Brachymetacarpia - our experience with internal device for distraction osteogenesis in adolescent patients.

What's New in Limb Lengthening and Deformity Correction.

The aim of this study was to present the results of seven cases of metacarpal lengthening by distraction osteogenesis and to discuss the ideal daily rate of distraction. Metacarpal lengthening was performed by distraction osteogenesis in the seven metacarpals of four patients (3 females, 1 male; mean age: 14.9 years). A unilateral external fixator was used for lengthening. Lengthening was initiated with a distraction rate of 2x0.5 mm/day in the patient with bilateral involvement of the middle and ring metacarpals. On the tenth day of lengthening, distraction was discontinued due to pain and contracture. Then, distraction was continued with a rate of 2x0.25 mm/day. In all other cases, the distraction rate was 0.5 mm/day. Pre- and postoperative range of motion was measured with a goniometer. Patient satisfaction was evaluated with visual analog scale. The mean pre- and postoperative metacarpal lengths were 34.6 mm (range: 33 to 37) and 49.7 mm (range: 47 to 52), respectively. The mean lengthening achieved was 15.1 mm (range: 14 to 17), while the mean distraction rate was 0.55 mm/day (range: 0.48 to 0.63). No functional loss was observed in the fingers at the final check-up. The patients were happy with the functional and cosmetic results. Distraction osteogenesis is a safe method providing acceptable cosmetic and functional results in patients with congenital metacarpal shortness. The length of metacarpals and muscles that will be affected from lengthening should be considered when determining the daily rate of distraction.

Objectives:The primary objective of this study was to evaluate the correlation between height and metacarpal length in normal adults using computed tomographic (CT) scans. A secondary aim was to determine if differences exist between various finger metacarpals. We hypothesized a direct correlation between height and metacarpal length, with consistent proportions across different finger metacarpals.Methods:This radiographic study analyzed 40 CT scans of skeletally mature adult patients. Measurements of the metacarpal lengths were taken using the Sectra IDS7 diagnostic imaging platform. Patient demographics, including age, sex, height, weight, and BMI, were collected. Differences between genders and among metacarpals were assessed using independent sample t-tests, while Pearson correlation coefficients determined the relationship between height and metacarpal length. Statistical significance was defined at P<0.05.Results:The study population consisted of 28 men and 12 women, with an average age of 42.6 years. The mean heights and weights were 175.3 cm and 87.4 kg, respectively. The average lengths of the metacarpals were: index, 67.7 mm; long, 66.1 mm; ring, 58 mm; small, 52.3 mm. Pearson correlation coefficients between height and metacarpal lengths averaged 0.71, indicating a statistically significant positive correlation across all metacarpals. The index metacarpal most closely correlated with patient height.Conclusion:Our findings confirm a significant positive correlation between height and metacarpal length, supporting the hypothesis of a direct relationship. These results suggest that height can be a useful predictor for metacarpal length, potentially aiding in the selection of orthopedic implants and surgical planning for metacarpal fractures. CT scans provide precise measurements, underscoring their value in assessing bony anatomy. Future studies with larger and more diverse populations are needed to validate these findings and explore potential sex-based differences in metacarpal dimensions.

Meta-analysis of complications and functional outcomes in cosmetic limb lengthening.

Metacarpal lengths & ratios as a marker of sexual dimorphism in population of Haryana and Jammu & Kashmir. A radiological study

