Lengthening Index Research Articles

Management of metacarpophalangeal bone defects after hand trauma by distraction osteogenesis with mini external fixation

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

Distraction Osteogenesis by Ilizarov Technique for Infected Gap Non-Union of the Femur

Introduction: Purpose- To review records of 36 patients who underwent distraction osteogenesis or bone transport by Ilizarov fixator for infected gap non-union of femoral shaft. Materials and Methods: 30 men and 6 women aged 20 to 57 years underwent adequate debridement and resection of the nonviable bone, followed by bone transport using Ilizarov fixator for infected gap non-union of the femoral shaft. All patients had a bone defect of >4 cm. The lengthening index, x-ray consolidation index, functional status, bone healing and complications encountered during the treatment were assessed. Results: The patients had undergone a mean of 3 (range 1-6) surgical procedures before presentation. The mean duration from trauma to presentation was 6.5 (range 5-16) months. The mean bone defect after adequate resection was 8.9 (range 4.5-13) cm. The mean treatment time was 8.5 (range 6-16) months. The mean lengthening index was 12.5 (range 10.5-14) days/cm. The mean treatment index was 25.5 (range 25-45) days/cm. The mean follow up time was 18.5 (range 15-45) months. Functional outcome was excellent in 20, good in 10 and fair in 6 patients. All patients had solid union and eradication of infection. None had neurovascular complications and refracture of the regenerated bone, but encountered knee stiffness (n=7) i.e, knee extension contracture which was managed by Judet’s Quadriceps Plasty later on, we did not do any bone grafting for any cases. Conclusion: Bone transport by Ilizarov fixator is safe, stable, and effective for treating infected gap non-union of the femoral shaft.

Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame.

This retrospective review assesses 55 tibial nonunions with bone loss to compare union achieved with combined Ilizarov and Taylor spatial frames (I–TSF) versus a conventional circular frame with the standard Ilizarov procedure. Seventeen (31 %) of the 55 nonunions were infected. Thirty patients treated with I–TSF were compared with 25 patients treated with a conventional circular frame. In the I–TSF group, an average of 7.6 cm of bone was resected and the lengthening index (treatment time in months divided by lengthening amount in centimeters) was 1.97. In the conventional circular frame group, a mean of 6.5 cm was resected and the lengthening index was 2.1. Consolidation at the docking site and at the regenerate bone occurred in 49 (89 %) of 55 cases after the first procedure. No statistically significant difference was shown between the two groups. Superiority of one modality of treatment over the other cannot be concluded from our data. Application of combined Ilizarov and Taylor spatial frames for bone transport is useful for treatment of tibial nonunion with bone loss. Level of evidence Case series, Level III.

Management of complex femoral nonunion with monorail external fixator: A prospective study.

To evaluate 30 patients who underwent distraction osteogenesis with monorail external fixator for complex femoral nonunion. Complex femoral nonunion includes infective non-union, gap nonunion, and limb-length discrepancy secondary to traumatic bone loss, which needs specialized treatment to ensure the functional integrity of femoral bone. 30 patients, including 28 male and 2 female (aged 22-62 years) patients, underwent surgical debridement followed by bone transport with monorail fixator. The lengthening index, radiographic consolidation index, functional status, bone healing, and various problems, obstacles, and complications encountered during the treatment were assessed. Patients underwent a mean of 2.2 (range 1-4) surgeries before presentation. The mean bone defect after surgical debridement was 5.83cm (range 2-16cm). The mean treatment duration was 204.7 days (range 113-543 days). The mean lengthening index was 13.06days/cm with range from 12 to 16days/cm. Mean maturation index was 23.51days/cm with range from 17 to 45.5days/cm. In our study, bone result was excellent in 17, good in 9, fair in 3, and poor in 1 patient. In our study functional outcome is excellent in 9 [30%], good in 14 [46.67%], fair in 5, and poor in 2 patients. In our study, we encountered 34 problems, 17 obstacles, and 8 complications. We concluded that monorail external fixator is an effective treatment option for complex nonunion femoral shaft fracture and its functional outcome is comparable with any other treatment options. Lack of complications and its effectiveness makes monorail external fixator the treatment of choice for complex nonunion femoral shaft.

