg, Austria 22nd June 2024

A pre-meeting workshop on Long Bone Pathology in Children with Achondroplasia was held in Salzburg, Austria at the 11th International Conference on Children's Bone Health (ICCBH) 22-25 June 2024. There remains poor understanding and awareness amongst physicians managing achondroplasia of the underlying pathophysiology, radiology, natural history and orthopaedic procedures available for long bone deformities and restrictions. The structure of the workshop consisted of presentation of the results of a multinational patient survey on views of leg lengthening in achondroplasia, lectures, a debate and an interactive round table discussion. In total 150 attendees from 71 different cities and 31 countries were in attendance.

Bilateral humeral lengthening and deformity correction with hexapod external fixator in an achondroplastic patient: A case report

INTRODUCTION AND IMPORTANCE

Achondroplasia, a prevalent skeletal dysplasia, often results in limb asymmetry and functional limitations, typically managed surgically with bone lengthening techniques.

CASE PRESENTATION

We present the case of a 10-year-old girl with achondroplasia who underwent bilateral humeral lengthening using hexapod external fixators. The patient, previously treated for lower limb lengthening, exhibited significant upper limb shortening affecting daily activities. Surgical intervention involved two stages, employing two hexapod external fixators for precise correction and lengthening. Symmetrical lengthening of 6 cm in both humeri was achieved without major complications. Follow-up assessments revealed improved functionality and satisfactory outcomes, emphasizing the importance of addressing upper limb deformities in achondroplasia patients.

CLINICAL DISCUSSION

While humeral lengthening is less common than lower extremity lengthening due to historical concerns about neurovascular complications and functional implications, recent advancements highlight its potential benefits, particularly in achieving functional and aesthetic balance.

CONCLUSION

This case highlights the efficacy and safety of hexapod fixators in achieving multiplanar correction and functional improvement in upper limb lengthening. Further investigation should be carried out to study broader application in similar cases.

PRECICE nail bending in femur lengthening

Intro

Intramedullary nails (ILNs) are commonly used in orthopedic surgery for the fixation of long bone fractures and limb lengthening. Understanding the structural mechanics (i.e. nail bend) of an ILN device is crucial in determining its performance under various loading conditions. Furthermore, nail diameter was found to play a key role in an ILN's susceptibility to plastic deformity. This study aims to investigate the degree of nail bending and incidence of plastic deformity in patients receiving antegrade femoral ILNs (PRECICE, NuVasive, Inc.).

Methods

Retrospectively evaluated 130 ILNs (PRECICE, NuVasive, Inc.) in 100 adult patients who underwent limb lengthening done in a single center. Patients who had concomitant osteotomies, tibial lengthening, malunion, non-union, mechanical failure, or revision surgery for any reason were excluded. All nails were inserted through the greater trochanter or piriformis. Patients' age, weight, height, and body mass index (BMI)were extracted. Radiologic assessments involved analyzing long lower limb standing X-rays before, during, and at consolidation for total distraction and nail bend. Naildiameter and patient characteristics were directly sourced from medical records.

Results

Nail bend at consolidation averaged 2.4° (SD 2.4), ranging from 0 to 9. Additionally, total femoral lengthening was assessed, with a mean value of 5.3 cm (SD 2.1). A significant positive association was observed in the nail bend and weight (weight in kg/nail diameter in mm) coefficient (P < 00.01). Bilateral limb lengthening was also correlated to increase nail bend (P < 00.05).

Conclusion

Patient's weight to nail diameter ratio and bilateral limb lengthening were found to be significant factors affecting nail bend. These findings advance our understanding of the interrelation between the nail biomechanical profile and the patient's physical attributes, offering important implications for limb lengthening.

Level of evidence

III.

Finite element analysis of distraction osteogenesis with a new extramedullary internal distractor

Distraction osteogenesis (DO) is a bone regenerative maneuver, which is conventionally done with external fixators and, more recently, with telescopic intramedullary nails. Despite the proven effectiveness, external approaches are intrusive to the patient's life while intramedullary nailing damages the growth plates, making them unsuitable for pediatric patients. An internal DO plate fixator (IDOPF) was developed for pediatric patients to address these limitations. The objective of this study was to test the hypothesis that the IDOPF can withstand a partial weight bearing scenario and create a favorable mechanical microenvironment at the osteotomy gap for bone regeneration as the device elongates. A finite element model of a surrogated long bone diaphysis osteotomy fixation by means of the IDOPF was created and subjected to axial compression, bending and torsion. As the osteotomy gap increased from 2 mm to 20 mm, under compression, The average axial interfragmentary strains decreased from 2.33% to 0.35%. Stress increased from 179 MPa to 281 MPa at the contact interfaces of the telescopic compartments, which exceeded the endurance limit of stainless steel (270 MPa) but was below its yield limit (415 MPa). These results demonstrate, that the IDOPF can withstand a partial load bearing scenario and provide a stable biomechanical environment conductive to bone healing. However, high contact stresses at the telescopic interfaces of the device are likely to cause wear, as is frequently reported in telescopic fixators. This study is a step towards refining the IDOPF design for clinical use.

Comparison of free vascularized fibular grafts and the Masquelet technique for the treatment of segmental bone defects with open forearm fractures: a retrospective cohort study

PURPOSE

Severe open forearm fractures commonly involve segmental bone defects. Although several methods have been proposed to treat segmental bone defects with such fractures, research comparing the radiological and clinical outcomes of free vascularized fibular grafts (FVFG) and the Masquelet technique (MT) is rare.

METHODS

Data on 43 patients with open forearm fractures and segmental bone defects treated surgically in our hospital from January 2005 to January 2021 were retrospectively analyzed, and these patients were divided into an FVFG group (18 cases) and an MT group (25 cases). Clinical and radiological evaluations were performed regularly, and the minimum follow-up was 18 months.

RESULTS

All 43 patients were followed up for 18 to 190 months, with a mean of 46.93 months. The mean follow-up time was significantly longer in the FVFG group than in the MT group (p = 0.000). Bone healing time was 3-16 months, with a mean of 4.67 months. The QuickDASH score at the last follow-up was 0-38.6, with a mean of 17.71, and there was no statistically significant difference between the two groups. Operative time, hospital stay, and intraoperative bleeding for bone defect reconstruction were higher in the FVFG group compared to the MT group (p = 0.000), whereas the number of procedures was lower in the FVFG group than in the MT group (p = 0.035).

CONCLUSIONS

FVFG and the MT showed satisfactory clinical results for segmental bone defects of the forearm. Compared with FVFG, the MT exhibited a lower operative time, hospital stay, and intraoperative bleeding.

LEVEL OF EVIDENCE

Level IV. Trial registration This study was registered in the Chinese Clinical Trial Registry (registration no. ChiCTR2300067675; registered 17 January 2023), https://www.chictr.org.cn/showproj.html?proj=189458 .

International expert opinion on the considerations for combining vosoritide and limb surgery: a modified delphi study

BACKGROUND

Achondroplasia is the most common form of skeletal disorder with disproportionate short stature. Vosoritide is the first disease-specific, precision pharmacotherapy to increase growth velocity in children with achondroplasia. Limb surgery is a standard approach to increase height and arm span, improve proportionality and functionality, as well as correcting deformities. The aim of this study was to gain expert opinion on the combined use of vosoritide and limb surgery in children and adolescents with achondroplasia.

METHODS

An international expert panel of 17 clinicians and orthopaedic surgeons was convened, and a modified Delphi process undertaken. The panel reviewed 120 statements for wording, removed any unnecessary statements, and added any that they felt were missing. There were 26 statements identified as facts that were not included in subsequent rounds of voting. A total of 97 statements were rated on a ten-point scale where 1 was 'Completely disagree' and 10 'Completely agree'. A score of ≥ 7 was identified as agreement, and ≤ 4 as disagreement. All experts who scored a statement ≤ 4 were invited to provide comments.

RESULTS

There was 100% agreement with several statements including, "Achieve a target height, arm span or upper limb length to improve daily activities" (mean level of agreement [LoA] 9.47, range 8-10), the "Involvement of a multidisciplinary team in a specialist centre to follow up the patient" (mean LoA 9.67, range 7-10), "Planning a treatment strategy based on age and pubertal stage" (mean LoA 9.60, range 8-10), and "Identification of short- and long-term goals, based on individualised treatment planning" (mean LoA 9.27, range 7-10), among others. The sequence of a combined approach and potential impact on the physes caused disagreement, largely due to a lack of available data.

CONCLUSIONS

It is clear from the range of responses that this modified Delphi process is only the beginning of new considerations, now that a medical therapy for achondroplasia is available. Until data on a combined treatment approach are available, sharing expert opinion is a vital way of providing support and guidance to the clinical community.