Bone age in children is mainly assessed using the Greulich and Pyle (GP) atlas, a validated method with limited interobserver accuracy. While automated methods increase interobserver accuracy, they represent considerable costs and technical requirements. A proof-of-concept study to create and evaluate an onlinesoftwareprogram, Boneureka©, based on linear metacarpal length measurements, to assess bone age in healthy children. The study retrospectively included 434 consecutive children (215 girls) who underwent a left-hand radiograph to rule out trauma between March 2008 and December 2017. Two reviewers measured the second to fourth metacarpal lengths on each radiograph and the distance between the centre of the epiphyses of the second and fifth metacarpals. A single reviewer estimated the bone age using the GP atlas. The automated software assessed the bone age for all radiographs. A mathematical model was developed based on linear regressions to provide the mean bone age and standard deviation based on the estimates. Pearson and intraclass correlation coefficient (ICC) were used to evaluate the correlation and agreement between the estimated bone ages using Boneureka©, the GP atlas and BoneXpert® compared to chronological age. The measure that showed the highest correlation (r2=0.877 for girls and r2=0.834 for boys; P<.001) and the highest ICC (ICC=0.937 for girls and ICC=0.926 for boys; P<0.001) with chronological age was length of the second metacarpal. TheGP atlas and the automated software evaluation had excellent ICC with chronological age (ICC>0.95 for both methods and sexes). Using this data, we created an online software programbased on the second metacarpal length to obtain bone age estimates, means and standard deviations. The newly createdonline software Boneureka,©based on the second metacarpal length, is a reliable and user-friendly tool to assess bone age in healthy children. Further studies on a larger population should be performed to validate thedeveloped reference values.