Defects of crural composite tissues treated by acute angular shortening and delayed distraction histogenesis with an external fixator

Objective To evaluate the efficacy of acute angular shortening and delayed distraction histogenesis with an external fixator in the treatment of crural composite tissue defects. Methods From May 2009 to August 2014, 6 patients with crural composite tissue defects were treated by acute angular shortening and delayed gradual distraction histiogenesis with an external fixator. They were 5 men and one woman, from 23 to 65 years of age (average, 38.8 years). According to the Gustilo classification, 2 cases were graded as type Ⅲ A and 4 as type ⅢB. Four of them received primary treatment at our department while the other 2 were transferred to our hospital after primary management in other hospitals. Radical debridement was rapidly performed once life threatening factors were eliminated. The lower limbs were maximally bended to close the skin defects. The wounds were closed directly in 4 cases; the remnant wounds in the other 2 cases were cured by daily dressing in one and covered by skin graft in the other. Next, about 2 to 3 weeks after complete wound healing the pre-constructed circular fixators were mounted to the bended cms before they were adjusted to correct angulation deformity and reconstruct bone defects. Results All the wounds in the 6 cases healed successfully without additional microsurgical transfer of osteocutaneous flap. The regenerative skin tissue was similar to the skin in situ. The follow-ups ranged from 8 to 24 months (mean, 16.8 months). The average length of lengthened tibia was 8.0 cm and the time for Ilizarov external fixation ranged from 10 to 25 months (mean, 17.3 months). The average bone lengthening index was 2.3 months/cm. The limb functional recovery was rated as excellent in 2 cases and good in 4. The radiography revealed complete reconstruction of bone defects and restoration of mechanical alignments in all the cases. No disability was recorded during follow-up. Conclusions Acute angular shortening and delayed distraction histogenesis with an external fixator is a very effective treatment of crural bone and soft tissue defects. It can provide rapid management of acute or subacute open injury because it does not necessitate microsurgical flap transfer or bone graft, thus avoiding donor site morbidity. Key words: Fractures, open; External fixators; Bone lengthening; Ilizarov technique

Medial Longitudinal Arch Mechanics Before and After a 45 Minute Run.

Abstract BACKGROUND:Medial longitudinal arch integrity following prolonged running has yet to be well documented. Our purpose was to quantify changes in medial longitudinal arch kinematics before and after a 45 minute run in healthy recreational runners. METHODS:Thirty runners performed barefoot seated, standing, and running trials before and after a 45 minute shod treadmill run. Navicular displacement, arch lengthening, and arch height index were used to quantify arch deformation, and arch rigidity index was used to quantify arch stiffness. RESULTS:There was no statistical difference in navicular displacement (mean (95% CI): 5.6 (4.7-6.4)), arch lengthening (3.2 (2.6-3.9)), change in arch height index (0.015 (0.012-0.018)), or arch rigidity index (0.95 (0.94-0.96)) after the 45 minute run (all MANOVA P{greater than or equal to}0.065). CONCLUSIONS:Since there was no statistically significant change in arch deformation or rigidity, either the structures of a healthy, intact medial longitudinal arch are capable of adapting to cyclical loading or they are capable of withstanding a 45 minute run without compromise.

Paediatric lower limb deformity correction using the Ilizarov technique

Limb length discrepancy (LLD) and other patient factors are thought to influence the complication rate in (paediatric) limb deformity correction. In the literature, information is conflicting. This study was performed to identify clinical factors that affect the complication rate in paediatric lower-limb lengthening. A consecutive group of 37 children was analysed. The median proportionate LLD was 15 (4-42)%. An analysis was carried out on several patient factors that may complicate the treatment or end result using logistic regression in a polytomous logistic regression model. The factors analysed were proportionate LLD, cause of deformity, location of corrected bone, and the classification of the deformity according to an overall classification that includes the LLD and all concomitant deformity factors. The median age at the start of the treatment was 11 (6-17) years. The median lengthening index was 1.5 (0.8-3.8) months per centimetre lengthening. The obstacle and complication rate was 69% per lengthened bone. Proportionate LLD was the only statistically significant predictor for the occurrence of complications. Concomitant deformities did not influence the complication rate. From these data we constructed a simple graph that shows the relationship between proportionate LLD and risk for complications. This study shows that only relative LLD is a predictor of the risk for complications. The additional value of this analysis is the production of a simple graph. Construction of this graph using data of a patient group (for example, your own) may allow a more realistic comparison with results in the literature than has been possible before.

