Characterizing the Magnitude and Risk Factors of Functional and Anatomic Limb Lengthening in Patients Undergoing Revision Total Knee Arthroplasty

BACKGROUND

In revision total knee arthroplasty (TKA), there is little information on the magnitude of potential limb lengthening, risk factors for lengthening, or its impact on patient-reported outcome measures. We aimed to quantify limb length alteration during revision TKA and assess risk factors for lengthening.

METHODS

We identified 150 patients over a 3-year period who underwent revision TKA and had preoperative and postoperative EOS hip-to-ankle standing radiographs. The average patient age was 64 years, 51% were women; 68% had a preoperative varus deformity and 21% had a preoperative valgus deformity. Outcomes assessed included change in functional and anatomic limb length, risk factors for lengthening, and clinical outcome scores, including the Knee Osteoarthritis Outcome Score Joint Replacement, and the Veterans RAND 12-item Physical and Mental Scores.

RESULTS

There were 124 patients (83%) who had functional limb lengthening, and 108 patients (72%) had anatomic limb lengthening. Patients had an average functional limb lengthening of 7 mm (range, -22 to 35) and an average anatomic limb lengthening of 5 mm (range, -16 to 31). Patients undergoing revision for instability experienced significantly greater anatomic lengthening (7.6 versus 4.6, P = .047). Patients who had ≥ 10° of deformity were more likely to be functionally lengthened (91 versus 79%) and had significantly greater average functional lengthening (12 versus 6 mm; P = .003). There was no significant change in clinical outcome scores at 6 weeks and 1 year for patients lengthened ≥ 5 or 10 mm compared to those not lengthened as substantially.

CONCLUSIONS

There is major potential for functional and anatomic limb lengthening following revision TKA, with greater preoperative deformity and revision for instability being risk factors for lengthening.

Treatment of Large Femoral and Tibial Bone Defects With Plate-Assisted Bone Segment Transport

OBJECTIVES

The purposes of this study were to assess clinical and radiographic outcomes following plate-assisted bone segment transport (PABST) in large bone defects of the lower extremities.

METHODS

DESIGN

Retrospective study of prospectively collected data.

SETTING

Level-1 trauma center located in Germany.

PATIENT SELECTION CRITERIA

Patients who underwent PABST and were at least 1 year postoperatively were included.

OUTCOME MEASURES AND COMPARISONS

Demographic data were collected. Radiographic apparent bone gap (RABG), time to consolidation, time to full weight-bearing, and consolidation index were calculated. Numeric rating scale, lower extremity functional scale (LEFS), and complications were assessed.

RESULTS

Fifteen patients [13 male; mean age 51 years (range, 20-75)] underwent PABST and had follow-up at a mean of 29.1 months. The tibia was affected in 8 and the femur in 7 patients. Preoperative RABG was 60 mm [interquartile range (IQR): 40-125], and bone defects were caused by septic nonunions in 73% of patients. Fourteen patients (93%) demonstrated consolidated transport callus at 7.3 months [95% confidence interval (95% CI), 6-8.5], and 9 patients (60%) demonstrated complete consolidation of both docking site and transport callus at 11.5 months (95% CI, 7.3-15.3). Postoperative RABG was 0.1 mm (IQR: 0-0.8), and consolidation index was 1.9 months/cm (95% CI, 1.3-2.5). All patients achieved full weight-bearing at 8.7 months (IQR: 6.5-10.3). LEFS was 42 (95% CI, 34-50), and numeric rating scale was 3 (95% CI, 2-4). Patients treated for tibial defects had a significantly higher consolidation rate compared with patients treated for femoral defects ( P = 0.040).

CONCLUSIONS

PABST demonstrated high consolidation of transport callus with few complications. Although full weight-bearing was achieved in all patients, complete consolidation of the docking site was only present in 60% of cases.

LEVEL OF EVIDENCE

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

Limb Reconstruction Using the Ilizarov Technique Following Giant Cell Tumour Excision in the Proximal Tibia of a 19-Year-Old Female: A Case Report

Giant cell tumours (GCTs) of the proximal tibia are a relatively uncommon lesion among all benign tumours. They can occur at various sites including distal femur, proximal tibia and distal end radius. Various management modalities of GCTs occurring in the knee joint have been described for reconstruction as well as arthrodesis. We present a case of a 19-year-old adolescent patient with GCT of the proximal tibia with cortical breach with the collapse of the medial articular surface of the tibia. The patient reported experiencing knee pain and swelling for a long duration. Radiological investigations were suggestive of GCT of the proximal tibia with the medial cortical breach and collapse of the medial tibial articular surface. The patient was managed with a resection followed by arthrodesis using intramedullary nails with bone grafting, followed by Ilizarov reconstruction due to osteomyelitis of the surgical site. When dealing with relatively aggressive tumours that have breached the cortex, wide resection of the tumour is required. Following this, the reconstruction procedure must ensure good biomechanical tenacity, biological healing, infection resistance, and intact function of the knee joint extension. One option for achieving this is total knee replacement with a customized prosthesis, though this can be costly. Another option is joint arthrodesis with intramedullary nailing or the Ilizarov fixator, which is strongly supported by the existing literature. This case was managed successfully with the above-described method, and complete healing was observed. In conclusion, periarticular long bone tumours, especially around the knee joint, can be managed effectively with the Ilizarov method. Though it has a few disadvantages, such as a long duration of external fixator, non-compliance, and pin tract infections, it still stands as a viable alternative for limb reconstruction due to its cost-effectiveness and time-tested efficacy.

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.

Accuracy of the hexapod external fixator in treating tibial angular deformities with or without limb length discrepancy: a retrospective study

OBJECTIVE

Hexapod external fixator systems allow simultaneous deformity correction in multiple planes as well as limb lengthening. The aim of this study is to evaluate the accuracy of a hexapod frame (smart correction frame) in different types of tibial deformities requiring correction with or without lengthening.

METHODS

A total of 54 tibial angular deformities and limb length discrepancies operated with a hexapod frame between January 2015 and January 2021 were classified into four groups: "Group A ( n  = 13): only lengthening," "Group B ( n  = 14): lengthening and uniplanar correction," "Group C ( n  = 16): only uniplanar correction," and "Group D ( n  = 11): biplanar correction." The accuracy of angular deformity correction/lengthening was calculated by dividing the actual correction/lengthening achieved after frame removal by the preoperative planned lengthening/correction.

RESULTS

The lengthening accuracy in Group A and Group B was 96.3 ± 7.1% and 95.7 ± 5.9%, respectively ( P  = 0.685). The angular deformity correction accuracy was 85.1 ± 9.9% for Group B, 85.2 ± 13.9% for Group C, and 80.2 ± 18.4% for Group D ( P  = 0.852). A revision program was performed in six cases (1 in Group B, 1 in Group C, and 4 in Group D) for full correction of the deformities.

CONCLUSION

The accuracy of tibial lengthening is high with the hexapod frame and is minimally affected by simultaneous deformity correction; however, the accuracy of angular correction slightly reduces as the deformity becomes more complex. Surgeons should be aware that reprogramming may be required after complex deformity correction.

Is the High Healing Index a Complication of Progressive Long Bone Lengthening? Observations from a Cohort of 178 Children Treated with Circular External Fixation for Lower Limb Length Discrepancy

The use of external fixators (EFs) for lower limb lengthening is common for treating lower limb length discrepancy (LLD) in children. The concern at present revolves around extended treatment times, with some suggesting a healing index (HI) > 45 days/cm as a major complication. The aim of this study is to assess the factors affecting bone healing and treatment duration in children who undergo limb lengthening for LLD using circular EFs. A total of 240 lengthening procedures on 178 children affected by congenital or acquired LLDs (mean age at surgery 13.8 ± 2.8 years) were retrospectively evaluated. Complications according to Lascombes' classification and treatment duration factors were analyzed. Mean HI was 57 ± 25 days/cm for the femur and 55 ± 24 days/cm for the tibia, with an HI > 45 days/cm in 64% of the procedures. A total of 189 procedures (79%) reported complications; 85 had an HI > 45 days/cm as the sole complication. While reducing the frame time is crucial, revising the classifications is necessary to avoid the overestimation of complications.

