Limb Deformity Correction Research Articles

The risks following the exposure to radiation associated with the surgical correction of limb deformities in children are minimal.

The aim of this study was to quantify the risk of developing cancer from the exposure to radiation associated with surgery to correct limb deformities in children. A total of 35 children were studied. There were 19 girls and 16 boys. Their mean age was 11.9 years (2 to 18) at the time of surgery. Details of the radiological examinations were recorded during gradual correction using a Taylor Spatial Frame. The dose area product for each radiograph was obtained from the Computerised Radiology Information System database. The effective dose in millisieverts (mSv) was calculated using conversion coefficients for the anatomical area. The lifetime risk of developing cancer was calculated using government-approved Health Protection Agency reports, accounting for the age and gender of the child. Correction was undertaken in five femurs, 18 tibiae, and 12 feet. The median duration of treatment was 45 months (11 to 118). The mean effective dose was 0.31 mSv (0.05 to 0.64) for the femur, 0.29 mSv (0.01 to 0.97) for the tibia, and 0.027 mSv (0.001 to 0.161) for the foot. The cumulative exposure gave 'negligible' risk in 26 children and 'minimal' risk in nine children, according to Public Health England categories. These results are below the mean annual background radiation in the United Kingdom. The lifetime attributable risk of developing cancer from repeated exposure to radiation was negligible or minimal in all children. This is the first study to quantify the exposure to radiation from serial radiographs in children with limb deformities who are treated surgically using circular external fixation, linking this to the risk of developing cancer. Cite this article: Bone Joint J 2019;101-B:241-245.

Research progress of fully implantable intramedullary lengthening nail

Limb length discrepancy is caused by either congenital or acquired conditions, such as growth arrest, osteomy-elitis, trauma or tumor. Conventional Limb lengthening utilizes external fixators which lead to great inconvenience to patient's daily life. Complications are however common including pin-site infection, soft tissue tethering from the pins and wires resulting in pain, regenerate deformity or fracture after frame removal and intolerance of the frames. In order to reduce the time of external fixator treatment, various combinations techniques of both external and internal fixation have been developed. However, there is still a risk of deep infection of the implant due to contamination of the previous pin tracts of the external fixation. Fullly implantable intramedullary lengthening nail can avoid the problems of external fixator, including discomfort, pin sites infection, muscular transfixation and soft tissue tethering. There are still some problems including serious pain, too quick lengthening and authorization, so the earlier generations of products could not be safely and widely used. The newest generation of magnetic intramedullary lengthening nail represented by PRECICE (NuVasive, Inc., Irvine, CA, USA) has obtained good early clinical results with its stability, precision and controllability. PRECICE is broadly used in the world, which may become the new direction of treatment for limb lengthening and deformity correction. This article aims to review the recent development of fully implantable intramedullary lengthening nail, including clinical application, preoperative planning, key points of surgery, postoperative rehabilitation, and complications.

Bone Ninja app as a body image simulation tool for shared decision-making

Background: Reconstruction of preoperative digital photographs to simulate surgery outcomes is a common practice in esthetic surgery and is proven to enhance shared decision-making. Methods: We used the Bone Ninja app to visualize postoperative results of limb deformity correction. To our knowledge, this is the first attempt to use a body image simulation to predict orthopedic surgery. Results: Two patients decided to undergo surgery only after seeing the postoperative simulation. Two patients reported that the actual postoperative results were identical to the simulation, and one patient said that it was very similar. Conclusion: In the authors' opinion, it is a useful educational tool resulting in lesser decisional conflict and unrealistic expectations, better understanding, and improved satisfaction with results. It also helps surgeons with accurate planning and better judgment regarding esthetics.

Diagnosis and treatment of diastematomyelia in children: a perspective cohort study.