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.

Aquatic therapy in congenital malformation during the use of external fixator for bone lengthening: It is possible?

OBJECTIVES

The objective of this study is to describe the rehabilitation of individuals with Congenital Malformations (CMF) during the use of an External Fixator (EF) in Aquatic Therapy (AT) and to analyze the association between diagnosis, EF type and location with rehabilitation process outcomes, surgical intervention, and adverse effects.

METHODS

This retrospective study included 29 medical records from which the personal and rehabilitation data of the patient were collected. The AT used was described and the outcome variables were associated. The medical records were selected by screening the database of the CMF clinic at the AACD. The inclusion criteria were participants with CMF who used EF treated between 2011 and 2019 of both genders and without age restriction. The exclusion criteria were incomplete medical record data or not undergoing AT while using EF. The extracted data included diagnosis, gender, age, EF type and location, objective of the surgery, adverse events, surgical interventions, time of rehabilitation in AT, physiotherapeutic objectives, and rehabilitation process outcomes in AT.

RESULTS

The mean age of the participants was 12.1 ± 3.99 years, with male predominance (55 %) and hemimelia cases (37 %). The most used EF was circular (51 %), located in the femur (37 %), and the main objective of surgery was bone lengthening (52 %). The most recurrent adverse effect was infection (62 %) and 76 % completed AT. There was no association between the variables analyzed.

CONCLUSIONS

It was possible to describe CMF rehabilitation with EF in AT. There was no association between the variables analyzed.

Physiotherapy assessment and treatment of patients with tibial external fixator: a systematic scoping review

PURPOSE

To map evidence regarding physiotherapy assessment and treatment of patients with tibial external fixator (EF), and to point out literature gaps for further research.

METHODS

Systematic scoping review conducted in four databases. We included both experimental and non-experimental studies involving patients with tibial EF and outcomes of interest. We recorded study design, population, sample size, sample age, reason for EF use, type of surgery, type of EF used, instruments used for assessing function, pain, quality of life, satisfaction, psychosocial aspects, and physiotherapy treatment descriptions from included studies. We categorised data accordingly to outcomes assessed and physiotherapy treatments description.

RESULTS

Eighty-six studies were included involving 3070 patients. Causes of fixator use were traumatic conditions, acquired and congenital deformities, and non-traumatic conditions, like compartmental osteoarthritis. Function was assessed in about three-quarters of included studies, though other outcomes were not presented in most studies. Only one study described satisfactorily the physiotherapy treatment. Almost half of the studies did not provide any description of the rehabilitation process.

CONCLUSIONS

There is little evidence about the assessment of function, pain, quality of life, satisfaction, psychosocial aspects, and other outcomes in tibial EF patients. Physiotherapy treatment in these patients is poorly reported.Protocol registration: Open Science Framework: doi:10.17605/OSF.IO/UT2DA.

Quality of Life in Children With Achondroplasia Undergoing Paired Limb Lengthening With an External Fixator and Modified Distraction Control: Observational Nonrandomized Study

BACKGROUND

Transosseous distraction osteosynthesis is prioritized in orthopedic care for children with achondroplasia. However, difficulties encountered during treatment and rehabilitation directly impact patients' quality of life. Using rod external fixators within a semicircular frame for osteosynthesis is less traumatic compared to spoke circular devices. Their straightforward assembly and mounting on the limb segment can help significantly reduce treatment duration, thereby improving children's quality of life during treatment and rehabilitation.

OBJECTIVE

This study aimed to conduct a comparative analysis of the quality of life (measured by postoperative pain syndrome, physical activity, and emotional state) among children with achondroplasia undergoing paired limb lengthening using either an external fixator with modified distraction control or a circular multiaxial system developed by the authors.

METHODS

This was an observational, prospective, nonrandomized, and longitudinal study with historical control. The study group consisted of 14 patients ranging from 5 to 15 (mean 7.6, SD 2.3) years old with a genetically confirmed diagnosis of achondroplasia. All patients underwent paired limb lengthening with a rod external fixator and a modified distraction control developed by the authors. A total of 28 limb segments, among them 4 (14%) humeri, 8 (29%) femurs, and 16 (57%) tibias, were lengthened in 1 round. Unpublished data from the previous study served as the control group, comprising 9 patients (18 limb segments) of the same age group (mean age at surgery 8.6, SD 2.3 years), who underwent limb lengthening surgery using a circular multiaxial system-2 (11%) humeri, 6 (33%) femurs, and 10 (56%) tibias. The Wong-Baker Faces Rating Scale was used to measure pain symptoms, while the Russified Pediatric Quality of Life (PedsQL) v4.0 questionnaire assessed quality of life.

RESULTS

During the latent phase (7 to 10 days after surgery), a more pronounced decrease in the indicators of physical activity and emotional state on the PedsQL v4.0 questionnaire was noted in the control group (mean 52.4, SD 4.8 versus mean 52.8, SD 5.5 points according to children's responses and their parents' responses, respectively) compared to the experimental group (mean 59.5, SD 6.8 points and mean 61.33, SD 6.5 points according to the children's responses and their parents' responses, respectively). The differences between the groups were statistically significant (P<.05 for children's responses and P<.01 for parents' responses). Importantly, 6 months after surgery, these quality-of-life indicators, as reported by children in the experimental group, averaged 70.25 (SS 4.8) points. Similarly, their parents reported a mean of 70.54 (SD 4.2) points. In the control group, the corresponding values were 69.64 (SD 5.6) and 69.35 (SD 6.2), respectively. There was no statistically significant difference between the groups.

CONCLUSIONS

The external fixator with modified distraction control developed by the authors provides a higher standard of living compared with the circular multiaxial system during the latency phase.

Vosoritide Therapy in Children with Achondroplasia: Early Experience and Practical Considerations for Clinical Practice

INTRODUCTION

Vosoritide is the first precision medical therapy approved to increase growth velocity in children with achondroplasia. Sharing early prescribing experiences across different regions could provide a framework for developing practical guidance for the real-world use of vosoritide.

METHODS

Two meetings were held to gather insight and early experience from experts in Europe, the Middle East, and the USA. The group comprised geneticists, pediatric endocrinologists, pediatricians, and orthopedic surgeons. Current practices and considerations for vosoritide were discussed, including administration practicalities, assessments, and how to manage expectations.

RESULTS

A crucial step in the management of achondroplasia is to determine if adequate multidisciplinary support is in place. Training for families is essential, including practical information on administration of vosoritide, and how to recognize and manage injection-site reactions. Advocated techniques include establishing a routine, empowering patients by allowing them to choose injection sites, and managing pain. Patients may discontinue vosoritide if they cannot tolerate daily injections or are invited to participate in a clinical trial. Clinicians in Europe and the Middle East emphasized the importance of assessing adherence to daily injections, as non-adherence may impact response and reimbursement. Protocols for monitoring patients receiving vosoritide may be influenced by regional differences in reimbursement and healthcare systems. Core assessments may include pubertal staging, anthropometry, radiography to confirm open physes, the review of adverse events, and discussion of concomitant or new medications-but timing of these assessments may also differ regionally and vary across institutions. Patients and families should be informed that response to vosoritide can vary in both magnitude and timing. Keeping families informed regarding vosoritide clinical trial data is encouraged.

CONCLUSION

The early real-world experience with vosoritide is generally positive. Sharing these insights is important to increase understanding of the practicalities of treatment with vosoritide in the clinical setting.

First Clinical Case of Ilizarov Femur Lengthening over a Bioactive and Degradable Intramedullary Implant

Introduction

The Ilizarov distraction osteogenesis is a recognized method of limb lengthening in orthopaedic practice. Its most challenging problems are long duration of external fixation and related pin-tract infection and joint contractures. The solution might be the use of a bioactive degradable intramedullary implant stimulating bone healing. Case Presentation. We present a case of a 14-year-old boy with 6 cm posttraumatic shortening of the femur and associated varus deformity of 20 degrees. He was treated with the Ilizarov technique of femur lengthening over an intramedullary degradable polycaprolactone (PCL) implant with hydroxyapatite (HA) filling. We faced no complications within the lengthening process. Shortening and deformity of the femur were corrected in 90 days. The index of external fixation was 15 days/cm. External fixation time was reduced almost twice comparing to the conventional method. Degradable intramedullary nails ensured the advantage of avoidance of the removal procedure. Radiography and CT confirmed faster new bone healing and remodeling.

Conclusion

The combined lengthening technique over a PCL/HA implant might be used to shorten external fixation time and to stimulate bone healing especially in patients with compromised bone. Using a bioabsorbable material presents the benefit of eliminating the need for a second surgery to remove the nail, thereby reducing soft tissue damage.