A Rare Case of Salter-Harris Type I Growth Plate Injury in a Patient Undergoing Limb-Lengthening Procedure

Growth plate injuries over the distal femur typically occur due to high-energy trauma. It is commonly associated with serious complications such as growth disturbance. Its occurrence in children undergoing limb-lengthening procedures is uncommon. We report a case of distal femur growth plate injury in a 13-year-old boy undergoing a limb-lengthening procedure for femoral hypoplasia. Conservative treatment yielded a good functional outcome in this patient.

Case of Infected Non-Union of Distal Femur Treated with Ilizarov Fixator Assisted Knee Arthrodesis and Limb Lengthening Surgery

Introduction

Femoral fractures in adults are around 3-6% and 0.4% of all the fractures are usually distal femoral fractures, frequently consisting of high-energy injuries which are associated with compound trauma. Conventionally, femoral-tibial fusion remains one of the last treatment choices for the recurrent septic failure.

Case Report

We report a unique case where a 52-year-old male had presented with a post-operative infected non-union of distal femur and patella with discharging sinus and distal femur plate in situ. The patient presented to our outpatient department with complaints of pain and swelling over right knee with discharging sinus with fixed flexion deformity of 20° for 1-year post trauma and post-surgery. The discharging sinus was over lateral aspect of knee with purulent discharge. His blood parameters were suggestive of high erythrocyte sedimentation rate, and C-reactive protein levels and a Gram staining were suggestive of Gram-negative bacilli. X-ray showed non-union of distal femur and osteomyelitic changes and knee subluxation with distal femur plate and encirclage with K-wire for patella in situ. The patient underwents three-stage procedure of debridement with implant removal, followed by knee arthrodesis and ultimately limb lengthening surgery.

Conclusion

Our case report is unique and distinctive as it shows that, when a case of infected non-union of distal femur comes with stiff and non-salvageable knee with severe arthritic changes and financial constraints, we should consider for knee arthrodesis with ilizarov ring fixator and limb lengthening surgery. Although it yielded stiff knee but with functioning limb without limb length discrepancy.

Telescoping Allograft Prosthetic Composite (APC) Reconstruction of the Femur Following Revision Arthroplasty for Neglected Developmental Dysplasia of the Hip (DDH)

Although uncommon, neglected developmental dysplasia of the hip (DDH) poses a technically demanding problem for treating surgeons. Due to the congenital malformation of the native hip joint and distortion of the surrounding soft tissue, addressing limb-length discrepancy is intricate. Despite detailed planning and meticulous soft tissue handling, complications can be difficult to avoid in these patients even under experienced hands. In this case report, we present a 73-year-old lady with neglected DDH who had undergone initial total hip arthroplasty and subsequent revision surgery that failed due to aseptic loosening. Due to limited length in the distal femur, we used a telescoping allograft prosthetic composite (APC) to provide adequate length to the native distal femur during revision with proximal femur fixation. This technique can help avoid the need for total femur replacement (TFR) surgery, which is more invasive and may require tibia replacement.

[Preliminary study of Ilizarov technique in treatment of lower limb deformity caused by achondroplasia]

Objective

To investigate the surgical method and preliminary effectiveness of Ilizarov technique in the treatment of lower limb deformity caused by achondroplasia.

Methods

The clinical data of 38 patients with lower limb deformity caused by achondroplasia treated by Ilizarov technique between February 2014 and September 2021 were retrospectively analyzed. There were 18 males and 20 females, the age ranged from 7 to 34 years, with an average of 14.8 years. All patients presented with bilateral knee varus deformity. The preoperative varus angles was (15.2±4.2)°, and knee society score (KSS) was 61.8±7.2. Nine of these patients underwent tibia and fibula osteotomy, 29 cases underwent tibia and fibula osteotomy and bone lengthening at the same time. Full-length bearing position X-ray films of bilateral lower limbs were taken to measure the bilateral varus angles, analyze the healing index, and record the occurrence of complications. KSS score was used to evaluate the improvement of knee joint function before and after operation.

Results

All 38 cases were followed up 9-65 months, with an average of 26.3 months. Needle tract infection occurred in 4 cases and needle tract loosening occurred in 2 cases after operation, which were improved after symptomatic treatment such as dressing change, Kirschner wire change, and oral antibiotics, and no neurovascular injury occurred in all patients. The external fixator was worn for 3-11 months after operation, with an average of 7.6 months, and the healing index was 43-59 d/cm, with an average of 50.3 d/cm. At last follow-up, the leg was 3-10 cm longer, with an average of 5.5 cm. The varus angles was (1.5±0.2)° and the KSS score was 93.7±2.6, which significantly improved when compared with those before operation ( P<0.05).

Conclusion

Ilizarov technique is a safe and effective method for the treatment of short limb with genu varus deformity caused by achondroplasia, which can improve the quality of life of patients.

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.

Tibial Lengthening along Submuscular Plate with Simultaneous Acute Tibial Deformity Correction by High-Energy Osteotomy: A Comparative Study

Submuscular plating and osteotomy using power saw have shown the benefits in certain situations of limb lengthening. However, no previous studies combining both procedures have been conducted for acute tibial deformity correction and limb lengthening. Nineteen cases were enrolled in this study. Ten patients received tibial lengthening with acute knee angular deformity correction using high-energy osteotomy (Group 1), and nine patients received tibial lengthening only with osteotomy using multiple drills and osteotome (Group 2). Radiographic parameters retrieved before and after the operation included leg-length discrepancy, tibial length, length gained, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), and mechanical axis deviation (MAD). There were significant differences between groups in terms of external fixator index (EFI) (p = 0.013) and healing index (HI) (p = 0.014), but no significance in the length gained (p = 0.356). The latest postoperative mLDFA (p = 0.315), MPTA (p = 0.497), and MAD (p = 0.211) of Group 1 were not distinguishable from Group 2. The functional outcomes were excellent, and there were no permanent complications. Despite showing a longer healing time, this alternative lengthening procedure which combines fixator-assisted plate lengthening in the tibia with simultaneous surgical intervention of acute tibial deformity correction using an oscillating saw is appropriate for patients with leg-length discrepancy and angular deformity of the tibia.

Use of the PRECICE Nail for distraction osteogenesis after tumor resection

INTRODUCTION

Reconstructing long bone defects following intercalary tumor resection presents an exciting challenge with a greater range of surgical solutions than more typical situations requiring arthroplasty. Segmental bone transport (distraction osteogenesis) is the least utilized option for intercalary reconstruction, however, it arguably provides patients with the most desirable result. Distraction osteogenesis can be used in the management of multiple skeletal conditions including deformity (either congenital or acquired), or in the presence of bone defects (by trauma or planned surgical excision). Lack of broader adoption of transport is likely due to the highly technical demands and common complications of utilizing fine-wire fixators via the Ilizarov method. More recently, internal lengthening nails such as the PRECICE nail have been employed to facilitate distraction osteogenesis without the added complexity of external fixation.

AREAS COVERED

This review will examine the literature on the indications, design, and safety of the PRECICE nail (NuVasive) for intercalary reconstruction after tumor resection.

EXPERT OPINION

Bone transport using the PRECICE nail represents a viable alternative to Ilizarov distraction and has the benefit of avoiding the complications of an external fixator. For large defects, the PRECICE nail can be supplemented with a locking plate for additional stability and maintenance of limb length.