Results and biomechanical consideration of treatment of congenital lower limb shortening and deformity using the Ilizarov method.

One of the applications of the Ilizarov apparatus is the correction of congenital shortening and deformities. Ilizarov external fixator produces biomechanical structure with surrounding tissue, which is the reason why very important is correct stability of fixator. Large distraction in the case of high value of lengthening, and large deformity corection result in shear stresses that occur additionally in the regenerate, which can potentially lead to damage of the regenerating nutritive microcirculation of bone tissue and bone fragment displacements. Our objective was to assess the results of the Ilizarov method in the treatment of congenital shortening taking into account treatment strategy and the size of the axis of lengthening and correction. Our research problems include presenting the effects of biomechanics of musculoskeletal deformations on treatment results, presenting complications and their treatment. Between 1989 and 2009, 62 patients underwent surgery to correct congenital lower limb deficiencies at our Clinic; 33 patients were followed-up. In total, there were 70 surgeries (2.12/patient). Axial correction was performed in 26 patients (78.79%). Average age at the start of the treatment was 15.58 years. Mean follow-up was 8.58 years. Mean lengthening per surgery was 3.17 cm with the lengthening index of 50.7 day/cm. Results were very good for 23 patients, good for 7 patients, satisfactory for 3 patients. Complications appeared in 24 patients, problems occurred in 74.42% of the cases, obstacles in 4.65% of cases, and true complications in 20.93% of the cases. The best results were achieved in the treatment of patients with two-stage and two-segment lengthening with a total elongation of less than 7 cm, and without correction of the axis. Congenital shortening of the lower limb should be treated comprehensively because the shortening applies to all segments, and disturbs biomechanics of all lower limb. In the case of axial correction and large amount of elongation high soft tissue forces counteract the distraction forces. Hybrid construction may help to shorten treatment time, increase fixator stability and decrease rate of complications. We suggest use of hybrid Ilizarov fixator, especially when large elongation and axis corection are planned.

Factors Influencing Bone Regenerate Healing in Distraction Osteogenesis

The dynamics and effectiveness of new bone formation in the Ilizarov method varies according to different factors. Some of them may result in substantial prolongation of treatment time. The lengthening index (LI), defined as the number of months in a frame necessary to achieve 1 cm lengthening, is the main indicator of bone healing potential. The purpose of the study was to assess the effectiveness of distraction osteogenesis by analysing the lengthening index (LI) in relation to: age, limb length discrepancy, aetiology, bone segment involved, axial correction and lengthening achieved. We studied 251 patients between the ages of 3 to 50 years (mean 15.3) treated with the Ilizarov method because of lower limb inequality. A total of 319 lengthening procedures were analyzed (tibia--155, femur--164). Total treatment time (time in a frame) and magnitude of lengthening were recorded in all patients to calculate LI (months per 1cm of lengthening). Patients were divided into several groups according to these factors. Mean LI in the entire sample was 1.6 months/cm (from 0.7 to 5.9). The lowest LI (1.4) was recorded in the youngest patients (from 3 to 9 years) and increased with age, amounting to 1.6 in the 10-17 years' age group, 1.7 in the 18-21 years' age group and 2.4 in the 22-50 years' age group. The mean LI for femoral lengthening was lower (1.5) than for the tibias (1.8). In a group of 63 cases of lengthening up to 4 cm, LI was 2.3; in another group (from 4 to 7 cm - 189 procedures) LI was lower (1.6), and in the last group (more than 7 cm) it was 1.2. There was no significant difference in mean LI between the groups with and without axial correction. However, differences between aetiology groups were statistically significant, with a mean LI of 1.2 in achondroplasia patients, 1.4 in post-septic patients and patients with and Ollier disease, 1.6 in patients with congenital deformities, 1.8 in post-traumatic patients and 2.0 in neurogenic and clubfoot patients. According to the lengthening index analysis, the effectiveness of distraction osteogenesis is related to age, aetiology, bone segment involved and the magnitude of lengthening, while it is not related to axial correction.