Cohort study. The objectives of this study were examination, observation and surgical interventions of pediatric patients with diastematomyelia, a rare congenital deformity of the spinal cord. Spine surgery and neurosurgery clinic under ministry of health, the Russian Federation. Twenty children (1-18 years of age) with diastematomyelia participated in this study. Diagnosis was based on subjects' medical history, results of clinical examination, spine radiography in anteroposterior and lateral views, and neurophysiological examinations. Septum resection surgery was done in seventeen subjects. All the subjects had skin manifestations along the midline of the back. Neurological symptoms were noted in 17 subjects: paraparesis in 11, urinary incontinence in 2, monoparesis in 4, and spasticity in 2 subjects. Three subjects did not show any neurological deficit. Orthopedic examination revealed spinal deformities of various degrees of severity. In 4 subjects, partial restorations of neurological functions were observed; and in 1 subject, bladder incontinence developed after the surgery. Patients who have limb length discrepancy, congenital scoliosis, skin manifestations should be examined for the presence of diastematomyelia. Patients having neither neurological deficit nor orthopedic deterioration should be monitored, and in case of deterioration, surgical treatment should be reserved. We advocate for performing resection of the septum in patients with diastematomyelia prior to surgical correction of scoliosis or orthopedic correction of lower limb deformities.

Limb lengthening and deformity correction with externally controlled motorized intramedullary nails: evaluation of 50 consecutive lengthenings

Background and purpose — Limb lengthening with an intramedullary motorized nail is a relatively new method. We investigated if lengthening nails are reliable constructs for limb lengthening and deformity correction in the femur and the tibia.Patients and methods — 50 lengthenings (34 Precice and 16 Fitbone devices) in 47 patients (mean age 23 years [11–61]) with ≥12 months follow-up are included in this study. 30 lengthenings were done due to congenital and 20 because of posttraumatic deformity (21 antegrade femora, 23 retrograde femora, 6 tibiae). Initial deformities included a mean shortening of 42 mm (25–90). In 15 patients, simultaneous axial correction was done using the retrograde nailing technique.Results — The planned amount of lengthening was achieved in all but 2 patients. 5 patients who underwent simultaneous axial correction showed minor residual deformity; unintentionally induced minor deformities were found in the frontal and sagittal plane. The consolidation index was 1.2 months/cm (0.6–2.5) in the femur and 2.5 months/cm (1.6–4.0) in the tibia. 2 femoral fractures occurred in retrograde femoral lengthenings after consolidation due to substantial trauma. There were 8 complications, all of which were correctable by surgery, with no permanent sequelae.Interpretation — Controlled acute axial correction of angular deformities and limb lengthening can be achieved by a motorized intramedullary nail. A thorough preoperative planning and intraoperative control of alignment are required to avoid residual and unintentionally induced deformity. In the femur relatively fast consolidation could be observed, whereas healing was slower in the tibia.

Data analysis of 8 113 cases of limb deformities corrected by external fixation

To analyze the data of external fixation instruments (including Ilizarov instruments) used by QIN Sihe orthopaedic surgical team in the treatment of limb deformities in the past 30 years, and to explore the indications for the application of modern external fixation techniques in the correction of limb deformities and individual device configuration selection strategy. According to QIN Sihe orthopaedic surgical team, the use of external fixator between January 1988 and December 2017 was analyzed retrospectively. The total use of external fixation and the proportion of different external fixators were analyzed in gender, different operation time, different age, different parts, and different diseases. External fixators were used in 8 113 patients, 69 of them were used simultaneously in both lower extremity surgery, so 8 182 external fixators were used. Among them, there were 4 725 (57.74%) combined external fixators, 3 388 (41.41%) Ilizarov circle fixators, 64 (0.78%) single arm external fixators (including Orthofix), 5 (0.06%) Taylor space external fixators. There were 4 487 males (55.31%) and 3 626 females (44.69%). According to the analysis of different time periods, the number of external fixators increased year by year, and the number of applications increased after 2000. The main age of the patients was 11-30 years old, of which 1 819 sets (22.23%) were used at the age of 21-25 years. The use of the external fixator covered almost all parts of the limbs, with the ankle and toe areas being the most common, reaching 4 664 sets (57.00%), and the upper extremities the least, with 152 sets (1.86%). The 8 113 cases covered more than a dozen disciplines and more than 150 kinds of diseases. The top 5 diseases were poliomyelitis sequelae, cerebral palsy, deformity of lower extremity after spina bifida, traumatic sequelae, and congenital equinovarus foot. Ilizarov technique has been widely used in extremity deformity, disability, and complicated orthopedic diseases caused by vascular, lymphoid, nerve, skin, endocrine, and other diseases. The indication of operation is far beyond the scope of orthopedics. The domestic external fixator and its mounting tools can basically meet the requirements of various treatments. The technique of external fixation has entered a new era of tension tissue regeneration under stress control, natural repair of tissue trauma and deformity, and reconstruction of limb function.