Characterizing the Magnitude of and Risk Factors for Functional Limb Lengthening in Patients Undergoing Primary Total Knee Arthroplasty

Background: There is little data on the magnitude and factors for functional leg lengthening after primary total knee arthroplasty (TKA). Questions/Purpose: We sought to determine the incidence of and risk factors for functional leg lengthening after primary TKA. Methods: We retrospectively reviewed consecutive unilateral primary TKAs at a single institution from 2015 to 2018. Of the 782 TKAs included, 430 (55%) were performed in women; the mean age was 66 years, and the mean body mass index was 29 kg/m². Preoperatively, 541 (69%) knees were varus deformities and 223 (29%) were valgus deformities. Hip to ankle biplanar radiographs were obtained preoperatively and 6 weeks postoperatively for all patients. Two independent researchers measured leg length, coronal plane deformity, lateral knee flexion angle, and overall mechanical alignment on all preoperative and postoperative radiographs. Results: The mean overall ipsilateral functional leg lengthening was 7.0 mm. Seven hundred knees (90%) were overall functionally lengthened, including 462 (59%) knees lengthened >5 mm and 250 (31%) knees lengthened 10 mm or more. A valgus deformity and coronal plane deformity of 10° or more were significant risk factors for increased functional lengthening. Patients with severe valgus deformities (>10°) had the largest amount of functional lengthening, at a mean of 13.5 mm. Conclusion: After primary TKA, 90% of limbs are functionally lengthened, including roughly one-third over a centimeter. Valgus knee deformities and severe deformities (>10°) were significant risk factors for increased limb lengthening.

Efficacy and safety of botulinum toxin type A in distraction osteogenesis of the lower extremities: a meta-analysis of randomized controlled trials

Background

To explore the efficacy and safety of botulinum toxin in patients who received distraction osteogenesis of the lower extremities.

Methods

We searched the PubMed, Medline, Cochrane Library, and Web of Science databases for randomized controlled trials that administered botulinum toxin to individuals who underwent distraction osteogenesis of the lower limbs. The final search was conducted on July 6, 2021. Quality assessments were conducted using the Cochrane risk of bias tool and the Jadad scale. We performed random-effects meta-analysis to calculate the standardized mean differences (SMDs) and confidence intervals (CIs) of the pooled effect sizes, and subgroup analysis and meta-regression were performed for potential moderators.

Results

Our analysis of four randomized controlled trials, which enrolled a total of 257 participants, revealed that the difference in pain during the distraction phase was not statistically significant between groups (SMD, − 0.165; 95% CI, − 0.379 to 0.050, p = 0.133, I² = 0.0%). The meta-regression analyses did not find any influence on the effect size, considering age (β = − 0.0092; p = 0.61) and the amount of lengthening (β = 0.0023; p = 0.99). Subgroup analysis did not reveal difference between different doses of botulinum toxin and single or multi-site study design. An analysis of two randomized controlled trials enrolling a total of 177 individuals demonstrated a limited effect of botulinum toxin in reducing postoperative pain (SMD, − 0.239; 95% CI, − 0.641 to 0.162, p = 0.24, I² = 37.6%), total adverse events (SMD, − 0.207; 95% CI, − 0.505 to 0.090, p = 0.17, I² = 0.0%), and infection of pin site (SMD, − 0.131; 95% CI, − 0.428 to 0.165, p = 0.39, I² = 0.0%). No botulinum toxin–related adverse events were reported.

Conclusions

The current evidence does not support the administration of botulinum toxin in patients who receive distraction osteogenesis of the lower limbs. However, we were unable to draw decisive conclusions because of the limitations of our meta-analysis. Future well-designed, large-scale randomized controlled trials are necessary to confirm our conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05175-2.

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.

Comparison of Intramedullary Magnetic Nail, Monolateral External Distractor, and Spatial External Fixator in Femur Lengthening in Adolescents with Congenital Diseases

The aim of this study is to evaluate the course of the treatment and clinical and functional outcomes of femur lengthening in adolescents with congenital disorders by the application of different surgical methods. This retrospective study comprised 35 patients (39 procedures). A total of 11 patients underwent femur lengthening with the use of the intramedullary magnetic nail (IMN) Precise 2 (NuVasive, San Diego, CA, USA), 7 patients (11 procedures) with the use of the monolateral external distractor Modular Rail System (MRS) (Smith and Nephew, Memphis, TN, USA), and 17 with the use of the computer-assisted external fixator Taylor Spatial Frame (TSF) (Smith and Nephew, Memphis, TN, USA). The inclusion criteria were as follows: (1) congenital femoral length deficiency without any axial deformities and (2), independently of the finally applied treatment, the technical possibility of use of each of the analyzed methods. The distraction index did not differ significantly between the groups (p = 0.89). The median lengthening index was the lowest in the IMN group (24.3 d/cm; IQR 21.8–33.1) and statistically different in comparison to the MRS (44.2 d/cm; IQR 42–50.9; p < 0.001) and the TSF groups (48.4 d/cm; IQR 38.6–63.5; p < 0.001). Similarly, the consolidation index in the IMN group (12.9 d/cm; IQR 10.7–21.3) was statistically lower than that in the MRS (32.9 d/cm; IQR 30.2–37.6; p < 0.001) and the TSF (36.9 d/cm; IQR 26.6–51.5; p < 0.001) groups. This study indicates that IMN is a more valuable method of treatment for femoral length discrepancy without axial deformity than MRS and TSF in complication rate and indexes of lengthening and consolidation.

Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison

BACKGROUND AND AIMS

An enlarged gastrojejunal anastomosis (GJA) is associated with weight regain after Roux-en-Y gastric bypass (RYGB) and can be corrected with endoscopic or surgical revision; however, there has been no direct comparison between techniques. This study aims to compare serious adverse event (AE) rates and weight loss profiles between endoscopic and surgical revisional techniques over a 5-year period.

METHODS

This is a retrospective matched cohort study of RYGB patients who underwent endoscopic or surgical revision for weight regain with an enlarged GJA (>12 mm). Patients who underwent endoscopic revision (ENDO group) were matched 1:1 to those undergoing surgical revision (SURG group) based on completion of 5-year follow-up, age, sex, body mass index, initial weight loss, and weight regain. Demographics, GJA size, serious AEs, and weight profiles were collected. The primary outcome was comparison of serious AE rates between groups. Secondary outcomes included weight loss comparisons. A Fisher exact test was used to compare the serious AE rate, and a Student t test was used for weight comparisons.

RESULTS

Sixty-two RYGB patients with weight regain and an enlarged GJA (31 ENDO, 31 matched SURG) were included. Baseline characteristics were similar between groups. The AE rate in the ENDO group (6.5%) was lower than the SURG group (29.0%, P = .043). Zero and 6 (19.4%) serious (severe) AEs occurred in the ENDO and SURG groups, respectively (P = .02). There was no significant difference in weight loss at 1, 3, and 5 years.

CONCLUSIONS

Endoscopic revision of the GJA is associated with significantly fewer total and serious AEs and similar long-term weight loss when compared with surgical revision.

Quality of life, physical functioning, and psychosocial function among patients with achondroplasia: a targeted literature review

PURPOSE

Achondroplasia (ACH) is the most common form of skeletal dysplasia, resulting in disproportionate short stature and medical complications. We review the literature on physical functioning, psychosocial function, and quality of life (QoL) in ACH individuals compared to average stature individuals or other short stature conditions. Studies that assess the association between these outcomes and height, limb length/lengthening surgery in ACH patients are also summarized.

MATERIALS AND METHODS

PubMed/MEDLINE and Embase were searched through April 2021. Study inclusion criteria were: (1) quantitative design; (2) study population consisting solely/mainly of ACH patients; (3) reports of physical functioning, psychosocial functioning, and/or QoL. Included studies were summarized separately for pediatric and adult populations.