Neglected war injuries: Reconstruction versus amputation

INTRODUCTION

War injuries are remarkably different situations with profound severity and significant contamination compared to civilian injuries. Delayed definitive management makes the situation much more complicated. This study aimed to report the outcomes of limb reconstruction of neglected war injuries with a previous decision of amputation.

PATIENTS AND METHODS

From 2010 to 2021, 1104 patients with war-related fractures from conflict-zone countries were referred to our center including 589 open tibial fractures. Of these tibial fractures, amputation had already been decided in 54 cases, and the patients were looking for a trial of reconstruction and avoiding amputation. These cases were included in the current study. The treatment approach was a single-stage procedure with bone and soft tissue reconstruction.

RESULTS

This study included 54 male patients with a mean age of 26.3 years. Infection was the predominant feature in 43 cases (79.6 %). CT angiography revealed a one-vessel limb in 17 patients. Peripheral nerve injuries affected 15 patients. The mean time from injury to presentation was 8.5 weeks. The bone gap (2-13 cm) was evident in 44 cases. In four cases, the contralateral limb was amputated below the knee. There were associated injuries in nine cases. Rotational flap coverage was done in the same setting for 19 legs. Gastrocnemius flap was done in two cases. The mean follow-up duration was 45.1 months. The treatment methods included bifocal management (33 cases), trifocal management (17 cases), fibular transfer (two cases), and a mono-focal approach in two cases. All fractures healed successfully. The mean external fixation period was 7.6 months. Recurrence of infection occurred in three patients. A non-displaced refracture developed in one case. Five cases had a residual angular deformity. Eventually, the ASAMI bone and functional results were good in all cases.

CONCLUSIONS

Neglected war injuries constitute a complex problem where amputation may be indicated. Our approach includes one-stage limb reconstruction with the corticotomy-first technique, conservative debridement of the docking site, concomitant osteoplastic procedure, and gradual distraction to tackle all the aspects of the problem. The good results obtained in the presented series make it a valid approach to avoid amputation in neglected war injuries.

Results and complications of bilateral limb lengthening in achondroplasia: a retrospective analysis

Background

Achondroplasia is one of the main causes of disharmonic dwarfism. Patients with achondroplasia might have physical and psychological limitations due to their disproportionate stature. Surgical limb lengthening is the only practical option available to achieve a stature comparable to normal population range. The purpose of this study is to analyze results and complications of our lengthening protocol.

Methods

A retrospective analysis was performed on 33 patients with achondroplasia (21 females and 12 males) undergoing simultaneous bilateral tibia or femur lengthening in four surgical stages from 2017 to 2021 (46 lengthening procedures, with a total of 56 tibias and 36 femurs). For each patient, patients' characteristics and antero-posterior and lateral radiographs were obtained. The following parameters were analyzed: duration of lengthening with external fixator, amount of lengthening, complications or events that influenced outcomes and the healing index (HI).

Results

The average tibial and femoral gain was 7.9 cm and 6.9 cm, respectively. The tibiae achieved better results than the femurs (p = 0.005). Nineteen complications were reported for 92 segments (20.7%), and the variables influencing complications were: step (p = 0.002) and fixation duration (p = 0.061).

Conclusions

Bilateral parallel lower limb lengthening in four surgical steps may be a viable technique in patients with achondroplasia.

Ulnar osteotomy and monolateral external fixator for the treatment of chronic Monteggia fractures in children: comparison between gradual and acute radial head reduction

This study evaluated the outcomes of chronic Monteggia fractures (CMFs) treated by ulnar osteotomy and monolateral external fixator (MEF), and compare the outcome of gradual versus acute radial head reduction. Two groups of patients were identified. Group 1: gradual reduction of the radial head ( n = 13); group 2: acute reduction ( n = 6). Clinical outcome was evaluated by Kim Elbow Score, whereas radiographic outcome was assessed on plain radiographs. The effect of age, side, time from initial trauma to surgery, rate of unplanned surgery, amount of angulation and lengthening, and final outcome were evaluated. Univariate analysis was performed to identify factors associated with good radiographic outcome. Thirteen patients underwent gradual correction of the ulna. The mean duration of correction was 43.4 days (range, 21-82); the mean angulation and lengthening of the ulna were 22.8° (range, 0°-35°) and 22.2 mm (range, 12.2-40.9), respectively. Six patients underwent acute reduction intraoperatively, the mean angulation and lengthening of the ulna were 17.2° (range, 4°-33.9°) and 5.2 mm (range, 2.5-12.2), respectively. CMF treated by ulnar osteotomy and gradual distraction had better radiological outcome (Group 1; 92.3% 12/13) than those treated by acute reduction of the radial head (Group 2; 3/6, 50%) ( P = 0.071). Reoperation rate was found to be significantly correlated with a fair or poor radiographic results ( P = 0.016). Good clinical and radiological outcomes should be expected in CMF patients treated by gradual lengthening and angulation of the ulna with a MEF.

PRECICE nail for the management of posttraumatic bone defects with nonunion or malunion: Experience from a Latin American center

BACKGROUND

To evaluate the clinical outcomes using the PRECICE magnetic limb lengthening intramedullary nail for the correction of lower limb length discrepancies (LLD) in adults with posttraumatic nonunion or malunion defects in a Latin American center.

METHODS

A retrospective review of 25 adult patients with LLD associated with posttraumatic nonunion or malunion defects of femur or tibia treated with the PRECICE nail between January 2018 and December 2020. The primary outcomes considered were lengthening length achieved in mm, incidence of complications and quality of life (EQ-5D-3 L questionnaire).

RESULTS

Twenty-five cases (20 femoral and 5 tibial nails) were performed, with a median follow-up of 27 months (Interquartile range-IQR: 17.5 to 34.5). The average age was 36.5 ± 12.9 years; 10 cases were women. Fifteen cases had an LLD secondary to a malunion defect and 10 cases had an LLD secondary to a nonunion. PRECICE nails were inserted for the treatment of a median LLD of 40.0 mm (IQR: 30.2 to 74.2) in the femur and 30.0 mm (28.5 to 50.0) in the tibia. An accuracy of 100% was reported in 18 cases (Femur: 14 and tibia: 4) and consolidation was achieved in 22/25 cases with the PRECICE nail in situ. Complications were recorded in 9 (36%) cases (6/20 femur, 3/5 tibia), mainly related to the consolidation process (5/9). The median EQ-5D and EQ-VAS were 0.79 (IQR: 0.63 to 0.79) and 80.0 (IQR: 50.0 to 90.0), respectively.

CONCLUSIONS

The results of this study demonstrated that the PRECICE nail is an effective device for the management of posttraumatic LLD during the treatment of nonunion or malunion bone defects of femur and tibia, offering a reasonable quality of life, despite its postoperative complication risk.

Safety and Complication Rate of Ring External Fixation in the Foot and Ankle

External fixation is a powerful tool for foot and ankle surgeons. Currently, there is no consensus on true complication rate. The purpose of this study was to report our institution's complication rate of ring external fixation performed by a single surgeon. We retrospectively evaluated electronic medical record of 224 patients with 238 circular frames between 2009 and 2021 at a single institution. Minor complications were defined as a frame managed without early frame removal or return to operating room. Major complications were defined as early return to operative room or early removal defined by our institution as less than 2 months. We recorded over 1642 Ilizarov wires and 278 half pins; 10% (n = 163) of wires and 7% (n = 19) of half pins had a complication. We recorded 44% (n = 104) minor complications and 9% (n = 22) major complications. Minor complications average (mean) onset was 4 weeks, 89% (n = 93) involved wires, and 73% resolved without additional care. Major complications average (mean) onset was 3.7 weeks. Of these, 32% (n = 7) went on to successful revision. This revealed a significant correlation between minor complications and history of osteomyelitis (p < .05). While minor complications do appear high, this was due to wire irritation and local erythema which resolved without additional intervention. To better assess complications with external fixation the authors believe that wire irritation and pin site erythema should be recognized as an expected outcome. A better understanding of ring external fixation in foot and ankle surgery is vital to appropriate perioperative management and patient care.

How pain affect real life of children and adults with achondroplasia: A systematic review

The clinical features of achondroplasia can cause acute self-limited pain that can evolve into chronic pain. Pain causes a low quality of life, in terms of physical, emotional, social, and school functioning in both adult and children with achondroplasia. We conducted a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement to describe prevalence, assessment tools, causes and management strategies of pain in this rare disease. We found that shoulder and knee pain is typically referred during infancy, while knee pain is generally referred around 5-6 years of age. The prevalence of general pain in adolescence can be as high as 90%. Chronic pain in the achondroplasia population increases with age, with up to 70% of adults reporting general pain and back pain. Recognizing the multiple determinants of acute and chronic pain in patients with achondroplasia may enable physicians to better understand and manage this burden, particularly with the advent of new drugs that may modify some of the striking features of achondroplasia.