The Limb Lengthening and Reconstruction Society (LLRS) celebrated its 28th year as an orthopaedic subspecialty, with a combined meeting with the Pediatric Orthopaedic Society of North America (POSNA) at the 2019 American Academy of Orthopaedic Surgeons (AAOS) meeting in Las Vegas. The LLRS 28th Annual Scientific Meeting was held on July 19 and 20, 2019, in Boston, Massachusetts, featuring papers and workshops from around the world. A diverse subspecialty society, we overlap with trauma, pediatric, foot and ankle, sports, arthroplasty, and oncologic orthopaedic surgeons in the diagnosis and treatment of deformities of length, alignment, contracture, nonunion, and bone healing. The purpose of this update was to summarize the important articles with regard to these subjects published since 2018. Guided Growth The technique of temporary, asymmetric growth plate tethering continues to be a successful method of deformity correction in growing children. The concept, known as guided growth, was developed by Dr. Peter Stevens, using a small, 2-hole plate to span the growth plate on 1 side, allowing the opposite side to grow unresisted, and thereby correcting angular deformity without osteotomy. The screws within the plate provide an articulation, with the apex of the correction occurring at the perichondrial ring. A multinational retrospective study described results of guided growth in 537 children with 967 physes treated1. Distal femoral and proximal tibial correction rates were similar, averaging 0.77° per month for the distal part of the femur and 0.79° for the proximal part of the tibia, despite the commonly held opinion that the femur corrects faster than the tibia. Patients with >3 years of growth remaining had a better quality of correction. Infection was uncommon, occurring in 1.78% of patients. Seven of the 8 infections occurred at the upper medial part of the tibia. The study was unable to correlate the effect of body weight on the result, nor did it assess the incidence of rebound deformity. A modified guided growth technique has been previously advocated for only removing the metaphyseal screw and leaving the plate and epiphyseal screw in place once a correction is complete. Thus, in the event that a deformity recurs, a simpler procedure to reinsert a single screw could be performed. A study by Keshet et al. refuted this practice2, as they observed permanent bar formation in 2 of 55 cases using the technique. They also observed that only 12 of their 55 patients required reinsertion of the metaphyseal screw and that 9 of those actually required plate repositioning. Anterior guided growth of the distal part of the femur to treat fixed knee flexion contracture in cerebral palsy has been reported to have favorable results, provided that implants are placed sufficiently anterior and adequate growth remains3. Congenital Pseudarthrosis of the Tibia Congenital pseudarthrosis of the tibia remains a challenge for the orthopaedic surgeon. Richards and Anderson4 reported using bone morphogenetic protein (BMP)-2 without deleterious effects in 21 children with congenital pseudarthrosis. They applied a single sponge around an autologous cancellous bone graft with intramedullary pinning that crossed the ankle joint. This technique seemed to shorten the time to union, but did not eliminate nonunion or refracture, the latter occurring in 5 of the 16 initially healed patients. In a retrospective multicenter study of 119 patients with Crawford type-II congenital pseudarthrosis of the tibia followed to maturity, Shah et al. reported an 86% primary union rate, with 69% still united at maturity5. They did not identify specific factors influencing rates of union or refracture and recommended a larger, prospective, multicenter study. Three-Dimensional Printing Three-dimensional printing, originally known as additive manufacturing, creates models by printing layers of materials on top of one another. These models can be physically held, manipulated, and studied, providing the surgeon preoperative assessment of the specific anatomical geometry. Haleem and Javaid6 described methods to create 3-dimensional models for preparation and practice of orthopaedic procedures. Exact fit models, based on magnetic resonance imaging (MRI) or computed tomography (CT) scanning techniques, can allow for preoperative planning and mock surgical procedures and can create implants specific for complex cases. Corona et al.7 described using 3-dimensional printed titanium truss cages in conjunction with the Masquelet technique to treat massive infected posttraumatic defects. Bone Defects Nauth et al.8 described a 3-stage protocol of (1) radical debridement and resection of infected skeletal elements; (2) defect space management using antibiotic blocks, spacers, or beads, which provide a local depository of culture-specific antibiotic and develop a vascularized membrane; and (3) 8 weeks later, carefully opening the membrane and exchanging the spacer for an autologous graft. Napora et al.9 described excellent functional outcome of patients at 2 to 8 years after tibial defects were treated with bone transport using a stacked hexapod frame. Corticotomy and transport were delayed for 6 to 8 weeks in patients undergoing concurrent flap coverage. The authors noted improved ease and accuracy of the docking with hexapod frames and described a method to augment frame stability near the end of treatment. The Short Musculoskeletal Function Assessment (SMFA) score was not influenced by age, sex, or diabetic status. Seventeen of 38 patients required an additional fixation surgical procedure (plate, nail, or fixator reapplication) at some point during their treatment. Barinaga et al.10 published a case report of successful tibial bone transport combining the use of a motorized magnetic lengthening nail and a limited contact dynamic compression plate, sparing the patient adjunctive external fixation. Limb Lengthening Distraction osteogenesis is the spontaneous formation of new bone in a gradually widening osteotomy site using external fixation. The more recent development of motorized internal limb-lengthening nails has advanced the capabilities of treating patients with limb lengthening and reconstruction needs. Additional authors have reported safe and successful lengthening with motorized intramedullary devices. Iobst et al.11 reported on simultaneously performing distal femoral angular correction and insertion of a retrograde intramedullary lengthening nail, while controlling the fragments with a temporary intraoperative external fixator. Length was subsequently achieved with the motorized intramedullary lengthening nail. Acute corrections of up to 15° were possible with the technique. The authors preoperatively planned their cases using the Baumgart method of reverse planning. Magnetic lengthening nails were used with liberal application of blocking screws preventing postoperative deformity. A cost study suggested that patients undergoing intramedullary lengthening have higher initial implant costs than fixator lengthening over a nail, but the former undergo fewer procedures overall12. Reuse of a PRECICE nail (Nuvasive) was reported in a case of a femoral discrepancy after an infection in which a 3-cm lengthening was successfully performed, distal locking screws were removed, the telescopic portion of the nail was retracted, and a second corticotomy and lengthening were performed13. Radiographic evaluation of bone regenerate formation during lengthening is possible by a number of means. A radiographic pilot study by Vulcano et al.14 found that a pixel-density ratio of >0.89 (ratio of pixel density in the regenerate relative to the surrounding cortex) may correlate with osseous healing and may be the threshold for allowing full weight-bearing. In pediatric patients, Archer et al.15 also found that the most reliable radiographic assessments of regenerate were by the pixel value ratio and the Ru Li technique. The mechanical environment of distracted callus affects the quality of new bone formation. An ovine study was performed by Claes et al.16 in which lateral callus distraction was undertaken in tibiae and various cyclic loads were applied at the end of lengthening. Tibiae that underwent compressive loading had more bone formation, higher spicule height, and higher blood vessel density than those experiencing shear or distractive loading. Growth Prediction Makarov et al.17 evaluated 77 patients at their institution, comparing the predictive accuracy of the White-Menelaus, Anderson-Green, Moseley, and multiplier methods for correctly timing epiphysiodesis. Final leg-length prediction errors varied from 0.7 to 1.1 cm, with the multiplier method proving to be the least accurate. Makarov et al.18 also reported a 7% complication rate among 863 epiphysiodeses, the most common of which was incomplete arrest in 31 patients resulting in angular deformity and requiring reoperation in half of such cases. Physeal Violation A sheep model was used by Knapik et al.19 to assess the consequences of distal femoral physeal violation by a retrograde intramedullary implant, noting that violations of ≤7% of the cross-sectional area were associated with continued growth of the physis without bar formation. Congenital Limb Deficiencies A review from the Finnish Register of Congenital Malformations and Care Register for Health Care20 identified all children born with lower-limb deficiencies, comparing their hospital admissions and stays with the general pediatric population of Finland. In the 16-year study period, the authors found that children with lower-limb deficiencies (terminal, long bone, foot, and toe) had 6 times the number of hospital admissions and 10 times the number of days in the hospital per child than all of the children born without limb deficiency. Two-thirds of the patients born with congenital lower-limb deficiencies required an operation, and approximately half of those operations were orthopaedic. The ratio of the short lower extremity to the contralateral, longer lower extremity in patients with congenital deficiencies has