Proximal tibial lengthening using Ilizarov technique after healing of congenital pseudarthrosis of the tibia in children

Objective To investigate clinical outcomes of proximal tibial lengthening by distraction osteogenesis (Ilizarov technique) after healing of congenital pseudarthrosis of the tibia (CPT) in children.Methods From March 2007 to January 2012,11 children received proximal tibial lengthening by distraction osteogenesis (Ilizarov technique) after successful union of CPT.They were 10 boys and one girl,with an average age of 8 years and 5 months (range,from 3 years and 9 months to 14 years and 5 months).The tibial shortening averaged 5.6 cm (from 2.0 to 8.2 cm).The anteroposterior and lateral X-ray films revealed proximal tibial dysplasia in 8 children.And 10 children are complicated with type 1 neurofibromatosis(NF-1).The clinical outcomes were assessed by the lengthening index,healing index and morphological evaluation of callus.Relative risk factors were also analyzed.Results All the 11 children were followed up from one year and 2 months to 4 years and 3 months (average,2 years and 3 months).The average lengthening was 5.3 cm (from 3.5 to 8.0 cm).The average healing index was 63.1 d/cm (from 47 to 77 d/cm).The 8 children with proximal tibial dysplasia developed callus maldevelopment during the lengthening,with lateral callus formation in 5 and central callus formation in 3 cases.The callus formation was hollow in the other 3 cases who had an average healing index of 52.7 d/cm.Pin tract infection occurred in 5 cases,but there was no axial displacement,bone non-union or delayed union of the lengthened segment.Conclusions Proximal tibial lengthening using Ilizarov technique after healing of CPT is effective,but the callus growth is slow and the lengthening index is high.The tibial lengthening can be affected by concomitant NF-1 and proximal tibial dysplasia. Key words: Lower extremity deformities, congenital; Bone lengthening; Ilizarov technique; Child

Ilizarov technique for treatment of congenital brachymetatarsia

Objective To evaluate the clinical therapeutic effectiveness of Ilizarov technique for the treatment of congenital brachymetatarsia.Methods We retrospectively analyzed the 5 patients who had been treated in our department for congenital brachymetatarsia (12 metatarsal bones in 10 feet) from January 2008 to January 2011.All of them were female,aged from 22 to 26 years (mean,24.2 years).All cases were bilaterally involved.Three of them suffered from bilateral brachymetatarsia of the first metatarsal bone,one from bilateral brachymetatarsia of the fourth metatarsal bone,and the other one from bilateral brachymetatarsia of the first and fourth metatarsal bones.Bone transport was conducted with a monolateral mini-fixator in 3 patients and with a modified semi-ring Ilizarov fixator in the other 2.Dorsal incision was used for all osteotomy before the external fixator was mounted.Bone transport began 7 days after surgery at a rate of 0.3 mm/d and was completed in 3 times.Results The 5 patients were followed up from 12 to 48 months (mean,22.0 months).The metatarsal bones were lengthened by 13.5 mm(12 to 17 mm) on average.The functions of the toe and ankle joint were normal without skin necrosis,vascular or nerve injury,tylosis of the footplate,or walking pain.The lengthened segments were mineralized well,with an average lengthening index of 48 d/cm(45 to 53 d/cm) and average time of external fixation of 64.8 days.At the last follow-up,the average AOFAS score was 92.2 points (90 to 95 points).Conclusions Although the Ilizarov technique necessitates a patient's prolonged fixation with an external fixator in the treatment of congenital brachymetatarsia,it has advantages of simplicity,minimal invasion,and satisfactory correction of brachymetatarsia.Consequently it is a good treatment for this disease. Key words: Lower extremity deformities,congenital; Ankle joint; Clubfoot; Ilizarov technique