A Novel Electromechanical Intramedullary Nail System for Limb Lengthening

Background/Purpose of the Study

Many methods have been developed to treat leg length discrepancies. Extensible intramedullary nails are the most commonly used systems. However, complications such as excessive distraction, blockage of the nail, aditional surgery, uncontrolled lengthening and much pain occur during the use of these systems, and the desired success rate cannot be achieved. This study aims to develop a new extensible intramedullary system with two mechanisms (electronical and mechanical) for femur and tibia that treats leg length inequalities in a way that allows lengthening without complications as much as possible and does not require a second surgical intervention. It was planned to perform basic mechanical and cadaver functional tests of the new system, which will be designed and developed for this purpose.

Methods

The 3D design of the system has been completed with 3D computer software. A compact system has been developed that is mechanically activated by sudden axial loading and electronically activated by a controllable electric motor. Basic mechanical and functional tests of the new system have been performed within a cadaver.

Results

The rapid prototype of the system with electronical and mechanical units has been produced. As a result of the mechanical tests (axial loading), the nail was found to be resistant to compression forces. Its application to the cadaver and function tests was successfully performed.

Conclusions

We believe that the system we have developed will have advantages, such as working principle, ease of application, controlled lengthening, patient mobility compared to existing leg lengthening methods. The success of the system in practice will be evaluated by in-vivo animal experiments after more detailed mechanical experiments on cadavers. According to the results, it will be ready for human use by performing necessary restorations.

Distraction osteogenesis at the site of neutral wedge ostectomy for angular limb deformity in the hind limb in 2 young dogs

Our objective was to report the use of distraction osteogenesis at the site of angular limb deformity correction using external skeletal fixation for treatment of 1 femoral and 1 tibial angular limb deformity in 2 large-breed puppies. Medical records were reviewed from 2 dogs (a 7-month-old intact male golden retriever and a 4-month-old intact female German shepherd mixed breed) diagnosed with angular limb deformities and truncation of a pelvic limb. Surgical treatment consisted of neutral wedge ostectomy and distraction osteogenesis at the site of bone deformity with an external skeletal fixator (ESF). The surgical technique and postoperative period of distraction osteogenesis were reviewed along with postoperative complications and clinical outcomes after complete bone healing was evident radiographically. Both dogs had adequate bone formation during distraction osteogenesis and the ESFs remained intact and structurally stable. At ESF removal, femoral length had increased 2.6 cm for Dog 1 and tibial length increased 3.88 cm for Dog 2, distal femoral valgus improved 16.3 degrees for Dog 1, and tibial procurvatum improved 19.5 degrees and distal tibial valgus improved 6.2 degrees for Dog 2. At the last follow-up examinations, 5 mo (Dog 1) and 3 mo (Dog 2) postoperatively, both dogs were ambulating without any visible lameness. Key clinical message: Acute angular correction and subsequent distraction osteogenesis at the site of bone deformity and corrective ostectomy using an ESF enabled successful treatment of femoral (Dog 1) and tibial (Dog 2) truncation and angulation in 2 large-breed puppies. Optimal deformity correction and lengthening were achieved through distraction osteogenesis at the site of neutral wedge ostectomy, minimizing soft tissue dissection and risk for potential complications that can occur with bifocal deformity correction (i.e., correction of the deformity at 1 osteotomy/ostectomy and correction of bone length at another, remote osteotomy).

Beyond the gut: spectrum of magnetic surgery devices

Since the 1970s, magnetic force has been used to augment modern surgical techniques with the aims of minimizing surgical trauma and optimizing minimally-invasive systems. The majority of current clinical applications for magnetic surgery are largely centered around gastrointestinal uses-such as gastrointestinal or bilioenteric anastomosis creation, stricturoplasty, sphincter augmentation, and the guidance of nasoenteric feeding tubes. However, as the field of magnetic surgery continues to advance, the development and clinical implementation of magnetic devices has expanded to treat a variety of non-gastrointestinal disorders including musculoskeletal (pectus excavatum, scoliosis), respiratory (obstructive sleep apnea), cardiovascular (coronary artery stenosis, end-stage renal disease), and genitourinary (stricture, nephrolithiasis) conditions. The purpose of this review is to discuss the current state of innovative magnetic surgical devices under clinical investigation or commercially available for the treatment of non-gastrointestinal disorders.

Osmotic pump with potential for bone lengthening distracts continuously in vitro and in vivo

BACKGROUND

In pediatric orthopedics, long bone lengthening procedures are routinely performed using manual, motorized or magnetically controlled implants. This study aims to prove expansion of a newly designed osmotic pump prior to long bone lengthening in living organisms and to rule out any complications related to in vivo conditions, such as congestion of the semipermeable membrane, local infection, or lack of water to drive the osmotic pump, as well as to compare in vivo and in vitro expansion data.

METHODS

Osmotic pumps, which were designed to distract a plate osteosynthesis, were inserted in the dorsal paraspinal musculature of four piglets. To compare the performance of the pumps in in vivo and in vitro conditions, another set of pumps was submerged in physiologic saline solution at different temperatures. The lengthening progress was measured radiographically and sonographically in the study animals.

RESULTS

Both, in vitro and in vivo tested osmotic pumps started distraction after an intended rest phase of four days and distracted evenly over the following twelve days. No complications, clogging or damages occurred. However, we observed a temperature dependency of the distraction rate ranging from 0.98 mm/day at 39°C to 1.10 mm/day at 42°C. With a second setup, we confirmed that the distraction rate differed by 72% within a measured temperature interval of 14° C.

CONCLUSIONS

The data presented here confirm that the novel osmotic pump showed comparable lengthening characteristics in vivo and in vitro. No complications, such as congestion of the semipermeable membrane, local infection, or lack of water to drive the osmotic pump were observed. Thus, osmotic pumps may have great potential in future applications such as long bone lengthening procedures, where continuous distraction probably provides a better bone quality than intermittent lengthening procedures. The fact that one pump failed to elongate in each condition, highlights the importance of technical improvement, but also demonstrates that this was not due to different circumstances within the in vivo or in vitro condition.

[Possibilities of orthopedic technical care for extremity lengthening and reconstruction]

BACKGROUND

Orthopedic technical care plays a crucial role in improving function and mobility for patients undergoing limb lengthening and reconstruction. The treatment strategy is based on a precise classification of the defect, taking into account factors such as joint instability, muscle pathology and limb length discrepancy.

CHOICE OF AIDS

The selection of orthopedic aids depends on the specific deformity, its classification and the individual needs of the patient. Through interdisciplinary decision-making and customized adaptations of prostheses and orthoses, optimal function and aesthetically pleasing outcomes can be achieved. The utilization of custom-made technical components, such as traction devices combined with elastic liners, is essential for long-term treatment success and can support surgical interventions. The treating physician's expertise is crucial in selecting the appropriate orthopedic technical device following limb lengthening and reconstruction.

Burden and Treatment of Achondroplasia: A Systematic Literature Review

BACKGROUND

Achondroplasia is the most common form of skeletal dysplasia. Recent advances in therapeutic options have highlighted the need for understanding the burden and treatment landscape of the condition. This systematic literature review (SLR) aimed to identify health-related quality of life (HRQoL)/utilities, healthcare resource use (HCRU), costs, efficacy, safety and economic evaluation data in achondroplasia and to identify gaps in the research.

METHODS

Searches of MEDLINE, Embase, the University of York Centre for Reviews and Dissemination (CRD), the Cochrane Library and grey literature were performed. Articles were screened against pre-specified eligibility criteria by two individuals and study quality was assessed using published checklists. Additional targeted searches were conducted to identify management guidelines.

RESULTS

Fifty-nine unique studies were included. Results demonstrated a substantial HRQoL and HCRU/cost-related burden of achondroplasia on affected individuals and their families throughout their lifetimes, particularly in emotional wellbeing and hospitalisation costs and resource use. Vosoritide, growth hormone (GH) and limb lengthening all conferred benefits for height or growth velocity; however, the long-term effects of GH therapy were unclear, data for vosoritide were from a limited number of studies, and limb lengthening was associated with complications. Included management guidelines varied widely in their scope, with the first global effort to standardise achondroplasia management represented by the International Achondroplasia Consensus Statement published at the end of 2021. Current evidence gaps include a lack of utility and cost-effectiveness data for achondroplasia and its treatments.