RESULTS

Of 1664 records identified, 23 primary studies (sample size 8-437 participants) were included. Multiple tools were used across studies, including the generic PedsQL and SF-36 and height-specific QoLISSY.

CONCLUSIONS

The literature demonstrates that ACH patients experience limitations in physical functioning and poorer QoL outcomes compared to average stature people across the life span. This appeared to be at least in part due to disproportionate short stature. Future research to better characterize QoL in ACH patients will assist clinicians to better evaluate the effectiveness of management programs including novel interventions.IMPLICATIONS FOR REHABILITATIONPatients with achondroplasia experience limitations in physical functioning and poorer quality of life throughout their life course when compared to average statured individuals.Psychosocial issues are also heightened in adults with achondroplasia compared to average statured peers but are observed less frequently in children and adolescents with achondroplasia.The overall impact that limb lengthening has on physical functioning and QoL remains unclear, although there is some evidence that greater height or upper limb length may lead to an improvement in these parameters.Rehabilitation professionals should regularly assess physical functioning, psychosocial wellbeing, and quality of life in individuals with achondroplasia using condition-specific tools.

Bone Lengthening with a Motorized Intramedullary Nail in 34 Patients with Posttraumatic Limb Length Discrepancies

The Fitbone® motorized nail system has been used to correct limb length discrepancies (LLD) for several years. This study focuses on its application in posttraumatic limb lengthening surgery, its outcome and challenges.

MATERIALS AND METHODS

A prospective, single center study was conducted between 2010 and 2019 in patients treated with motorized lengthening nails. The inclusion criteria were symptomatic LLD of 20 mm or more. An imaging analysis was done using TraumaCad® software (Brainlab AG, Munich, Germany) to compare frontal alignment angles and limb length discrepancy (LLD) on preoperative and latest follow-up radiographs of the lower limbs.

RESULTS

Thirty-four patients were included with a mean age of 28.8 ± 9.7 years, a mean follow-up of 27.8 ± 13 months and a mean hospital stay of 4.4 ± 1.7 days. The mean LLD was 44 ± 18 mm in 29 femoral and 32 ± 8 mm in 4 tibial cases, which was reduced to less than 10 mm in 25/34 (74%) patients. The mean healing index was 84.6 ± 62.5 days/cm for femurs and 92 ± 38.6 days/cm for tibias. The mean time to resume full weight-bearing without walking aids was 226 days ± 133. There was no significant difference between preoperative and final follow-up alignment angles and range of motion. The mechanical lateral distal femoral angle (mLDFA) was corrected in the subgroup of 10 LLD patients with varus deformity of the femur (preoperative 95.7° (±5.0) vs. postoperative 91.5° (±3.4), p = 0.008). According to Paley's classification, there were 14 problems, 10 obstacles and 2 complications.

DISCUSSION

Six instances of locking screw pull out, often requiring reoperation, raise the question of whether a more systematic use of blocking screws that provide greater stability might be indicated. Lack of compliance can lead to poor outcomes, patient selection in posttraumatic LLD patients is therefore important.

CONCLUSION

Limb lengthening with a motorized lengthening nail for posttraumatic LLD is a relatively safe and reliable procedure. Full patient compliance is crucial. In-depth knowledge of lengthening and deformity correction techniques is essential to prevent and manage complications.

[Research progress of intramedullary lengthening nail technology]

Objective

To review the research progress of intramedullary lengthening nail technology.

Methods

The foreign literature on the development history, types, advantages and disadvantages, indications and contraindications, complications, and effectiveness of intramedullary lengthening nail were reviewed and analyzed.

Results

The intramedullary lengthening nail system mainly includes mechanical type, electric motor drive type, and magnetic drive type. Compared with traditional external fixation and lengthening technology, the intramedullary lengthening nail technology has certain advantages in incidence of complications, bone healing, postoperative functional rehabilitation, incision aesthetics, convenience, and patient satisfaction. However, there are also shortcomings, such as pain, uncontrollable distraction rate, device failure, etc. In the clinical application of intramedullary lengthening nails for limb lengthening, the indications should be grasped reasonably, and the related complications should be prevented and treated.

Conclusion

Intramedullary lengthening nails provide a new option for limb lengthening, and the initial effectiveness is good. It is one of the development direction of limb lengthening technology.

Intramedullary Bone Lengthening Following Preceding Hip Surgery-A Case Series

Limb length discrepancy (LLD) is a common problem after joint-preserving hip surgeries, hip dysplasia, and hip deformities. Limping, pain, sciatica, paresthesia, and hip instability are common clinical findings and may necessitate limb-lengthening procedures. The study included five patients (two female and three male, mean age of 28 years (20–49; SD: 12)) with symptomatic limb length discrepancy greater than 2.5 cm (mean: 3.6 cm) after total hip arthroplasty (THA), hip dysplasia, or post-traumatic hip surgery. They underwent either ipsi- or contralateral intramedullary limb-lengthening surgeries using the PRECICE™ telescopic nail. All patients achieved complete bone healing and correction of the pelvic obliquity after intramedullary lengthening. None of the patients had a loss of proximal or distal joint motion. The mean distraction-consolidation time (DCT) was 3.8 months, the distraction index (DI) 0.7 mm/day, the lengthening index (LI) 1.8 months/cm, the consolidation index (CI) 49.2 days/cm, the healing index (HI) 1.1 months/cm, and the modified healing index (HI*) 34 days/cm. Intramedullary limb lengthening after LLD in cases of hip dysplasia, hip deformity, and various kinds of hip surgery is a useful and safe procedure in young patients to achieve equal limb length. No functional impairment of the preceded hip surgery was seen.

Limb lengthening in the treatment of posteromedial bowing of the tibia

PURPOSE

Posteromedial bowing of the tibia is an uncommon but recognized congenital lower extremity deformity in children that can lead to limb length discrepancy (LLD) and residual angulatory deformity. The purpose of this study is to report a series of children at a single institution with posteromedial bowing treated by lengthening.

METHODS

A retrospective review was carried out at our institution identifying 16 patients who were treated with limb lengthening for posteromedial bowing of the tibia and followed to skeletal maturity. Projected LLD was a mean of 7.7 cm (range 5.0 cm to 14.2 cm). Three patients were treated in a staged fashion with lengthening and deformity correction at age three to four years and subsequent definitive tibial lengthening. The remaining 13 patients were treated with limb lengthening approaching adolescence using circular external fixation.

RESULTS

All patients were pain free and ambulated without a limp at final follow-up. The mean final LLD was 0.3 cm short. In spite of correction of distal tibial shaft valgus in 11 of the 16 patients, eight of the 16 (50%) required later correction of persistent, symptomatic ankle valgus by either hemiepiphyseodesis (seven patients) or osteotomy (one patient).

CONCLUSIONS

Children with posteromedial bowing of the tibial with projected LLD over 5cm can be effectively treated with lengthening. Patients with severe valgus of more than 30° of shaft valgus and difficulty ambulating at age three years can be successfully treated with a two-stage lengthening procedure. Attention should be paid in patients with posteromedial bowing to ankle valgus.

LEVEL OF EVIDENCE

IV.

Microsurgical reconstruction of congenital upper extremity deformities of malformations

We present two rare microsurgical reconstructions. A case with phocomelia was treated with lengthening of soft tissues following vascularized fibula grafting with epiphysis, and a case with cleft hand was reconstructed with spare-part toe transfer.