historically been considered constant in the orthopaedic literature. Tsai et al.21 attempted to verify this concept of constant inhibition and to further elucidate the pattern of skeletal maturation in patients with fibular hemimelia. They confirmed the concept of constant inhibition, with a mean deviation ranging from 0.1% to 3.3% in the femur and 0.1% to 3% in the tibia. They also noted that the growth patterns of the lower extremities in patients with unilateral fibular hemimelia did not differ when compared with the normal population. Kowalczyk and Kuźnik-Buziewicz22 reported outcomes of rotation-plasty for unilateral proximal femoral focal deficiency, reviewing postoperative function, time to knee fusion, and complications in 8 adolescents followed for 6 to 12 years postoperatively. Intensive preoperative physical therapy was performed to maximize strength and motion, especially ankle dorsiflexion. Patients were all pain-free and were able to walk without assistive devices. The 2 patients who did not exhibit a Trendelenburg gait had undergone preoperative hip stabilization procedures. Spontaneous derotation of the foot occurred in 5 of 8 patients, necessitating a repeat surgical procedure in 2 patients. All patients reported acceptance of the limb appearance and satisfaction with the result. Radhakrishna et al.23 reviewed 6 patients with Jones type-II tibial hemimelia presenting with an absent distal part of the tibia who were treated with limb salvage. All patients were reconstructed with the following elements: gradually moving the fibula distally using an external fixator to normalize the relationship of the proximal parts of the tibia and fibula; centralizing the fibula with creation of a synostosis between the fibula and tibia; and centralizing the foot relative to the fibula distally, creating a fibular-talar fusion, using external fixation and soft-tissue releases. The mean increase in leg length was 4 cm, with a mean time of 43 days in the fixator. Each child required 2 to 4 procedures, with all patients achieving union. Walker et al.24 analyzed a group of patients with ulnar deficiency and noted that a lower-extremity deficiency was present in 55% of patients. The patients with lower-extremity deficiencies and ulnar deficiencies had less severe presentation of ulnar deficiency. The authors observed no patients with tibial hemimelia (pre-axial deficiency) associated with ulnar deficiencies (post-axial deficiency). They pointed out that the upper-limb bud forms earlier than the lower-limb bud, considering the possibility that a developing limb insult would explain the observation that more lower-extremity involvement was related to less upper-extremity involvement. Physeal Arrest and Epiphysiodesis Physeal bar formation was assessed in a rat model by Wattenbarger et al.25. They selectively induced injury by scraping and drilling the metaphyseal and epiphyseal sides of the physis. Basement plate penetration on the epiphyseal side was associated with radiographic and histologic physeal injury, whereas hypertrophic zone violation on the metaphyseal side was associated with continued growth. Arthroscopic and navigation-assisted physeal bar resection is being increasingly reported. Miyamura et al.26 reported a case with a 2-year follow-up of a distal radial bar excision and concomitant osteotomy, planned using 3-dimensional CT, patient-specific guides, and intraoperative endoscopic visualization. Foot and Ankle Ankle arthrodesis for neuropathic foot deformity is historically associated with poor union rates. A fusion technique combining an external fixator and an intramedullary nail was reported to achieve fusion in 22 of 24 patients by El-Mowafi et al.27. Neuropathic foot deformity with concurrent osteomyelitis is the subject of an article by Kliushin et al.28. Seventy-seven patients were treated for a mean time of 180 days in an external fixator, with infection eradicated in 90.9% of patients at a 1-year follow-up. The American Orthopaedic Foot & Ankle Score (AOFAS) increased marginally, which the authors attributed to the pain component of the outcome score. Brandão et al.29 discussed the management of diabetic neuropathy of the foot with both internal and external fixation techniques, with particular attention to the concept of beaming of the midfoot with axial internal fixation. This concept was described as stiff, thick, intramedullary longitudinal support from hindfoot to forefoot. Staged distraction osteogenesis and ankle arthrodesis were performed by Lou et al.30 in 12 patients with posttraumatic or infectious bone loss of the distal part of the tibia who were treated with simultaneous proximal lengthening and distal compression osteosynthesis using circular fixation to provide ankle fusion. The AOFAS improved from a mean of 37.3 to 75.3 points, and successful regenerate was formed in all, although 2 patients underwent bone-grafting. Ahmad et al.31 reported the results of the treatment of rigid equinus foot deformity with circular external fixation in an adolescent and pediatric population. They reported a mean correction angle of 47.4°. Pin-track infections occurred in 4 of the 30 patients. Equinus deformity secondary to burn contractures treated with circular external fixation was the subject of a report by Zhang et al.32. The authors described a wire technique in the foot, predominantly using hindfoot wires, recognizing the need to avoid injury to the posterior tibial neurovascular bundle. A cadaver study by Kelly et al.33 identified safe hindfoot wire insertion using an entry point one-third of the distance along a line from the posterior aspect of the calcaneus to the lateral malleolus to predictably avoid the posteromedial neurovascular bundle. Nepalese children who were 1 to 5 years of age and had neglected clubfoot deformity were treated by the Ponseti method34. Ninety-five percent of feet remained plantigrade at a minimum of 10 years. Despite some residual deformity, patient-reported outcomes were satisfactory, with a relapse rate of 3%. Trauma The role of external fixation in the management of tibial fractures was described in a number of publications. In a retrospective study, Berven et al.35 compared Ilizarov frame fixation with locking plate fixation of proximal tibial fractures between 62 patients treated at 1 center using the Ilizarov technique and 68 patients treated at a different institution using internal fixation. Time to union was considered faster in the internal fixation group. Deep infection, alignment, reoperation, and range of motion were similar in the 2 groups. Lovisetti et al.36 reported the results of circular external fixation in bicondylar tibial plateau fractures, with a mean follow-up period of 37.3 months. All 20 cases were initially managed with knee-spanning fixation. The results were measured by radiographs and Hospital for Special Surgery (HSS) score and were described as favorable when compared with other series presented in the literature. Napora et al.9 examined functional outcomes in 38 patients with infected tibial nonunion managed with stacked hexapod external fixators for the purpose of bone transport. Corticotomy and transport were delayed for 6 to 8 weeks in patients undergoing concurrent flap coverage. The study noted that, with an intact fibula, the proximal and distal portions of the frame programs must be a mirror image of each other and that if angular, translational, rotation, or additional length deformity correction is built into the frame, a fibular osteotomy is required. Patients completed an SMFA survey at the time of final follow-up. The SMFA score was not influenced by age, sex, or diabetic status. Of 38 patients, 17 required an additional fixation surgical procedure (plate, nail, or fixator reapplication) at some point during their treatment. Arsoy et al.37 reported that patients presumed to have aseptic nonunion but later determined to have positive cultures had an 84% union rate with systemic antibiotic therapy. Tumor Elalfy et al.38 determined that chemotherapy had a negative effect on bone healing and diminished bone hypertrophy when using modulated compliant compressive forces to induce osteointegration in a tumor prosthesis. The 49 patients receiving chemotherapy postoperatively had less bone formation than the 44 patients who did not receive chemotherapy. Implant survival was not affected by chemotherapy, with 10-year survival rates of 85%. Limb-salvage techniques in the management of pediatric sarcoma continue to evolve. Segmental metadiaphyseal distal femoral defects after resection can be reconstructed with a novel vascularized fibular A-frame technique, augmented with an intramedullary nail. This provides a biological reconstruction with greater cross-sectional area than a single vascularized fibula, with a segment amenable to later limb lengthening39. For patients with limb growth potential remaining who require endoprosthetic reconstruction, growing prostheses are described. These include both minimally invasive devices (requiring lengthening under fluoroscopic guidance) and noninvasive devices (driven by an external magnet), and these were compared in a survival analysis by Medellin et al.40. Prosthesis survival was demonstrated as 79% (minimally invasive) and 70% (noninvasive) at 10 years. Patients receiving noninvasive prostheses had a higher mean Musculoskeletal Tumor Society Score (27 points) compared with patients who received minimally invasive devices (24.7 points), which, although not attaining significance (p = 0.295), was attributed by the authors to higher patient satisfaction, better gait, and greater independence. A novel approach to limb salvage in sarcoma of the distal part of the tibia was also described by Lou et al.30, with 5 patients undergoing resection of tumor (including the distal part of the tibia and the talar chondral surface) and subsequent tibial bone transport to achieve tibiotalar fusion. The segment was plated 1 month following the transport phase to expedite frame removal, with mean final Musculoskeletal Tumor Society Score of 88 points.