CONCLUSIONS

This SLR provides a comprehensive overview of the current burden and treatment landscape for achondroplasia, along with areas where evidence is lacking. This review should be updated as new evidence becomes available on emerging therapies.

Tibial Bone Transport With a Single Implant All-Internal Bone Transport Nail

SUMMARY

A single implant all-internal magnet-driven bone transport nail (BTN-NuVasive Specialized Orthopaedics Inc) has recently been introduced as a treatment method for segmental tibial bone defects. This innovation provides promise in the management of segmental bone defects because it negates numerous complications associated with circular external fixation and the need for multiple implants when considering hybrid plate-assisted bone segment transport constructs. Given the novelty of the BTN, description of the surgical application and patient outcome measures are scarce in the current literature. To date, we have treated 4 patients with an average age of 27 years (range 19-44 years) using the BTN for segmental tibial defects ranging from 50 to 128 mm. We have accumulated data over an average follow-up of 18.07 months (range 12.96-25.13 months), demonstrating good patient tolerance of the device. Three patients successfully completed their treatment course with a calculated average bone healing index of 41.4 days/cm (range 31.41-54.82 days/cm). One patient was noted to experience an asymptomatic docking site nonunion requiring subsequent surgery for nonunion repair. Implant-associated complications included symptomatic implant, axial malalignment, docking site nonunion, and external remote control technical malfunction. Injury-related complications were encountered and noted to include: superficial infection, wound dehiscence, peroneal tendonitis, and joint rigidity. In this study, the authors present a case series using this implant to date and discuss our experiences with the BTN with reference to clinical indications, tibial bone preparation, BTN implantation, transport protocol, docking site procedure, and clinical/radiographic outcomes.

Results of Ilizarov external fixator lengthening compared to lengthening and then plating in management of femoral shortening in children

Femoral shortening in children is a challenging condition with complex functional and psychological implications. We study the results of Ilizarov external fixator (IEF) lengthening compared to lengthening and then plating (LAP) in the management of femoral shortening in children. Forty patients were included in the study and equally divided randomly into 2 groups, in group I LAP was used and in group II lengthening by IEF only was done. The two groups were analyzed for postoperative variables to adjudge the surgical outcomes. The mean follow up time was 24.05 ± 2.99 months, The gained length was 5.60 ± 0.60 cm in group 1 and 5.48 ± 0.64 cm in group II, group I had a shorter external fixator period (3.96 ± 0.22) months, better healing index (24.6 ±2.76) days/cm, earlier complete weight-bearing (5.55 ± 0.78) months than group II. The period of hospitalization for group I was longer more than group II. The complications were less in group I (n=7, 35%) than in group II (n=11, 55%). There was no significant correlation between the healing index with age, also no significant difference was detected between the healing index and gender. There was a significant correlation between the gained length and complete weight-bearing. This study efficiently demonstrates that LAP may be better than lengthening with IEF alone in the management of femoral shortening in children.

Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms

Aims

The Precice Stryde® internal magnetic lengthening nail allowed many patients a full weight-bearing experience during femur and tibia lengthening, but concerns over corrosion, pain and radiographic changes led to the implant's recall. Despite the recall, it is important to understand the rate of these occurrences and their influence on the overall success of the lengthening procedure. We aimed to investigate radiographic changes, patient-reported symptoms and bone healing indices for our cohort of Stryde lengthening.

Materials and methods

Our surgical database and electronic medical record system were used to review and document patient demographics, indications for lengthening, length achieved, bone healing index (BHI), location and type of radiographic changes, time until radiographic changes were first visible, presence of pain symptoms (not attributable to surgery or distraction), time to implant removal and if the pain symptoms resolved following implant extraction.

Results

From January 2019 to February 2021, 90 Stryde nails (78 femur and 12 tibia) were implanted in 63 patients. The cohort included 48 males and 15 females. The average length [± standard deviation (SD)] achieved was 58.4 ± 22.7 mm. The 66 bones (73%) developed radiographic changes and were found to be 58/78 (74%) femurs and 8/12 (67%) tibias. The average time to initial radiographic changes was 168 ± 108.1 days (femur) and 276 ± 126.8 days (tibia). Late-onset pain developed in 10 femur lengthening (11.1% of all nails) surgeries across eight patients (12.7% of all patients). All patients' pain resolved; three instances prior to nail removal and the remaining seven after nail removal. No patients were re-presented with worsening pain or radiographic changes following implant removal. Radiographic or symptomatic abnormalities did not impair bone formation. The BHI for femurs with (29.6 ± 16.6 days/cm, n = 58) vs without (29.4 ± 17.9 days/cm, n = 20) radiographic or symptomatic irregularity were nearly identical (p = 0.961). The difference between BHI for tibias with (39.3 ± 7.8 days/cm, n = 8) vs without (86.1 ± 38.2 days/cm, n = 4) radiographic changes was influenced by outliers and underpowered to draw a conclusion.

Conclusion

Bone lengthening with the Stryde nail was associated with high rates of radiographic abnormalities, but symptoms were uncommon and resolved with explantation. The radiographic changes did not affect bone healing in the femur.

Clinical significance

Radiographic changes including bone hypertrophy and osteolysis were common after bone lengthening with the Stryde nail, but the development of pain following consolidation was rare and resolved with implant removal.The BHI in femurs was not affected by radiographic changes.

How to cite this article

Reif TJ, Geffner A, Hoellwarth JS, et al. Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms. Strategies Trauma Limb Reconstr 2023;18(2):94-99.

Re-implantation of foot and ankle following crush injury of the distal leg with 22 cm bone deficit: A case report

INTRODUCTION/IMPORTANCE

Crush injury with extensive soft tissue damage to an extremity is generally considered a contraindication to re-implantation and the extremity best managed by prosthesis. However good prosthesis is not easily available especially in resource constrained environment, the overall long term quality of life is also considered better with re-implantation.

CASE PRESENTATION

We report a 24 year old tourist patient who presented with post-traumatic amputation of the left leg following a road traffic accident. The patient had no other injuries. Clinical examination revealed extensive soft tissue damage to the involved leg. Radiograph done demonstrated segmental fracture of the distal tibia. The foot was successfully re-implanted after a lengthy surgery of 10 h. The patient was then subjected to an Illizarov bony lengthening procedure to correct the limb discrepancy length of about 20 cm.

CLINICAL DISCUSSION

Our patient through multidisciplinary approach and after a combination of many procedures had his foot salvaged with good functional outcome. Though the injury had both bony and soft tissue loss, limb shortening necessitated by the segmental fracture followed by Illizarov technique were able to ensure adequate length.

CONCLUSION

Post-traumatic crush amputation of the foot previously considered a contraindication for re-implantation could be salvaged by re-implantation in combination with bone lengthening procedure with good functional outcome.

Hydrotherapy for Patients With External Fixation: Effect on Infectious Events

BACKGROUND

Surgery to achieve long bone lengthening and deformity correction in skeletally immature patients is traditionally performed through external fixators. The incidence of infection during treatment is high. Hydrotherapy is highly beneficial during external fixation management, but the infection rates may impact its utilization. The objective of this paper is to document the incidence and duration of infection in patients who participated in a full hydrotherapy program when performed under medical supervision and in accordance with strict follow-up protocols.

METHODS

In this retrospective study, we documented the key characteristics of patients who participated in hydrotherapy after lower limb external fixation surgery including age, sex, diagnosis and surgery site, the incidence and duration of pin site infections, and the percentage of cases, which were able to comply with a full hydrotherapy protocol.

RESULTS

The hydrotherapy pool met all daily water quality metrics. Thirty-four children (19 males and 15 females) had a mean±SD age of 10.9±4.6 years. Of the cases, 80% were unilateral and 20% were bilateral. Diagnoses included congenital hereditary (eg, achondroplasia), congenital nonhereditary conditions (eg, fibular hemimelia), and acquired conditions (eg, traumatic). The location of osteotomy site was quite evenly spread between the femur and the tibia/fibula. Three out of the 34 patients were unable to receive hydrotherapy due to continuous secretions; 2 patients did not miss any sessions. The mean number of treatments was 3 per week. During the entire period, a total of 1200 treatments were performed for these patients with only 32 cancellations (about 3%) due to secretions or other signs of infection. Spearman correlation coefficients showed significantly high correlations between the duration of external fixation and the duration of hydrotherapy. There are no significant correlations between infections and other factors (sex, age segment, whether the problem is unilateral or /bilateral, diagnosis, and duration of treatment).

CONCLUSIONS

This is the first report, to our knowledge, that documents the low prevalence of infectious events during hydrotherapy treatment and demonstrates its feasibility.