Surgical Ectrodactyly Repair Using Limb-lengthening and Bone Tissue Engineering Techniques in a Toy Dog Breed

BACKGROUND/AIM

Bone tissue engineering is an emerging field of regenerative medicine that holds promise for the restoration of bones affected by trauma, neoplastic diseases, and congenital deformity. During the past decade, bone tissue engineering has evolved from the use of biomaterials that can only replace small areas of damaged bone, to the use of scaffolds in which grafts can be seeded before implantation. This case report proposes an alternative option for a veterinary patient suffering from ectrodactyly, which is one of several congenital deformities in dogs. A 2-month-old male toy poodle dog with ectrodactyly was treated using several stages of surgery involving pancarpal arthrodesis, limb lengthening, and bone tissue engineering techniques.

RESULTS AND CONCLUSION

Over a period of 2 years, the operated limb gained almost the same function as the contralateral limb. Bone tissue engineering techniques can be used for the treatment of congenital deformities in dogs.

Bifocal treatment for peri-articular femoral nonunions: A retrospective case series review

Aim

This is a retrospective review of complex periarticular femoral nonunions where bone loss from comminution at original fracture, subsequent infection or lysis was identified and treated by radical excision, internal fixation, and concurrent femoral lengthening from a different level.

Material and Method

Sixteen patients with a mean age of 41 years were treated. There were 6 infected nonunions. Ten nonunions were located in the distal femur and the remaining proximal. Case notes and radiograph review were used to determine fracture union, lengthening achieved, and complications. Patient outcome was assessed using the SF-12, Tegner-Lysholm Knee Score, and Oxford Hip Score.

Results

Fracture union was achieved in all patients. The mean lengthening performed was 51 mm (range 30-80) with a fixator time averaging 39 weeks (range 17-80). The bone healing index was 1.9 months/cm. All but 2 patients were restored to within 5 mm of opposite leg length; 1 patient subsequently underwent contralateral limb shortening. The SF-12 had a mean Physical Health Composite Score of 40.0 (22.4-52.9) and a mean Mental Health Composite Score of 49 (30.7-62.0). The Oxford Hip Score was scored at a mean of 39 (21-47) and the Tegner-Lysholm score had a mean of 71 (36-94). There were 3 cases of fracture/deformity from the lengthened bone column (regenerate) and 2 patients required a quadricepsplasty for knee stiffness that was present prior to the treatment for the nonunion.

Conclusion

Bifocal treatment of complex periarticular femoral nonunions offers a single solution for dealing with bone loss, nonunion, and instability. The method is safe and reliable but has, as with all methods involving distraction osteogenesis, a significant complication rate. Despite this caution, the patients' outcomes were satisfactory.

Femur Lengthening in a Patient with a Pseudoaneurysm of the Superficial Femoral Artery Treated with Covered Stent

This case report presents a 29-year-old male patient who presented an articular distal femoral fracture sustained in a road traffic accident in Benin. After the different surgical procedures, the patient presents a knee stiffness and a shortening of the left leg of 7 cm. An ablation of osteosynthesis material and a Judet procedure was done. After this surgical intervention, the patient developed pain, pulsatile swelling of the left knee. A false aneurysm of the superficial femoral artery was evidenced, and a percutaneous endovascular procedure was performed. As a result of the important leg-length discrepancy, a femoral lengthening of 6 cm was performed using intramedullary skeletal kinetic distractor nail. We show that a 6 cm femur lengthening in a patient with a femur stent is possible using intramedullary nails provided that orthopedic and vascular surgeons monitor the patient in strict clinical and paraclinical followup conditions.

Asymmetric limb lengthening in the treatment of tibial hemimelia caused by osteomyelitis: A case report

RATIONALE

Tibial hemimelia is known as a rare congenital lower limb deficiency. It has been classified into different types based on Jones classification, and the traditional treatment of tibial hemimelia is amputation. Here we present a variant and unclassified case of tibial hemimelia, which was caused by osteomyelitis. And the lower limb with tibial hemimelia was salvaged by asymmetric limb lengthening.

PATIENT CONCERNS

19-year-old girl had the shortened and curved left lower extremity with walking abnormalities.

DIAGNOSIS

The patient's deformity was caused by osteomyelitis of tibia occurred when she was 18 month old. The tibial shaft was absent, while the proximal and distal tibia was present but was hypoplastic with radiographic analysis. The fibula was hypertrophied and curved like the capital letter C. The leg length discrepancy (LLD), mostly coming from the left lower leg, was 22 cm.

INTERVENTIONS

We were able to salvage the limb successfully by 5 operations, including releasing soft tissue, fusing the proximal tibiofibular joint, fibular osteotomy, femur lengthening, and fibular lengthening.

OUTCOMES

The whole treatment time for the patient was 3 years and 2 months, and she was followed up for 5 years afterward. The length of femur lengthening and fibula lengthening during the reconstruction were 7.8 cm and 11 cm, respectively. Most of the deformities were corrected, except that the left lower limb was still 2 cm shorter than the contralateral limb, and the 34 mm of mechanical axis deviation (MAD) of left lower limb remained. The reason why the patient's lower limbs were asymmetric was that the femur and fibular lengthening were performed within the affected limb only. Overall, the patient was very satisfied with her asymmetric limbs and its function after surgeries.

LESSONS

The LLD in this case mainly came from tibial hemimelia. However, the fibula was unable to be lengthened to 22 cm during the lower leg distraction process because of blood flow disturbance. We could only lengthen the femur to salvage the limb in this situation. Even though the patient still had a few residual deformities and a pair of asymmetric lower limbs, she was satisfied with the function and appearance of the reconstructed limb. Therefore, the lower limb with tibial hemimelia can be salvaged by asymmetric limb lengthening in special cases.

Radiomorphological Manifestations of Femoral and Tibial Cortical Bones at Different Stages of Limb Lengthening

BACKGROUND

There has been a lot of research done on Ilizarov's limb lengthening; however, very few publications focus on the quantitative assessment of the distractional bone regeneration in tibial and femur lengthening. Data regarding quality of the bone after lengthening are needed to consider the time of frame removal and develop a rehabilitation program.

MATERIALS AND METHODS

Computed tomography (CT) assessment of a parent bone was performed on 136 patients with limb length discrepancy and bone deformity of various etiologies before and after lengthening. Transosseous osteosynthesis technique with the Ilizarov's external fixation was used for limb lengthening and deformity correction in all the cases. A 64-slice scanner was used for CT assessments. Specific Roentgen-negative units of the Ilizarov apparatus and techniques for interpreting CT findings were employed for artifact-free densitometric assessment.

RESULTS

Cortical density of the femur and tibia in patients with limb length discrepancy and bone deformity of various etiologies was shown to have differences as compared to the contralateral limb. The lengthening process was accompanied by decreased cortical density of the segment being lengthened, and the decrease in the density was greater in the areas adjacent to the distractional bone regeneration. The cortical structure underwent characteristic changes. Osteonal density of the cortical bone was higher in the norm and at long term followup as compared to the density of external and internal plates.

CONCLUSION

Cortical bone of the femur and tibia in patients with limb length discrepancy and bone deformity of various etiologies showed various preoperative local densities of external, internal, and osteon layers. The cortical bone demonstrated heterogenic structures with resorption areas of various magnitude and density, with minimal values at the boundary with regenerate bone during distraction and fixation with frame on and at short-term followup. Complete organotypical restructuring of the bone was shown to occur at a 1-to-3-year followup depending on the etiology of the disease and amount of lengthening performed.

Proximal Femoral Shape Changes the Risk of a Leg Length Discrepancy After Primary Total Hip Arthroplasty

BACKGROUND

To evaluate how canal morphology affects the technical aspects of total hip arthroplasty, we investigated the effects of femoral cortical index (FCI) on the re-establishment of leg length at the conclusion of surgery.