Introduction: Supracondylar fracture of humerus is very common fracture in pediatric age group. The current trends of management in displaced type are close reduction and per cutaneous pinning (CRPP), if reduction is not satisfactory then open reduction and internal fixation (ORIF) is done. Our study aims to compare the cosmetic, functional and radiological outcome between these two methods.&#x0D; Methodology: Children with displaced extension type supracondylar fracture of distal humerus presenting to emergency room and orthopedics OPD who could meet the inclusion criteria were taken up for study. Sixty-three such patients (37 CRPP and 26 ORIF) were included in the study. Radiological and functional outcomes were followed up at 8 weeks post-operatively.&#x0D; Results: Of the 63 patients enrolled, 26 (41.3%) patients had undergone open reduction and internal fixation and 37 (58/7%) had undergone close reduction and percutaneous pinning. The mean age of patients in CRPP and ORIF groups was 7.29±2.3 years and 8.11±2.02 years respectively. Maximum patients were from age group 7-9 years (46%). Left side was more commonly injured (66.7% vs. 33.3%) (P = 0.045). According to the Flynn’s criteria, cosmetically the outcome did not differ between the two surgical groups (P = 0.23). However, CRPP proved to have a significantly better functional outcome (P=0.000). The mean Bauman’s angle in CRPP and ORIF groups was 16.89±5.66 and 18.88±4.90 degrees respectively. However, there is no statistically significant difference between the type of fixation and Bauman’s angle or Anterior humeral line.&#x0D; Conclusions: Close reduction and percutaneous pinning (CRPP) has better functional and radiological outcome in comparison with open reduction and internal fixation (ORIF) in displaced supracondylar fracture of humerus in children.