LEVEL OF EVIDENCE

Level III; retrospective, comparative study.

Transporte sobre clavo respetando la membrana de Masquelet en defectos segmentarios severos. Serie de casos

Introducción: El adecuado tratamiento de los defectos óseos se presenta como un desafío para el cirujano ortopedista, en cuanto a la dificultad en la restitución de un miembro alineado, sin discrepancia ni infección. Se han descrito múltiples técnicas para reconstruir estos defectos, como el injerto óseo autólogo o de banco, la técnica de membrana inducida, la osteogénesis por distracción y los cilindros de titanio trabecular, pero ninguna ha demostrado ser significativamente superior a otra. Materiales y Métodos: Entre 2018 y 2021, 10 pacientes con defectos óseos de la tibia fueron tratados mediante transporte óseo guiado con osteosíntesis endomedular. Se realizó un estudio retrospectivo descriptivo analizando la magnitud de los defectos, el tiempo de transporte, las complicaciones y cirugías adicionales durante el proceso, si hubo consolidación y las deformidades residuales. Al final del proceso, se midió el puntaje de la ASAMI (óseo y funcional). Resultados: La longitud promedio de los defectos tratados fue de 9,75 cm y el índice de fijación externa promedio, de 40,62 días/cm. El 50% tenía un puntaje de la ASAMI óseo bueno; el 10%, excelente y el 40%, pobre al final del proceso reconstructivo. El 20% tenía un puntaje de la ASAMI funcional excelente; el 30%, bueno y el 50%, pobre. Conclusiones: El uso de tutores externos guiados mediante osteosíntesis es un método fiable para tratar defectos óseos, al mismo tiempo que se trata la infección de manera local y sistémica, acortando los tiempos de tutor externo y, por lo tanto, de internación y reintervención.

An Inexpensive 3D Printed Mouse Model of Successful, Complication-free Long Bone Distraction Osteogenesis

Distraction osteogenesis (DO) is used for skeletal defects; however, up to 50% of cases exhibit complications. Previous mouse models of long bone DO have been anecdotally hampered by postoperative complications, expense, and availability. To improve clinical techniques, cost-effective, reliable animal models are needed. Our focus was to develop a new mouse tibial distractor, hypothesized to result in successful, complication-free DO.

Methods

A lightweight tibial distractor was developed using CAD and 3D printing. The device was fixed to the tibia of C57Bl/6J mice prior to osteotomy. Postoperatively, mice underwent 5 days latency, 10 days distraction (0.15 mm every 12 hours), and 28 days consolidation. Bone regeneration was examined on postoperative day 43 using micro-computed tomography (μCT) and Movat's modified pentachrome staining on histology (mineralized volume fraction and pixels, respectively). Costs were recorded. We compared cohorts of 11 mice undergoing sham, DO, or acute lengthening (distractor acutely lengthened 3.0 mm).

Results

The histological bone regenerate was significantly increased in DO (1,879,257 ± 155,415 pixels) compared to acute lengthening (32847 ± 1589 pixels) (P < 0.0001). The mineralized volume fraction (bone/total tissue volume) of the regenerate was significantly increased in DO (0.9 ± 0.1) compared to acute lengthening (0.7 ± 0.1) (P < 0.001). There was no significant difference in bone regenerate between DO and sham. The distractor was relatively low cost ($11), with no complications.

Conclusions

Histology and µCT analysis confirmed that the proposed tibial DO model resulted in successful bone formation. Our model is cost-effective and reproducible, enabling implementation in genetically dissectible transgenic mice.

A Combination of Ilizarov Frame, Externalized Locking Plate and Tibia Bridging for an Adult with Large Tibial Defect and Severe Varus Deformity Due to Chronic Osteomyelitis in Childhood: A Case Report

Background: Various techniques have been reported to treat large, segmental tibial defects, such as autogenous bone graft, vascularized free fibula transfer and bone transport. We present a case of a 24-year-old male with a 17-year history of chronic osteomyelitis with obvious lower limb length discrepancy and severe varus deformity of the tibia secondary to osteomyelitis in childhood. Aim: The aim of this work is to provide an alternative choice for treating patients in developing countries with severe lower limb deformity caused by chronic osteomyelitis. Case Presentations: Without surgical intervention for a prolonged period of time, the patient was admitted in our institute for corrective surgery. Corrective surgery consisted of three stages: lengthening with Ilizarov frame, removal of Ilizarov frame and fixation with externalized locking plate, and removal of externalized locking plate. Tibia bridging was achieved at the distal and proximal junction. The range of motion (ROM) of the knee joint was nearly normal, but the stiffness of the ankle joint was noticeable. The remaining leg discrepancy of 0.1 cm required no application of a shoe lift. Moreover, the patient could engage in daily activities without noted limping. Conclusions: Distraction-compression osteogenesis using the Ilizarov apparatus is a powerful tool to lengthen the shortened long bone and adjust the deformity of the lower limbs. Externalized locking plates provide an alternative to the traditional bulky external fixator, as its low profile makes it more acceptable to patients without compromising axial and torsional stiffness. In all, a combination of Ilizarov frame, externalized locking plate and tibia bridging is an alternative for patients in similar conditions.

What to Expect of Feeding Abilities and Nutritional Aspects in Achondroplasia Patients: A Narrative Review

Achondroplasia is an autosomal dominant genetic disease representing the most common form of human skeletal dysplasia: almost all individuals with achondroplasia have identifiable mutations in the fibroblast growth factor receptor type 3 (FGFR3) gene. The cardinal features of this condition and its inheritance have been well-established, but the occurrence of feeding and nutritional complications has received little prominence. In infancy, the presence of floppiness and neurological injury due to foramen magnum stenosis may impair the feeding function of a newborn with achondroplasia. Along with growth, the optimal development of feeding skills may be affected by variable interactions between midface hypoplasia, sleep apnea disturbance, and structural anomalies. Anterior open bite, prognathic mandible, retrognathic maxilla, and relative macroglossia may adversely impact masticatory and respiratory functions. Independence during mealtimes in achondroplasia is usually achieved later than peers. Early supervision of nutritional intake should proceed into adolescence and adulthood because of the increased risk of obesity and respiratory problems and their resulting sequelae. Due to the multisystem involvement, oral motor dysfunction, nutrition, and gastrointestinal issues require special attention and personalized management to facilitate optimal outcomes, especially because of the novel therapeutic options in achondroplasia, which could alter the progression of this rare disease.

Application of 3D printed patient-specific instruments in the treatment of large tibial bone defects by the Ilizarov technique of distraction osteogenesis

Background

The Ilizarov technique of distraction osteogenesis is an effective treatment for tibia defect. However, repeated attempts to reduce due to the complexity of the bone defect during the operation will increase the operation time and iatrogenic injury, and excessive radiation exposure. Three-dimensional (3D)-printed patient-specific instrument (PSI) for preoperative 3D planning and intraoperative navigation have the advantages of accuracy and visualization. The purpose of this study is to investigate whether 3D-printed PSI is helpful to correct tibial bone defects accurately and effectively.

Method

From May 2019 to September 2022, 19 patients with tibial bone defects were treated, including 9 males and 10 females, aged 37 to 64 years. There were 4 cases in proximal tibia, 9 in midshaft tibia and 6 in distal tibia. All were treated with Ilizarov technique of distraction osteogenesis. 3D-printed PSI was used in 9 cases, while traditional surgery was used in 10 cases. All patients underwent computed tomography before surgery. Computer software was used to analyze the measurement results, design and print PSI. During the operation, PSI was used to assist in reduction of tibia. Operation times were recorded in all cases, the number of fluoroscopy during the operation, and the varus/valgus, anteversion/reversion angle after the operation were measured. All measurement data were expressed by means ± SD, and Student's t test was used to examine differences between groups. The chi square test or Fisher's precise test was used to compare the counting data of the two groups.

Result

All PSI matched well with the corresponding tibia bone defect, and were consistent with the preoperative plan and intraoperative operation. The affected limb had a good reduction effect. The operation time from the beginning of PSI installation to the completion of Ilizarov ring fixator installation was 31.33 ± 3.20 min, while that in the traditional operation group was 64.10 ± 6.14 min (p < 0.001). The times of fluoroscopy in the PSI group during operation was 10.11 ± 1.83, and that in the traditional operation group was 27.60 ± 5.82. The reduction effect of tibia in PSI group was better than that in traditional operation group, with the average angle of PSI group is 1.21 ± 0.24°, and that of traditional operation group is 2.36 ± 0.33° (p < 0.001).