METHODS

We retrospectively reviewed age, gender, body mass index, and radiographs of 516 patients with osteoarthritis or osteonecrosis who underwent unilateral cementless primary total hip arthroplasty between 2008 and 2015. Patients were divided into level of FCI and leg length discrepancy (LLD). Each cohort was compared in terms of demographics and LLD. One-way analysis of variance and Kruskal-Wallis test were used.

RESULTS

The mean FCI and LLD were 0.6 ± 0.1 and 3.5 ± 6.3 mm, respectively. Utilization of an extended offset stem was highest with Dorr type A and B hips (P = .001). High FCI increased the risk of lengthening (P = .017) and low FCI increased the risk of shortening (P = .005).

CONCLUSION

A high FCI increases the probability of a leg length increase and a low FCI increases the probability of a leg length decrease. Surgeons might consider informing patients in advance of possible variation in leg length depending on the patients' proximal femoral shape and bony quality.

A Comparison of Femoral Lengthening Methods Favors the Magnetic Internal Lengthening Nail When Compared with Lengthening Over a Nail

BACKGROUND

Bone lengthening with an internal lengthening nail (ILN) avoids the need for external fixation and requires one less surgical procedure than lengthening over a nail (LON). However, LON has been shown to be superior to femoral internal lengthening using a mechanical nail. The magnetic ILN, a remote-controlled and magnet-driven device, may have overcome the weaknesses of earlier internal lengthening technology and may be superior to LON.

QUESTIONS/PURPOSES

(1) Is the magnetic ILN more accurate than LON for femoral lengthening? (2) Does the magnetic ILN demonstrate more precise distraction rate control than LON? (3) Does the magnetic ILN result in faster regenerate site healing, with more robust callus, than LON? (4) Does the magnetic ILN result in fewer complications, including impediments to knee motion, than LON?

METHODS

We conducted a retrospective comparison of the records and radiographs of 21 consecutive patients with 22 femoral lengthenings using LONs and 35 consecutive patients with 40 femoral lengthenings using remote-controlled magnetic ILNs. Primary outcomes measured included accuracy, distraction rate precision, time to bony union, final knee range of motion, regenerate quality, and complications. The minimum follow-up times for the LON and ILN cohorts were 13 and 21 months, respectively.

RESULTS

Patients treated with ILN had a lower post-treatment residual limb-length discrepancy (0.3 mm) than those treated with LON (3.6 mm). The rate of distraction was closer to the goal of 1 mm/day and more tightly controlled for the ILN cohort (1 mm/day) than that for the LON group (0.8 mm/day; SD, 0.2). Regenerate quality was not significantly different between the cohorts. Bone healing index for ILN was not statistically significant. Time to union was shorter in the ILN group (3.3 months) than that in the LON group (4.5 months). A lower percentage of patients experienced a complication in the ILN group (18%) than in the LON group (45%). Knee flexion at the end of distraction was greater for ILN patients (105°) than that for LON patients (88.8°), but this difference was no longer observed after 1 year.

CONCLUSIONS

Femoral lengthening with magnetic ILN was more accurate than with LON. The magnetic ILN comports the additional advantage of greater precision with distraction rate control and fewer complications. Both techniques afford reliable healing and do not significantly affect knee motion at the final follow-up. The magnetic ILN method showed no superiority in regenerate quality and healing rate.

A Rare Fatal Complication of Llizarov Procedure

Ilizarov process is used for the management of multiple fractures, polytrauma conditions, cosmetic limb lengthening, and fracture malunion. Complications associated with the process are nerve palsy, joint contracture, premature or delayed osseous consolidation, a nonunion and permanent stiffness of the joint, pin tract infection, edema, and transient paresthesia, etc. In our case, there was a fatal complication. A 25-year-old African lady underwent the Ilizarov procedure for femur lengthening in a hospital in New Delhi, India. During her first distraction process, she suddenly collapsed at the hospital and could not be revived. At postmortem, a small hematoma was seen around the surgically fractured area. On histopathology of internal organs, fat globules were present in the vasculature of brain and lungs. Cause of death was opined as due to fat embolism. This is the first case reported of a fatal fat embolism following Ilizarov procedure for limb lengthening in a healthy adult.

[Application of Orthofix unilateral external fixator in the treatment of musculoskeletal tumors]

Objective

To investigate the surgical characteristics and preliminary effectiveness of Orthofix unilateral external fixator in the treatment of musculoskeletal tumors.

Methods

Twenty-two patients received Orthofix unilateral external fixator treatment for bone defect after tumor excision or complications after limb salvage surgery between June 2011 and March 2016. There were 11 males and 11 females with a median age of 23.5 years (range, 4-57 years). The bone defect or limb length discrepancy after tumor resection was at proximal femur in 6 cases, distal femur in 8 cases, diaphysis of femur in 3 cases, proximal tibia in 2 cases, and diaphysis of tibia in 3 cases. The external fixation was used for temporary fixation after reconstruction of bone defect in 10 cases [the length of bone defect was 6-19 cm (mean, 12.3 cm); using vascularized fibular graft in 2 cases, allograft bone and free fibular graft in 2 cases, allograft bone and autogenous bone graft in 5 cases, allograft bone reconstruction in 1 case]; bone distraction lengthening for limb length discrepancy in 5 cases [the length of shortening was 6.5-8.5 cm (mean, 7.5 cm)]; temporary fixation after open biopsy in 3 cases; bone transportation over locking plate in 1 case (the length of bone defect was 7.5 cm); fixation for preoperatively pathology fracture in 1 case; and joint distraction for dislocation after tumor ablation in 2 cases.

Results

All the patients were followed up 12-72 months (mean, 36 months). In 10 patients with bone defect reconstruction, the wearing external fixator time was 3-8 months (mean, 4.8 months); all got bone union with the healing time of 3-16 months (mean, 6.4 months); the Musculoskeletal Tumor Society 93 (MSTS 93) score was 73.3-93.3 (mean, 87.2); and no complication occurred during wearing external fixator. In 5 patients with bone distraction lengthening for limb length discrepancy, the wearing external fixator time was 7-15 months; 2 patients had axial deviation during distraction and2 had greenstick fracture after apparatus removal; pin site infection was observed in 2 cases with grade 1 and 1 case with grade 2 according to Checketts-Otterburn classification system; the MSTS 93 score was 80.0-96.7 (mean, 89.2). The remaining patients had no complications, the knee and ankle joint movement was normal.

Conclusion

Orthofix unilateral external fixator can be used in fixation for complex bone defect after tumor resection and to correct limb length discrepancy after limb salvage surgery.

Retrograde magnetic internal lengthening nail for acute femoral deformity correction and limb lengthening

INTRODUCTION

The Precice magnetic internal lengthening intramedullary nail is being used with great success in femur lengthening and deformity correction with a retrograde approach. Areas Covered: Our personal history of limb lengthening and the Precice nail will be reviewed. Several technical aspects are discussed including design updates, pre operative planning, selection of nail length, the use of blocking screws and intra operative temporary external fixation, osteotomy practice, post operative management, and cost analysis. Expert Commentary: The phenomenal bone healing ability for the retrograde Precice nail after femoral osteotomy for lengthening, even after acute deformity correction, is recognized throughout the growing body of scientific publications on this topic. The few failures that have occurred appear to be attributable to excessive loading of the femur and implant during a vulnerable time of bone healing. Further studies with more uniform outcome criteria need to be conducted to better standardize user's experiences. The higher one time cost of the implant is offset by the reduced number of surgeries needed when compared with the gold standard of lengthening-over-nail-technique, and we suspect that patients return to work sooner due to the ability to wear normal clothing and the reduction in pain throughout the entire lengthening process.

[Application of shortened replantation combined with limb lengthening in treatment of severe amputation of middle and distal lower leg]

Objective

To investigate the effectiveness and technical points of shortened replantation combined with limb lengthening in the treatment of severe amputation of middle and distal lower leg.