Femoral Lengthening Over a Pediatric Femoral Nail

Limb lengthening by callotasis as described by Ilizarov has become the standard method of lower extremity lengthening. Lengthening over an intramedullary nail to allow early removal of the external fixator has also become common in adults but few studies have addressed the efficacy in children. A retrospective review of 37 consecutive children who had undergone femoral lengthening with external fixator over an intramedullary nail was performed. Charts were reviewed for demographics, surgical details, and complications. Radiographs were examined to determine magnitude of lengthening and to calculate lengthening index. The average age of the 37 patients was 11.6 years (range, 8.1 to 17.0). The amount of lengthening averaged 7.0 cm (range, 3.0 to 11.4 cm), which represented a mean 20.4% increase in length. The mean time in the fixator was 81 days. The lengthening index was 1.21 days/mm. Thirteen patients developed major complications (37.8%) including 4 limbs that failed to lengthen initially, 3 fractures (1 before fixator removal and 3 after fixator removal), 2 nail failures, 4 deep infections, and 2 joint subluxations requiring operative care. The 3 fractures after fixator removal were treated with exchange nailing as were the 2 intramedullary nail failures. Four patients (10.8%) developed deep infections requiring irrigation, debridement, and IV antibiotics. One patient developed a late hip subluxation, which was treated with a shelf osteotomy but resulted in pain and limitation of motion. One patient developed knee subluxation during lengthening requiring operative intervention. The technique was successful in obtaining a good result with a functional lengthened femur without unresolved problems in 94% of the patients despite a significant rate of major complications, particularly in those with a congenital etiology. Only 2 of the 37 patients ultimately had results that were ultimately compromised by complications. Femoral lengthening over an intramedullary nail with the aid of an external fixator has shown to be an effective method for correcting limb length discrepancy. The technique has a high complication rate similar to other methods of lengthening. Level IV-Case Series.

Distraction Osteogenesis Using a Monolateral External Fixator for Infected Non-Union of the Femur with Bone Loss

To review records of 15 patients who underwent distraction osteogenesis/bone transport using a monolateral external fixator for infected non-union of the femoral shaft. 13 men and 2 women aged 18 to 47 years underwent adequate debridement and resection of nonviable bone, followed by bone transport using a monolateral external fixator for infected non-union of the femoral shaft with bone loss. All patients had a bone defect of >5 cm. The lengthening index, radiographic consolidation index, functional status, bone healing, and various problems, obstacles and complications encountered during the treatment were assessed. The patients had undergone a mean of 2.9 (range, 1-7) surgical procedures before presentation. The mean duration from trauma to presentation was 7.7 (range, 6-18) months. The mean bone defect after adequate resection/debridement was 7.9 (range, 5.5-17) cm. The mean treatment duration was 7.3 (range, 5-15) months. The mean lengthening index was 12.3 (range, 11.5-15) days/cm. The mean treatment index was 27.9 (range, 24-40) days/cm. The mean follow-up duration was 19.3 (range, 15-41) months. Functional outcome was excellent in 5, good in 8, and fair in 2 patients. All patients achieved bone union and eradication of infection. Bone healing was excellent in 12 and good in 3 patients. All the patients were satisfied with the procedure. None had neurovascular complications, joint subluxations, or refracture of the regenerated bone. True complications encountered included knee stiffness (n=6) and knee flexion contracture (n=1). Three patients with an initial bone defect of >10 cm had delayed union and underwent bone grafting. Bone transport using a monolateral external fixator is safe and effective for treating infected non-union of the femoral shaft.

Forearm lengthening by distraction osteogenesis in children

We present our experience of forearm lengthening in children with various conditions performed by a single surgeon between 1995 and 2009. A total of 19 children with a mean age of 9.8 years (2.1 to 15.9) at the time of surgery had 22 forearm lengthenings using either an Ilizarov/spatial and Ilizarov circular frame or a monolateral external fixator. The patients were divided into two groups: group A, in whom the purpose of treatment was to restore the relationship between the radius and the ulna, and group B, in whom the objective was to gain forearm length. The mean follow-up after removal of the frame was 26 months (13 to 53). There were ten patients (11 forearms) in group A with a mean radioulnar discrepancy of 2.4 cm (1.5 to 3.3) and nine patients (11 forearms) in group B. In group A, the mean lengthening achieved was 2.7 cm (1.0 to 5.5), with a lengthening index of 11.1 weeks/cm. Equalisation or overcorrection of the discrepancy was achieved in seven of 11 forearms, but lengthening was only partially successful at preventing subluxation or dislocation of the radial head. In group B, the mean lengthening achieved was 3.8 cm (1.9 to 6.8), with a lengthening index of 7.25 weeks/cm. Common complications in both groups were pin-site infection and poor regenerate formation. Forearm lengthening by distraction osteogenesis is a worthwhile procedure in children that can improve cosmesis and function, particularly in patients with shortening of both radius and ulna.