Conclusion

The PSI simplifies procedures, reduces the difficulty of the operation, improves the accuracy of the operation, and provides a good initial position when used in distraction osteogenesis to treat the tibial defects.

Growing Taller without Hormones? Dr. Consult Google-An Evaluation of Online Information Related to Limb Lengthening

PURPOSE

The aim of this study was to investigate the reliability, content and readability of the information available on the Internet related to limb lengthening surgeries, which have recently been progressively in fashion.

METHODS

The three most commonly used browsers on the Internet were determined and a search term for "Limb Lengthening Surgery" was typed for each browser. The websites were categorized by their type, and the content and the quality of them was evaluated using the DISCERN score, the Journal of American Medical Association (JAMA) benchmark and the Global Quality Score (GQS). The Flesch Kincaid Grade Level (FKGL) and the Flesch Reading Ease Score (FKRS) were used to evaluate the readability. Each website also assessed the presence (or absence) of the Health on Net (HON) code.

RESULTS

The academic category was found to be significantly higher than the medical and commercial categories. Mean FKGL and FCRS scores, DISCERN score values, JAMA, GQS and LLCS score values of Websites with HON code were significantly higher than those without.

CONCLUSIONS

The quality of online information related to limb lengthening was of low quality. Although some websites, especially academic resources, were of higher quality, the readability of their content is just about 2.5 degrees higher than the sixth-grade reading level.

Role of proximal tibiofibular fixation in leg lengthening with the Ilizarov method in the achondroplastic patient

The role of proximal tibiofibular joint (TFJ) transfixion during Ilizarov tibial lengthening is still debated in the literature. The aim of this study was to show that TFJ transfixion can be avoided with no impact on patient outcome. All achondroplastic patients undergoing tibia lengthening from 1999 to 2018 were included. Patients were divided in two groups: group A (11 patients) submitted to proximal TFJ transfixion and group B (22 patients) not submitted to TFJ transfixion. The results showed a statistically significant difference in proximal fibular migration (PFM) between the two groups of patients, with a mean PFM of 9.2 mm (range, 1-20 mm) and of 21 mm (range, 2.7-76 mm) in group A and in group B, respectively. We can state that PFM up to 41 mm in our series did not affect joint function and stability. There are no statistically significant differences in the other radiological parameters. Analysis of functional scores (Knee Society, Tegner-Lhysolm, Association for the Study and Application of Methods of Ilizarov) did not reveal significant differences between the groups. The scores of the Achondroplasia Personal Life Experience Scale were also similar in the two groups, demonstrating a good quality of life. There are no differences between the two groups in terms of clinical-functional outcome of the knee, radiographic results, and quality of life. Transfixion of proximal TFJ may not be necessary, but it is important to avoid premature consolidation of the fibular osteotomy.

Outcomes of intralesional osteotomy and distraction osteogenesis for limb length equalization in Ollier's disease

Limb length discrepancy and deformities resulting from Ollier's disease are challenging to treat and have increased complications. We aimed to assess the safety of intralesional osteotomy for distraction osteogenesis and report the results of guided growth as a method of deformity correction in such conditions. We retrospectively reviewed 13 patients (eight boys and five girls), 28 segments (12 femora and 16 tibias), treated using Ilizarov circular ring fixator in one center. Nine patients had an oblique plane deformity, whereas four had a coronal plane deformity. Femoral shortening ranged from three to 11 cm. Tibial shortening ranged from 3.5 to 12 cm. Intralesional osteotomy was carried out in all patients, and guided growth (hemiepiphysiodesis) was used in seven segments (25%). The median age was 11 years (6-14 years) at surgery, with a median follow-up of 4.5 years (3-18 years). The median achieved lengthening in the femur was 7 cm (5-11 cm) and in the tibia was 5 cm (3-9 cm). The average Bone Healing Index (BHI) for the femur was 32 days/cm (28-38 days/cm), and for the tibia was 36 days/cm (28-40 days/cm). Before frame removal, the mechanical axis was restored to the knee joint center in all cases. Normal radiographic bone regeneration was evident in all cases. Hemiepiphysiodesis successfully corrected the angular deformities. Intralesional osteotomy for distraction osteogenesis is well-tolerated and reliable in Ollier's disease. Radiological normal bone was formed at the distraction site. Guided growth is also a reproducible method for deformity correction in Ollier's disease, similar to other conditions.

To Angulate or Not to Angulate the Ulna during the Progressive Distraction Period Performed with a Monolateral External Fixator in Paediatric Patients with a Chronic Monteggia Fracture?

Background and Objectives: The purpose of this study was to compare the clinical and radiographic evolution of chronic Monteggia fractures (CMFs) treated by ulnar osteotomy and monolateral external fixators (MEFs) with or without angulation of the ulna during the distraction period. Materials and Methods: This retrospective study evaluated 20 children (14 boys and 6 girls) with CMFs. According to the strategy of ulnar lengthening, two groups of patients were identified: patients undergoing gradual lengthening with (Group A, n = 11) or without ulna angulation (Group B, n = 9). The mean age at the time of surgery was 7.7 years old (range, 5.4−12.9). The mean time from initial trauma to surgery was 26.3 months (range, 1−96), and the mean follow-up was 24.6 months (range, 5.5−45.4). Clinical outcomes were evaluated by Kim et al.’s Elbow Performance Score, while radiographic outcomes were assessed on plain radiographs. Results: Age at surgery, sex, laterality, time between trauma and surgery, and time of follow up in the two groups of patients showed no significant differences. The radial head was successfully reduced in 9 of 9 and 10 of 11 patients in Groups B and A, respectively (p = 1.00). The mean time to achieve radial head reduction was shorter in Group B (18.1 ± 5.3 days) than in Group A (39.2 ± 18.7 days; p = 0.004). The mean angulation of the ulna at the end of treatment was significantly lower in Group B (0.6° ± 1.1°) than in Group A (25.9° ± 6.3°; p < 0.0001). The average ulnar lengthening at the end of treatment in Group B (14.1 ± 5.8 mm) was, on average, 7.7 mm less than that in Group A (21.8 ± 9.7 mm; p = 0.05). The Kim et al. Elbow Performance Score at the last follow-up visit was comparable between the two groups of patients (p = 1.00). Conclusions: A shorter time to achieve radial head reduction and less deformity of the ulna can be expected in paediatric patients with CMFs undergoing intraoperative restoration of ulnar alignment and gradual lengthening without angulation postoperatively.

Complication of lengthening and the role of post-operative care, physical and psychological rehabilitation among fibula hemimelia

There is a clear clinical need for efficient physiotherapy and rehabilitation programs during and after bone lengthening and reconstruction for gaining the optimal effect and also prevention or treatment of lengthening side effects. Pin tract infection is the most prevalent side effect during lengthening which could be prevented and treated initially via proper wound care. Muscle contractures are typically a consequence of the generated tension on the distracted muscle. It can be managed by physiotherapy initially and surgically in later severe stages. Furthermore, it is essential to avoid muscle contracture development, which is the demonstration of the imbalanced muscle appeals on the joint to inhibit the following subluxation. The knee is the furthermost affected joint by the aforementioned problem due to the inherent lack of ligamentous and bony stability. Joint stiffness is the other possible unfavorable effect of lengthening. It happens because of extensive muscle contractures or may possibly be attributed to rigidity of the joint following the amplified pressure on the joint surface during the process of lengthening. Physiotherapy and occupational therapy including endurance and strength exercise as well as stretching play an important role during the rehabilitation periods for the prevention and also the treatment of muscle contracture and the following deformity and also joint stiffness. Likewise, the effect of mental and physical rehabilitation programs should not be overlooked.

Current trends on limb length discrepancy treatment: results of a survey among 11 dedicated Italian centres

Limb length discrepancies (LLD) are quite frequent, especially in lower limbs. The evolution of the available devices and the refinement of the techniques for correcting the differences in limb length have progressively improved the approach to these deformities. Nevertheless, several points still remain debated. The aim of the study was to investigate the Italian pediatric orthopedic surgeons' choices in approaching and treating LLD in both lower and upper limbs. A survey on the treatment of limb length discrepancy was sent to a group of 11 Italian orthopedic centers, specialising in limb lengthening and belonging to the Italian Society of Pediatric Orthopedics and Trauma and the Italian Society of External Fixation. Despite improvements in knowledge of bone biology and distractional osteogenesis as well as the increase in available hardware for lengthening, many aspects of LLD correction still remain debated. Both the relative rarity of the conditions which lead to significant shortening and the lack of wide groups of patients analysed at adult age, continue to be the main limitations for every surgeon who deals with LLD. Only by overcoming our own convictions and sharing our experiences in multicentric studies, may we reach our goal of developing a shared treatment protocol.