High tibial osteotomy has become an accepted treatment for patients with varus degenerative arthritis of the knee. We sought to determine factors associated with patient satisfaction and functional outcome following medial opening wedge high tibial osteotomy for the degenerative varus knee. Sixty-one patients (14 women and 47 men) undergoing medial opening wedge osteotomy and chondral resurfacing procedure (microfracture) for medial knee pain, with minimum 2-year follow-up, were identified through our clinical database. Mean patient age was 52.2 years (range: 35-65 years). Thirty patients were treated with plate fixation, and 31 with distraction osteogenesis and external fixation. Nineteen patients had Outerbridge grade III or IV patellofemoral lesions at initial surgery. The mean preoperative Lysholm score of 49.9 improved postoperatively to 75.4 (P < .001). Mean satisfaction score was 7.6 (1 = not satisfied, 10 = very satisfied). Women showed a significantly higher improvement in Lysholm and satisfaction scores than men (P = .029, P = .034). A positive correlation was observed between satisfaction and postoperative Lysholm score (P < .001). The independent multivariate predictor of patient satisfaction was the postoperative Lysholm score. Medial opening wedge high tibial osteotomy is an efficacious surgical option for the treatment of the degenerative varus knee, as demonstrated by both patient satisfaction and functional outcome scores.

Leg lengthening by an external fixation is associated with various difficulties. Pin-tract infections are commonly encountered, and muscle contractures and joint stiffness are additional complications associated with this method. Several researchers explored a purely intramedullary solution for leg lengthening since the 1970s. The purpose of this study was to evaluate the results of 10 adolescent patients who underwent leg lengthening with a motorized intramedullary lengthening device (the Fitbone System). We aimed to evaluate the effectiveness of the Fitbone system in deformity correction and lengthening of the femur and tibia in the pediatric and adolescent patients looking at whether the incidence of complications commonly associated with external fixators could be reduced. We compared our preliminary results with those from other reports, with a focus on leg length achieved and rate of complications. Ten patients were included, nine femoral nails and five tibial nails were implanted. The average lengthening distance was 4.8 cm (range, 2.8-10 cm). In 10 patients, leg lengthening was combined with successful correction of the mechanical axis alignment in three patients. The consolidation index averaged 24 days/cm (range, 20-39 days/cm). The average hospital stay was 8 days. No bone or soft tissue infections were observed. Only one patient had irritation and pain from the antenna system after lengthening and recovered fully after antenna removal. Our results suggest that the difficulties commonly associated with external fixators can be reduced with this method. It also allows good angular correction in patients with mechanical axis deviation. These features combined with a short time of hospitalization make it a promising procedure for limb lengthening in adolescent patients.