Methods

Twelve cases of severe amputation of middle and distal lower leg were treated with shortened replantation at the 1st stage and limb lengthening at the 2nd stage between April 2009 and May 2016. There were 9 males and 3 females with an average age of 28 years (range, 16-32 years). The injury causes included traffic accident injury in 4 cases, heavy pound injury in 6 cases, and machine crush injury in 2 cases. The interval from injuries to treatment ranged from 30 minuts to 6 hours (mean, 3 hours and 12 minutes). All of 12 cases, 6 cases were completely amputated in the right middle and distal lower leg, 4 were not completely amputated in the left middle and distal lower leg, and 2 were ankle amputations. The limbs were 4.0-12.5 cm shorter than the contralateral sides, with an average of 7.3 cm. Limb lengthening was performed at 1.5-8.0 months after replantation and the time of extension was 1.7-5.3 months (mean, 3.1 months).

Results

All 12 patients recovered the same lengths of both lower extremities after shortened replantation and limb lengthening. The lengthened segments gained good bone mineralization, bony union was achieved at lengthened segments and broken end of fracture at 7-16 months (mean, 11.3 months). All patients were followed up 6 months to 5 years (mean, 2 years and 5 months). The range of motion of the knee joint were 0-5° (mean, 3°) in hyperextension and 110-140° (mean, 120°) in flexion. Except for 2 cases of ankle arthrodesis, plantar flexion angles were 15-45° (mean, 26°) and dorsiflexion angles were 10-25° (mean, 15°) in the other cases. The plantar sensation was restored to the S _{3 ⁺} level in 4 cases, S ₃ level in 6 cases, and S ₂ level in 2 cases. At last follow-up, the affected limb function were excellent in 7 cases, good in 3 cases, fair in 2 cases according to Kofoed functional evaluation criteria.

Conclusion

It expanded indications for replantation of lower limb amputation, reduced the operation difficulty and trauma with shortened replantation combined with limb lengthening in the treatment of severe amputation of middle and distal lower leg.

Adult Posttraumatic Reconstruction Using a Magnetic Internal Lengthening Nail

A new generation of internal lengthening nail is now available that has reliable remote-controlled mechanisms. This allows accurate and well-controlled distraction rate and rhythm, and early clinical results have been very positive. In this article, 2 posttraumatic cases are presented that illustrate deformity correction and lengthening using the internal lengthening nail. Surgical planning and adjuvant techniques of fixator-assisted nailing and the use of blocking screws are discussed.

Tibial lengthening over intramedullary nails: A matched case comparison with Ilizarov tibial lengthening

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

Methods

In this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who underwent 19 Ilizarov tibial lengthenings were retrospectively matched to the LON group.

Results

The mean external fixation time for the LON group was 2.6 months and for the matched case group was 7.6 months. The mean lengthening amounts for the LON and the matched case groups were 5.2 cm and 4.9 cm, respectively. The radiographic consolidation time in the LON group was 6.6 months and in the matched case group 7.6 months. Using a clinical and radiographic outcome score that was designed for this study, the outcome was determined to be excellent in 17 and good in two patients for the LON group. The outcome was excellent in 14 and good in five patients in the matched case group. The LON group had increased blood loss and increased cost. The LON group had four deep infections; the matched case group did not have any deep infections.

Conclusions

The outcomes in the LON group were comparable with the outcomes in the matched case group. The LON group had a shorter external fixation time but experienced increased blood loss, increased cost, and four cases of deep infection. The advantage of reducing external fixation treatment time may outweigh these disadvantages in patients who have a healthy soft-tissue envelope.

Cite this article: J. E. Herzenberg. Tibial lengthening over intramedullary nails: A matched case comparison with Ilizarov tibial lengthening. Bone Joint Res 2016;5:1–10. doi: 10.1302/2046-3758.51.2000577

Knee arthrodesis as limb salvage for complex failures of total knee arthroplasty

Patients with multiple failures of total knee arthroplasty (TKA) are challenging limb salvage cases. Twenty one patients over the last 10 years were referred to our service for knee fusion by arthroplasty surgeons who felt they were not candidates for revision TKA. Active infection was present in 76.2% and total bone loss averaged 6.6 cm. Lengthening was performed in 7/22 patients. Total time in Ilizarov frames was 9 months, with 93.3% union. Patients treated with IM fusion nails had 100% union. Average LLD increased from 3.6 to 4.5 cm following intervention, while those with concurrent lengthening improved to 1.6 cm. Findings suggest that bone loss and the soft-tissue envelope dictate knee fusion method, and multiple techniques may be needed. A treatment algorithm is presented.

Diverse muscle architecture adaptations in a rabbit tibial lengthening model

BACKGROUND

during limb lengthening, muscles are thought to increase the number of sarcomeres. However, this adaptation may differ among muscles with diverse architecture.

PURPOSE

this study wish to clarify the differences in muscle adaptation in a rabbit model of tibial lengthening.

METHODS

twelve rabbits underwent tibial lengthening (0.7 mm/day for 4 weeks), with the contralateral limb serving as a control, and were euthanized after either the lengthening or the consolidation period. Six muscles around the tibia were investigated in terms of muscle belly length, muscle weight, sarcomere length and serial sarcomere number.

RESULTS

muscle belly length increased in all the lengthened muscles. No increases in muscle mass were noted. Sarcomere length increased in the ankle plantar-flexors and was kept longer than the optimal sarcomere length after the consolidation period. Nevertheless, significant increases in sarcomere number were observed in two ankle plantar-flexors.

CONCLUSION

this study demonstrated that muscle belly length largely adapted to the lengthening. The increase in sarcomere number did not match the increase in muscle belly length. We estimated that elongation of the intramuscular aponeuroses is another mechanism of the adaptation in addition to the increase in sarcomere number.

Osteosarcoma of the distal radius treated with segmental forearm resection, hand replantation, and subsequent limb lengthening: case report

A 9-year-old girl with osteosarcoma of the radius was treated with segmental forearm resection and replantation followed by forearm lengthening of 11 cm. At 9-year follow-up, she had recovered sensory function, and her pinch and grasp were sufficient for performing daily activities. Functional outcomes evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire and International Society of Limb Salvage functional score system were 4/100 and 23/30, respectively.

Role of sodium channels in recovery of sciatic nerve-stretch injury in rats

INTRODUCTION

To elucidate the mechanism of functional recovery after gradual nerve-stretch injury, we used rats in which the femur length was increased by 15 mm at 1.5 mm/day.

METHODS

We performed electrophysiology, mRNA analysis of tetrodotoxin-resistant voltage-gated sodium channels (TTX-R VGSCs) in dorsal root ganglia, and histology of unmyelinated sciatic nerve fibers and examined pain thresholds at 1, 10, 20, and 30 days after cessation of lengthening.

RESULTS

Electrophysiology revealed conduction block after cessation that recovered after 30 days. TTX-R VGSC levels decreased immediately after cessation but were restored after 10 (Nav1.9) or 20 (Nav1.8) days. Histology revealed that injured unmyelinated nerve fibers regenerate 30 days after cessation. Pain threshold decreased gradually during lengthening but had not recovered to the control group level after 30 days.

CONCLUSIONS

Early restoration of TTX-R VGSC mRNA in dorsal root ganglia preceded functional recovery of stretched nerves before regeneration of injured unmyelinated nerve fibers.

Distraction by a monotube fixator to achieve limb lengthening: predictive factors for tibia trauma

BACKGROUND

Management of post trauma tibia bone gap varied with orthopedic surgeons' experience and tools available. Study aims to determine predictive factors for distraction by a monotube fixator (DMF) outcome in post tibia trauma limb length discrepancy.