Treatment strategy for flail foot with sensory disorder of spina bifida sequela in adult

To summarize the main methods and comprehensive effects of limited surgery combined with external fixation for the treatment of flail foot with sensory disorder of spina bifida sequela in adult. The clinical data of 22 cases (30 feet) of the adult spina bifida sequela who suffered from flail foot with sensory disorder and treated by limited surgery combined with external fixation were retrospectively analysed between January 2005 and December 2015. There were 14 males and 8 females with an age of 8-38 years (mean, 21.5 years). All 30 feet were distal ankle sensory loss, including 2 cases (2 feet) on the left side, 2 cases (2 feet) on the right side, and 18 cases (26 feet) on both sides. There was 1 foot accompanied by ulcerative plantar ulcers, and 3 feet lost their toes due to foot osteomyelitis in the weight-bearing area. Combined with 3 cases of hip dislocation, 3 cases of scoliosis, 4 cases of knee deformity, and 3 cases of ptosis. There were 5 cases of normal control of urine and stool, 10 cases of partial control of urine and stool, 6 cases of overflow urinary incontinence, and 1 case of cystostomy. According to X-ray film, the lesion of spina bifida was evaluated, the laminar insufficiency was located at L 3-L 5 in 8 cases, L 5, S 1 in 9 cases, and L 3-S 3 in 5 cases. In the patients, 12 feet were performed ankle joint arthrodesis, 10 feet subtalar arthrodesis, and 8 feet tibia-talus-calcaneus arthrodesis. Ilizarov external fixator was used in 18 feet, Hybrid fixator in 8 feet, Hybrid fixator and cannulate screws in 3 feet, and Ilizarov fixator and cannulate screws in 1 foot. All 22 patients were followed up 10-80 months (mean, 48.5 months). All ankle deformities were corrected effectively after operation, the middle and hind feet were stable, the plantar foot was restored, the whole foot was loaded, and the ulcer healed without recurrence. There were 2 cannulate screws ruptured in the subtalar arthrodesis, bone healed after screws break; no complication such as surgical infection, neurovascular injury, and so on happened. At last follow-up, based on the evaluation criteria of QIN Sihe lower limb deformity correction, the results were excellent in 15 feet, good in 9 feet, and fair in 6 feet, with an excellent and good rate of 80.0%. The treatment of flail foot with sensory disorder of spina bifida sequela is more demanding. The limited surgeries combined with external fixation play an important role for recovering the stability of foot and ankle, better clinical results, and less complications.