Mini-Invasive Treatment for Brachymetatarsia of the Fourth Ray in Females: Percutaneous Osteotomy With Mini-Burr and External Fixation—A Case Series

Tratamiento de la braquimetatarsia mediante osteogénesis a distracción

Objective To evaluate the outcomes of distraction osteogenesis with mini external fixation in management of metacarpophalangeal bone defects after hand trauma. Methods From June 2010 to December 2015, 16 patients with metacarpophalangeal bone defects after hand trauma received distraction osteogenesis at our department. They were 11 men and 5 women, from 20 to 45 years of age (average, 32.5 years). There were altogether 20 bone defects: 8 cases had single metacarpal bone defect, 2 unilateral second and third metacarpal bone defects and 6 phalangeal shortening after repair of digital stump (involving thumb in 4 cases, index finger in one and index and middle fingers in one). The metacarpophalangeal bone defects averaged 1.8 cm (from 1.0 to 3.1 cm). Under the fluoroscopic guide, 4 or 6 mini half-pins in one line were directly drilled into the dorsal aspect of the involved metacarpophalangeal bone before the Orthofix fixator was mounted. The proximal (18 digits) or distal (2 digits) osteotomy between the second and third pinholes was performed via the dorsal approach. The external fixator and pins were removed without anesthesia after callus maturation. Results Average follow-up period was 12.2 months (range, from 9 to 26 months). All the metacarpal bone defects were reconstructed and all the phalangeal shortenings were lengthened; the bony callus was completely calcified at the lengthened part. The mean lengthening was 1.9 cm (from 1.0 to 3.1 cm); the percentage of lengthening ranged from 26% to 51% (average, 34%). The bone lengthening index (time cost by average 1 cm) was 70.9 d/cm (from 60.0 to 87.1 d/cm). According to the Tentative Assessment Criteria for Upper Extremity Function by Hand Surgery Society, Chinese Medical Association, the total activity of motion (TAM) was excellent in 13 cases, good in 4, fair in 2, and poor in one, yielding an excellent to good rate of 85.0%. Conclusion Distraction lengthening using mini external fixation is a valid option with a minor rate of complications which allows for early functional exercise to help restore the appearance and function of the affected fingers. Key words: Hand; Injury; External fixators; Bone lengthening; Bone defect