METHODS

A prospective descriptive cross sectional study of post traumatized tibia bone gap and limb length discrepancy patients at tertiary hospitals. Patient's informed consent and institutional ethical committee approval were obtained. Bio-data, clinical and healing indexes were documented. DMF was applied for patient that met inclusion criteria. The Statistic tests used included the Chi-square, the Student's two-tailed t test, and the Wilcox on rank-sum test when appropriate. Mantel-Haenszel Common Odds Ratio (OR) and 95% confidence intervals for poor outcome potential risk factors were recorded. Bivariate correlation and logistic regression were evaluated. Significance level was set at a p value <0.05.

RESULTS

Thirty-six patients with mean age, 37.2 ± 10.3 year and male/female ratio of 1:1.25 had DMF applied. Motorcycle accident accounted for 50.0% of patients and diaphyseal segment was most commonly affected 25 (69.4%). The mean bone lengthened was 10.1 ± 4.0 cm (range: 5-21 cm) and mean duration of bone transport was 105.6 ± 38.2 days. The means of rate of distraction, healing index and percentage of lengthening were 0.99 ± 0.14 mm/day, 15.6 ± 4.3 days/cm and 38.0 ± 14.3 respectively. The mean follow up was 9.7 ±4.9 months (range: 2-17.0). Per operative complications varied and outcome was satisfactory in 30 (83.3%). Obesity (p <0.0001), multiple surgery (p = 0.012) and transfusion (p = 0.001) correlated to poor outcome. Percentage lengthening ≥ 50%, bone gap >10 cm, anemia, blood transfusion, general anesthesia administration, distraction rate >1 mm/day, osteomyelitis and prolong partial weight bearing were significant predictive factors for poor outcome in post traumatic tibia distraction.

CONCLUSION

Distraction by a monotube fixator appears effective in achieving correction >38.0% original tibia lengthening following traumatic bone gap. Predictive factors for poor outcome were useful for prognostication.

Treatment of varus deformities of the lower limbs in patients with achondroplasia and hypochondroplasia

Angular deformities of the lower limbs are a common clinical problem encountered in pediatric orthopaedic practices particularly in patients with osteochondrodysplasias. The varus deformity is more common than the valgus deformity in achondroplasia and hypochondroplasia patients because of the unusual growth of the fibulae than that of the tibiae. We retrospectively reviewed six patients (four patients with achondroplasia and two patients with hypochondroplsia) with relevant limb deformities due to the above-mentioned entities. All patients manifested significant varus deformity of the lower limbs. Detailed phenotypic characterization, radiologic and genetic testing was carried out as baseline diagnostic tool. We described the re-alignment procedures, which have been applied accordingly. Therefore, bilateral multi-level procedures, multi-apical planning and limb lengthening have been successfully applied. While recognition of the underlying syndromic association in patients who are manifesting angular deformities is the baseline for proper orthopaedic management, this paper demonstrates how to evaluate and treat these complex patients.

Limb lengthening over plate

BACKGROUND

The limb lengthening over plate eliminates the associated risk of infection with limb lengthening over intramedullary nail. We present our experience of limb lengthening in 15 patients with a plate fixed on the proximal segment, followed by corticotomy and application of external fixator.

MATERIALS AND METHODS

15 patients (7 females, 8 males) were included in this consecutive series. The average age was 18.1 years (range 8-35 years). Fifteen tibiae and one femur were lengthened in 15 patients. Lengthening was achieved at 1 mm/day followed by distal segment fixation with three or four screws on reaching the target length.

RESULTS

The preoperative target length was successfully achieved in all patients at a mean of 4.1 cm (range 1.8-6.5 cm). The mean duration of external fixation was 75.3 days (range 33-116 days) with the mean external fixation index at 19.2 days/cm (range 10.0-38.3 days/cm). One patient suffered deep infection up to the plate, three patients had mild procurvatum deformities, and one patient developed mild tendo achilles contracture.

CONCLUSION

Lengthening over a plate allows early removal of external fixator and eliminates the risk of creating deep intramedullary infection as with lengthening over nail. Lengthening over plate is also applicable to children with open physis.

Limb lengthening over a nail can safely reduce the duration of external fixation

BACKGROUND

Limb lengthening using Ilizarov external fixation is safe, but the consolidation phase tends to take too long. A method that can safely reduce the time spent in external fixation would help increase patient tolerance and comfort. We report our results of lengthening over nails (LON) method in which an interlocking nail was used along with an Ilizarov external fixator to reduce external fixation duration in limb lengthening. This is a retrospective study.

MATERIALS AND METHODS

Twenty-seven lengthening surgeries were done with the LON method in 23 patients with 22 tibiae and five femora during the last 12 years. Length gain ranged from 1.5 cm to a maximum of 9.8 cm with a mean of 4.6 cm. The mean modified Paley difficulty score was 7.6 points. Fourteen associated procedures were performed in these patients, including equinus contracture releases, supracondylar osteotomies, ilizarov hip reconstruction and ankle fusion. We had a 29% rate of complications which included one problem, three obstacles and four complications with no serious deep intramedullary infections. Our rate of complications compares favorably with series reported in the literature. External fixation duration was reduced significantly to a mean of 17.8 days per cm.

CONCLUSIONS

A combination of intramedullary nailing along with external fixation significantly reduces external fixation time while maintaining low rate of complications. Great care needs to be taken to prevent pin track infection and deep intramedullary sepsis.

The mechanics of external fixation

External fixation has evolved from being used primarily as a last resort fixation method to becoming a main stream technique used to treat a myriad of bone and soft tissue pathologies. Techniques in limb reconstruction continue to advance largely as a result of the use of these external devices. A thorough understanding of the biomechanical principles of external fixation is useful for all orthopedic surgeons as most will have to occasionally mount a fixator throughout their career. In this review, various types of external fixators and their common clinical applications are described with a focus on unilateral and circular frames. The biomechanical principles that govern bony and fixator stability are reviewed as well as the recommended techniques for applying external fixators to maximize stability. Additionally, we have illustrated methods for managing patients while they are in the external frames to facilitate function and shorten treatment duration.

Taylor spatial frame-software-controlled fixator for deformity correction-the early Indian experience

BACKGROUND

Complex deformity correction and fracture treatment with the Ilizarov method needs extensive preoperative analysis and laborious postoperative fixator alterations, which are error-prone. We report our initial experience in treating the first 22 patients having fractures and complex deformities and shortening with software-controlled Taylor spatial frame (TSF) external fixator, for its ease of use and accuracy in achieving fracture reduction and complex deformity correction.

SETTINGS AND DESIGN

The struts of the TSF fixator have multiplane hinges at both ends and the six struts allow correction in all six axes. Hence the same struts act to correct either angulation or translation or rotation. With a single construct assembled during surgery all the desired axis corrections can be performed without a change of the montage as is needed with the Ilizarov fixator.

MATERIALS AND METHODS

Twenty-seven limb segments were operated with the TSF fixator. There were 23 tibiae, two femora, one knee joint and one ankle joint. Seven patients had comminuted fractures. Ten patients who had 13 deformed segments achieved full correction. Eight patients had lengthening in 10 tibiae. (Five of these also had simultaneous correction of deformities). One patient each had correction of knee and ankle deformities. Accurate reduction of fractures and correction of deformities and length could be achieved in all of our patients with minimum postoperative fixator alterations as compared to the Ilizarov system. The X-ray visualization of the osteotomy or lengthening site due to the six crossing struts and added bulk of the fixator rings which made positioning in bed and walking slightly more difficult as compared to the Ilizarov fixator.

CONCLUSIONS

The TSF external fixator allows accurate fracture reduction and deformity correction without tedious analysis and postoperative frame alterations. The high cost of the fixator is a deterrent. The need for an internet connection and special X-rays to operate the fixator add to its complexity.