Effect of external fixation rod coupling in computed tomography

External fixation is a common tool in the treatment of complex fractures, correction of limb deformity, and salvage arthrodesis. These devices typically incorporate radio-opaque metal rods/struts connected at varying distances and orientations between rings. Whilst the predominant imaging modality is plain film radiology, computed tomography (CT) may be performed in order for the surgeon to make a more confident clinical decision (e.g. timing of frame removal, assessment of degree of arthrodesis). We used a fractured sheep leg to systematically assess CT imaging performance with a Discovery CT750 HD CT scanner (GE Healthcare) to show how rod coupling in both traditional Ilizarov and hexapod frames distorts images. We also investigated the role of dual-energy CT (DECT) and metal artefact reduction software (MARS) on the visualisation of the fractured leg. Whilst mechanical reasons predominantly dictate the rod/strut configurations when building a circular frame, rod coupling in CT can be minimised. Firstly, ideally, all or all but one rod can be removed during imaging resulting in no rod coupling. If this is not possible, strategies for configuring the rods to minimise the effect of the rod coupling on the region of interest are demonstrated, e.g., in the case of a four-rod construct, switching the two anterior rods to a more central single one will achieve this goal without particularly jeopardising mechanical strength for a short period. It is also shown that the addition of DECT and MARS results in a reduction of artefacts, but also affects tissue and bone differentiation.

Treatment of bone tumor using external fixator

External fixation has been widely used for the treatment of limb length discrepancy, deformity correction, and bone defect using distraction osteogenesis. We have been using this technique for the treatment of obstacles due to benign bone tumor and reconstruction after malignant bone tumor resection. In this paper, we introduce the usefulness of external fixation for the treatment of various benign bone tumors and limb salvage surgery for reconstruction after tumor resection using distraction osteogenesis, according to the tumor site. The advantages of external fixation for the treatment of benign bone tumor include a possibility of complex deformity correction without treating the tumor itself and reconstruction of the aggressive benign bone tumor as well as solid fixation with wires, even for weak bone due to benign bone tumors. The advantages of treating malignant bone tumor include regeneration of living bone of sufficient strength and durability, biological affinity, resistance against infection, and lifelong restored function. The disadvantages include delayed union at the docking site and pin-or wire-tract infection, patient's psychological stress, and the procedure is time consuming. We conclude that external fixation is very efficient for the treatment of benign and malignant bone tumors.

What's New in Limb Lengthening and Deformity Correction.

Hamdy, Reggie C. MD, MSc, FRCS(C)1,a; Bernstein, Mitchell MD, FRCS(C)1,2; Fragomen, Austin T. MD3; Rozbruch, S. Robert MD3Author Information

Eight-plate epiphysiodesis: are we creating an intra-articular deformity?

Guided growth using eight-plates is commonly used for correction of angular limb deformities in growing children. The principle is of tethering at the physeal periphery while enabling growth in the rest of the physis. The method is also applied for epiphysiodesis to correct limb-length discrepancy (LLD). Concerns have been raised regarding the potential of this method to create an epiphyseal deformity. However, this has not been investigated. The purpose of this study was to detect and quantify the occurrence of deformities in the proximal tibial epiphysis following treatment with eight-plates. A retrospective study was performed including 42 children at a mean age of 10.8 years (3.7 to 15.7) undergoing eight-plate insertion in the proximal tibia for correction of coronal plane deformities or LLD between 2007 and 2015. A total of 64 plates were inserted; 48 plates (34 patients) were inserted to correct angular deformities and 16 plates (8 patients) for LLD. Medical records, Picture Archive and Communication System images, and conventional radiographs were reviewed. Measurements included interscrew angle, lateral and medial plateau slope angles measured between the plateau surface and the line between the ends of the physis, and tibial plateau roof angle defined as 180° minus the sum of both plateau angles. Measurements were compared between radiographs performed adjacent to surgery and those at latest follow-up, and between operated and non-operated plateaus. Statistical analysis was performed using BMDP Statistical Software. Slope angle increased in 31 (49.2%) of operated epiphyses by a mean of 5° (1° to 23°) compared with 29 (31.9%) in non-operated epiphyses (p = 0.043). Roof angle decreased in 29 (46.0%) of operated tibias and in 25 (27.5%) of non-operated ones by a mean of 5° (1° to 18°) (p = 0.028). Slope angle change frequency was similar in patients with LLD, varus and valgus correction (p = 0.37) but roof angle changes were slightly more frequent in LLD (p = 0.059) and correlated with the change in inter screw angles (r = 0.74, p = 0.001). The use of eight-plates in the proximal tibia for deformity correction and limb-length equalization causes a change in the bony morphology of the tibial plateau in a significant number of patients and the effect is more pronounced in the correction of LLD. Cite this article: Bone Joint J 2018;100-B:1112-16.