Bifocal femoral lengthening assisted by preoperative 3-dimensional design in the restoration of posttraumatic limb length discrepancy

Background

To assess the clinical outcomes of preoperative three-dimensional planning followed by bifocal femoral lengthening in the treatment of posttraumatic limb length discrepancy (LLD).

Methods

A total of 8 eligible patients with posttraumatic femoral LLD > 6 cm were admitted to our institution from January 2015 to January 2018 and treated by bifocal femoral lengthening with the assistance of 3-dimensional imaging technology. The following data were collected: detailed demographic information, the amount of lengthening, external fixation time (EFT), external fixation index (EFI), postoperative bone and functional outcomes, and complications in the follow-up period.

Results

All included patients were successfully followed up for in an average of 55.4 ± 6.7 months after removal of the external fixator. There were six males and two females with an average age of 38.4 ± 12.2 years. The mean preoperative LLD was 69.2 ± 6.2 mm. The mean lengthening amount was 67.5 ± 6.9 mm. The mean EFT was 180.1 ± 20.2 days. The EFI was 26.73 ± 1.36 days/cm on average. All patients achieved satisfactory postoperative bone and functional outcomes. No major complications such as nerve or vascular injury were observed.

Conclusions

Bifocal femoral lengthening with preoperative three-dimensional design provided precise surgical guidance and resulted in satisfactory postoperative outcomes, demonstrating that it is an effective treatment for posttraumatic femoral LLD.

All-Internal Limb Lengthening with Simultaneous Corrective Osteotomy After Internal Hemipelvectomy: A Case Report

CASE

A 27-year-old woman with a Grade II chondrosarcoma in the right acetabulum underwent a Type II internal hemipelvectomy with an ischiofemoral fusion. She developed a 7.0-cm functional limb-length discrepancy with adduction of the hip at rest. Four years after surgery, she underwent a corrective osteotomy and limb lengthening with a magnetic lengthening nail. Eleven years after tumor resection and a successful pregnancy, she had symmetric leg lengths and ambulated without an assistive device.

CONCLUSIONS

A magnetic lengthening nail is a viable option for correcting limb-length discrepancies after hemipelvectomy. If necessary, a simultaneous corrective proximal femoral osteotomy can be performed.

Evolution and Development of Ilizarov Technique in the Treatment of Infected Long Bone Nonunion with or without Bone Defects

The treatment of infected bone nonunion and bone defects is a considerable challenge in the orthopedics field. The standard clinical therapy methods include local free bone transplantation, vascularized bone graft, and the Ilizarov technique; the first two are controversial due to the iatrogenic self‐injury. The Ilizarov bone transport technique has been widely used to treat infected bone nonunion and bone defects, and good clinical effect has been demonstrated. Yet, it brings many related complications, which exerts additional suffering to the patient. The best treatment is to combine bone defect rehabilitation with infection control, intramedullary nail fixation, appropriate time for bone grafts, beaded type scaffold slippage and new Taylor fixation, reducing the external fixation time and the incidence of complications, thereby reducing the occurrence of patients' physical and psychological problems. This review focuses on the induction, summary and analysis of the Ilizarov bone transport technique in the treatment of infected long bone nonunion with or without bone defects, providing new ideas and methods for orthopedic disease prevention and treatment by the Ilizarov technique, which is following the development direction of digital orthopedics.

Are internal lengthening devices effective and associated with less complications compared to other lengthening devices? A systematic review and meta-analysis

Internal lengthening devices became more popular than external fixators. This was attributed to their effectiveness and lower complication rates. However, this is an assumption that is not on the basis of solid scientific evidence. Therefore, this study systematically reviewed the quality and strength of evidence supporting femoral internal lengthening devices' effectiveness and their associated complications. Six electronic databases (PubMed, Cochrane, Sage, Embase, Web of Science and Scopus) were searched from inception until 20 June 2020. Further, all included articles' bibliographies were searched manually. After screening of retrieved articles, five studies were eligible for qualitative and quantitative synthesis. Studies were assessed by two independent assessors using a modified 'assessment of the methodological quality both of randomized and nonrandomized studies of health care interventions'. Further, meta-analysis was conducted to compare the procedure's effectiveness, in terms of healing index and major complications incidence. Our findings showed internal validity as the major source of bias whereas external validity was the least. For healing index, there is limited evidence that internal lengthening devices lower healing index by 0.45 months/cm (95% CI, -0.62 to -0.28; P < 0.01) compared to LON/external fixators. The incidence of major complications, that were directly related to the procedures, did not differ between internal lengthening devices and other fixators (risk ratio=0.97; 95% CI, 0.39-2.44; P < 0.95). This review provides evidence that supports lower healing index and similar complications associated with internal lengthening devices compared to other procedures of femoral lengthening. However, the evidence is very limited to draw a solid conclusion.

Bone transport combined with bone graft and internal fixation versus simple bone transport in the treatment of large bone defects of lower limbs after trauma

Background

Bone transport has been successfully applied for the management of large segmental bone defects. However, its main shortcoming is the long-lasting consolidation period, which may cause lots of related complications. To overcome this shortcoming, we developed bone transport combined with bone graft and internal fixation technique. The purpose of this study was to compare the clinical effects of this modified technique with simple bone transport in the treatment of large segmental bone defects of lower limbs after trauma.

Methods

Eighty-four patients with large segmental bone defects treated in our institution from January 2014 to January 2017 were selected for retrospective study. A total of 77 cases were completely followed. Among them, 35 patients were treated by bone transport combined with bone graft and internal fixation technique (Group A), and 42 by simple bone transport technique (Group B). Patients with open injuries were classified according to Gustilo-Anderson (GA) classification. The general data of Group A and B were compared. The time in external fixator, total cure time and operation times of two groups were recorded. Ennecking score was used to evaluate the recovery of limb functions while self-rating anxiety scale (SAS) for the postoperative anxiety evaluation. In addition, the total complication incidence was compared between Group A and B.

Results

There was no significant difference in demographic data between Group A and B (p > 0.05). The time in external fixator of Group A and B was (4.8 ± 1.6) and (18.2 ± 3.9) months, respectively (p < 0.05). The total cure time was (17.6 ± 2.2) and (20.4 ± 2.8) months in Group A and B (p < 0.05). The number of operations in Group A and B was (4.9 ± 1.2) and (4.8 ± 1.0) (p > 0.05). Ennecking score of Group A and B was 84.7 and 75.7% (p < 0.05). SAS score and total complication incidence in Group A were significantly lower than those in Group B (p < 0.05).

Conclusions

The clinical effects of bone transport combined with bone graft and internal fixation technique were better than that of simple bone transport technique, including shorter time in external fixator, shorter total cure time, lower anxiety score and better limb functions.

Age-related Outcomes and Complications of Osteodistraction in the Pediatric Upper Extremity: A Large Retrospective Single-center Study of 61 Cases

BACKGROUND

The study purpose was to assess: (1) the complication rate of osteodistraction in the pediatric upper extremity, its severity and relation to patient-specific and treatment-specific parameters, and (2) dedicated patient-reported outcome scores after these procedures.

METHODS

This retrospective study analyzed a chart of patients undergoing osteodistraction of the upper limb between 2003 and 2020. Demographics, distraction-specific parameters, healing index, and any complications graded according to the Sink grading scale (grades 1 to 5) were extracted. An additional phone interview was performed to assess patient satisfaction and functionality of the elongated limb using the Quick-DASH (Disabilities of Arm, Shoulder, and Hand) score.

RESULTS

This study included 61 cases from 48 individual patients. The mean age at the start of distraction was 11.5±3.6 years. The ulna was the most frequently lengthened bone, with 21 (34.4%) cases. Ninety-four complications were observed, with an average complication rate of 77.0%. Based on the Sink grading scale (1 to 5), grade 3 complications were most common (n=29; 47.5%) followed by grade 1 (n=14; 23.0%), 2 (n=14; 23.0%), and 4 (n=4; 6.6%). A significantly lower and thus better bone healing index was observed for the age category less than 10 years compared with the 14 to 18 years group (P=0.006). The average satisfaction was 4.2±1.0 points of 5. The mean Quick-DASH score was 14.1±12.5, indicating very good clinical outcomes.

CONCLUSIONS

Despite the occurrence of numerous complications, high patient satisfaction and good daily life functionality of the treated limb was observed. An age of more than 14 years at the beginning of therapy had a negative prognostic effect on bone healing during distraction. Thus, osteodistraction in the upper extremity may preferably be performed less than 10 years of age because of enhanced bone regeneration.

LEVEL OF EVIDENCE

Level IV-retrospective case series.