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients. A retrospective review of prospectively collected data was undertaken of a consecutive series of 107 femoral lengthening operations in 92 patients. In total, 73 antegrade nails and 34 retrograde nails were inserted. Outcome was assessed by the regenerate healing index (HI), hip and knee range of movement (ROM), and the presence of any complications. The mean lengthening was 4.65 cm (1.5 to 8) in the antegrade group and 4.64 cm (1.6 to 8) in the retrograde group. Of the 107 lengthenings, 100 had sufficient datapoints to calculate the mean HI. This was 31.6 days/cm (15 to 108). There was a trend toward a lower (better) HI with an antegrade nail and better outcomes in adolescent patients, but these were not statistically significant. Hip and knee ROM was maintained and/or improved following commencement of femoral lengthening in 44 patients (60%) of antegrade nails and 13 patients (38%) of retrograde nails. In female patients, loss of movement occurred both earlier and following less total length achieved. Minor implant complications included locking bolt migration and in one patient deformity of the nail, but no implant failed to lengthen and there were no deep infections. Three patients had delayed union, five patients required surgical intervention for joint contracture. This study confirms excellent results in femoral lengthening with antegrade and retrograde Precice nails. There is a trend for better healing and less restriction in hip and knee movement following antegrade nails. There are clinical scenarios, that mandate the use of a retrograde nail. However, when these are not present, we recommend the use of antegrade nailing. Cite this article: Bone Joint J 2019;101-B:1168-1176.

Background:There is no consensus on the optimal operative treatment of isolated closed metacarpal fractures as every technique is associated with advantages and shortcomings. This retrospective study aims to compare the outcomes of single metacarpal, extra-articular fractures treated with closed reduction and percutaneous pinning (CRPP) versus open reduction and internal fixation (ORIF).Methods:The charts of all patients who underwent surgical repair of closed metacarpal fractures at our institutions from 2009 to 2016 were reviewed. 70 patients met the inclusion criteria, 44 had undergone CRPP and 26 ORIF with plate or lag screws. Subgroup analyses of all patients stratified by both fracture pattern and fracture location were performed. Additionally, subgroup analyses of outcomes based on the time from injury to surgery were conducted. Clinical outcomes included immobilization time, total active motion, stiffness, complication and reoperation rates, as well as occupational therapy referral rates and duration. Functional outcomes were determined using the Quick-DASH (Disabilities of the Arm, Shoulder and Hand) score via telephone questionnaire administered retrospectively.Results:Overall, there was no significant difference in functional outcome parameters including total active motion (CRPP 91% of normal vs. ORIF 87% of normal), stiffness, therapy referrals, and complications between treatment groups. Patients treated with CRPP, regardless of fracture pattern or location, were operated on earlier than those treated with ORIF (avg. 7 days vs. 15 days). The immobilization time for patients treated with ORIF was significantly less than those treated with CRPP (19.7 vs. 30.7 days; p=0.001). This difference in the immobilization time also reflected the outcomes of the subgroup analyses based on the post-injury time of surgery. When transverse shaft fractures were examined independently as a subgroup, ORIF resulted in improved post-operative range of motion vs. CRPP (100% normal vs. 91% normal). The mean DASH score for each group was satisfactory and the difference was not statistically significant (16.3 for the CRPP and 18.7 for the ORIF group, p=0.805).Conclusion:Both CRPP and ORIF are viable techniques with good clinical outcomes and low complication rates. ORIF of closed metacarpal fractures allowed for earlier mobilization when compared with CRPP without compromising fracture stability, clinical or functional short-term outcomes.