Ankle Valgus Deformity Secondary to Proximal Migration of the Fibula in Tibial Lengthening with Use of the Ilizarov External Fixator

Ankle valgus deformity secondary to proximal migration of the fibula following an Ilizarov tibial lengthening has not been discussed in detail in the literature. The purposes of this study were to determine the underlying mechanism of and to identify factors associated with proximal migration of the fibula that caused ankle valgus deformity after an Ilizarov tibial lengthening. We reviewed the outcome of seventy-four bilateral Ilizarov tibial lengthenings for short stature in thirty-seven patients. The mean age at the time of surgery was 21.7 years (range, thirteen to thirty-one years), and the mean duration of follow-up was forty-five months. Proximal migration of the fibula was assessed with changes in the malleolar tip distance. A valgus change of ≥ 5° in the tibiotalar angle was regarded as ankle valgus deformity following tibial lengthening. The average length gain was 6.9 cm (range, 4.7 to 11.5 cm), and the average lengthening index was 1.5 mo/cm. Valgus deformity developed in six ankles (8%) and fibular nonunion developed in ten (14%). Proximal migration of the lateral malleolus of ≥ 5 mm was related to valgus talar tilting. Bifocal tibial lengthening, rapid distraction rate of the fibula (>1 mm per day), and development of a fibular nonunion were factors associated with proximal migration of the distal end of the fibula of ≥ 5 mm, which suggests that regenerated bone of poor quality in the distraction gap may cause proximal migration of the distal end of the fibula following tibial lengthening. Proximal migration of the distal end of the fibula following tibial lengthening may occur even with the use of an Ilizarov ring fixator. This migration seems to be caused by collapse of regenerated bone of poor quality or fibular nonunion. Proximal migration of ≥ 5 mm is associated with the risk of valgus talar tilting. Surgeons should consider earlier intervention with bone-grafting if there are conditions that compromise regenerated bone formation in the fibular distraction gap, such as can occur with extensive tibial lengthening by bifocal corticotomy.

Limb lengthening combined with deformity correction in children with the Taylor Spatial Frame

It is difficult to replicate the regular rate and rhythm described by Ilizarov while lengthening with the Taylor Spatial Frame. The purpose of the study was to examine whether this breach of Ilizarov's principles has any deleterious effect on the ability of children to make healthy regenerate bone. A retrospective case-control study was performed comparing pediatric patients undergoing primarily lengthening with Taylor Spatial Frame rings and struts, and patients undergoing lengthening with Taylor Spatial Frame rings and Ilizarov clickers. Fifteen patients had primarily lengthening with Taylor Spatial Frame rings and struts, and six patients had lengthening with Taylor Spatial Frame rings and Ilizarov clickers. Statistically, there was no significant difference between the two groups in terms of age, latency, pre-operative bone length percentage, and average length gained. The lengthening index for the strut group (1.79 months/cm) was significantly different from the clicker group (1.33 months/cm) with P=0.012. For a pediatric patient with lower extremity long bone deformities in multiple planes, the Taylor Spatial Frame is an excellent option. However, the surgeon should anticipate a slightly longer duration of treatment with the Taylor Spatial Frame compared to Ilizarov frames and plan his/her fixation accordingly. For the straightforward lengthening of pediatric long bones without significant concomitant deformity, our results indicate that the Ilizarov method appears to be superior to the Taylor Spatial Frame struts and should still be considered the gold standard.

The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method

The purpose of this study was to demonstrate the effectiveness of the Ilizarov method and circular external fixator in order to eradicate the infection and restore bone union, limb anatomy and functionality in cases with infected nonunion of the tibia following intramedullary nailing. During 7 years nine patients suffering from infected nonunion of the tibia after intramedullary nailing were treated in our department. The series comprised seven men and two women with an average age of 39.7 years (range 21–75 years). The patients had previously undergone an average of 4.8 operations (range 3–6 operations). Active purulent bone infection occurred in all nine patients. Bone defect was present in all patients with a mean size of 5 cm (range 2–12 cm). In three cases with bone defect less than 2 cm, monofocal compression osteosynthesis technique was used. In the rest cases where bone defect exceeded 2 cm, bifocal consecutive distraction–compression osteosynthesis technique was applied. Three patients required a local gastrocnemius flap. The mean follow-up period was 26.6 months (range 13–42 months). Results were evaluated using Paley's functional and radiological scoring system. Bone union was achieved in all nine patients without recurrence of infection during the follow-up period. Bone results were graded as excellent in five cases and good in the rest four cases. Functional results were graded as excellent in three cases, good in four and fare in two cases. Mean external fixation time was 187.4 days (range 89–412 days) and mean lengthening index was 32 days/cm (range 27–39 days/cm). Complications observed included eight grade II pin tract infections, axial deformity at the lengthening site in two cases and at the nonunion site in another two cases. Ankle joint stiffness was detected in five cases. The Ilizarov method may be an effective method in infected nonunions of the tibia following intramedullary nailing.

Lower limb lengthening: is there a difference in the lengthening index and infection rates of lengthening with external fixators, external fixators with intramedullary nails or intramedullary nailing alone? A systematic review of the literature

A review of the current literature was undertaken to assess the lengthening index (LI) and infection rates found with different techniques of lower limb lengthening. We compared three methods of lengthening: external fixators, intramedullary nails and both methods used as a combined technique. Ten papers meeting the inclusion criteria were reviewed. The review found that by using either an ExFix with IMN or an IMN alone lengthening was achieved at twice the rate of ExFix alone. There were no infections recorded in the IMN group, 36.2% superficial and 2.5% deep in the ExFix group and 1.4% superficial and 5.5% deep in the ExFix + IMN group. When using LI and infection rates to compare techniques, the safest and most effective method of lower limb lengthening appears to be with IMN alone.

How to avoid complications of distraction osteogenesis for first brachymetatarsia

Background and purpose Distraction osteogenesis may be used for the treatment of brachymetatarsia. However, few reports have been published on first metatarsal lengthening by this method. We evaluated the complications of distraction osteogenesis for first brachymetatarsia and here we provide a solution.Patients and methods 16 patients (27 feet) underwent distraction osteogenesis for first brachymetatarsia. Mean age at time of surgery was 20 (12–34) years and mean duration of postoperative follow-up was 5 (2–13) years. A unilateral external fixator was fixed at the medial aspect of the metatarsus. The distraction axis was parallel to the plantar surface of the foot in the sagittal plane and to the second metatarsal axis in the transversal plane.Results First metatarsal length expressed as a proportion of second metatarsal length was 60% (55–64). Average degree of metatarsal lengthening was 42% (34–54), and the average lengthening index was 64 (39–93) days/cm. The most common complication was stiffness of the metatarsophalangeal joint (12 feet). Deformities that included cavus foot and hallux valgus occurred in 3 feet each, and callus fractures occurred in 3 feet. The other complications were pin breakage and pin tract infection in 2 feet each.Interpretation Distraction osteogenesis for first brachymetatarsia can give satisfactory cosmetic and functional results. However, several complications are commonly encountered. This report on complications and their solutions may help those attempting distraction osteogenesis for first brachymetatarsia.

Comparison of Distraction Osteogenesis for Congenital and Acquired Limb-length Discrepancy in Children

This study evaluated 116 lower limb lengthenings in 88 consecutive patients (mean age, 13.5 years) treated for congenital (31 patients [46 lengthened segments]) and acquired (57 patients [70 lengthened segments]) limb-length discrepancy. Mean follow-up was 3.8 years. Mean lengthening index was 34+/-16 days/cm in the congenital group and 32+/-9 days/cm in the acquired group; this difference was not statistically significant (P> .05). Mean length of distraction regenerate was 6.4+/-3.7 cm in the congenital group and 5.7+/-2.9 cm in the acquired group; this difference was not statistically significant (P> .05). Lengthening percentage was significantly higher in the congenital group (25+/-17.6) than in the acquired group (19+/-15.4). The increase in the complications rate in congenital limb-length discrepancy correlates with a significantly higher lengthening percentage. Bone regenerate is produced equally regardless of whether the etiology is acquired or congenital.