Use of Patient-Specific 3D-Printed Titanium Implants for Complex Foot and Ankle Limb Salvage, Deformity Correction, and Arthrodesis Procedures.

The advancement of 3D printing technology has allowed for the use of custom-designed implants for difficult-to-treat foot and ankle pathologies. This study reports on the radiographic and functional outcomes of a case series of patients treated with patient-specific 3D-printed titanium implants. Fifteen consecutive patients treated with custom-designed 3D-printed implant cages for severe bone loss, deformity correction, and/or arthrodesis procedures were included in this study. A minimum of 1 year of clinical and radiographic follow-up was required. No patients were lost to follow-up. Patients completed a visual analog scale for pain, the Foot and Ankle Ability Measure Activities of Daily Living score, and the American Orthopaedic Foot & Ankle Society Score outcomes questionnaires preoperatively and at most recent follow-up. All patients had postoperative radiographs and computed tomography (CT) scans to assess bony incorporation. The mean age was 53.3 years (range, 22-74 years) with a mean follow-up of 22 months (range, 12-48 months) for these 15 patients. Radiographic fusion verified by CT scan occurred in 13 of 15 patients. There was significant improvement in pain and all functional outcome score measures. All patients who went on to fusion were satisfied with their surgery. There were 2 failures, consisting of 1 infection and 1 nonunion, with an overall clinical success rate of 87%. These patients demonstrated the successful use of patient-specific 3D-printed titanium implants to treat complex large bony defects, deformities, and arthrodesis procedures. These implants offer surgeons a novel and promising approach to treat both lower extremity pain and deformity that is not always available with current techniques. Level IV, retrospective case series.

Anesthesia for removal of external fixation with hydroxyapatite-coated half pins

Background: External fixation utilizing hydroxyapatite (HA)-coated half pins has produced excellent clinical results revolutionizing the field of limb lengthening and deformity correction surgery. Removal of these pins is a painful patient experience that may be best conducted under anesthesia. Purpose: The current study documents how a deformity practice removes these external fixators (frames) under anesthesia. We asked: (1) How much anesthesia is needed for frame removal? (2) How effective was this protocol in controlling patient pain? (3) How did patients taking narcotic medications at the time of frame removal differ from those not taking narcotics during frame removal surgery? Patients and Methods: We prospectively recorded data during the removal of 53 consecutive external fixators that used HA-coated half pins including the use of pre operative narcotics at the time of frame removal, location and complexity of frames, type and dosages of medications administered, and adequacy of anesthesia. Results: All patients were managed with a combination of midazolam, propofol, fentanyl, and ketamine. Anesthesia was graded as good to excellent in 91% and unsatisfactory to poor in 9% of cases. The preoperatively medicated group was administered significantly less fentanyl (P = 0.020) and had significantly more frames located about the ankle and foot (P = 0.049) than the preoperatively non-medicated cohort. Conclusions: IV sedation administered by an anesthesiologist in the operating room provided adequate pain control to perform fixator removal and pin site debridement in most cases. External fixation used for foot and ankle reconstruction may provide a more painful experience for patients.

The Use of Patient-Specific 3D Printed Titanium Implants for Complex Foot and Ankle Limb Salvage, Deformity Correction, and Arthrodesis Procedures

Category: Ankle,Ankle Arthritis,Basic Sciences/Biologics,Trauma Introduction/Purpose: Large lower extremity bony defects, complex foot and ankle deformities, and high-risk arthrodesis situations can be difficult to treat. These challenging pathologies, often require a critical-sizes and/or shaped structural bone void filler which may not be available with allograft bone. The advancement of 3D printing technology has allowed for the use of custom designed implants for foot and ankle surgery. This study reports on the radiographic and functional outcomes of a case series of patients treated with patient-specific 3D printed titanium implants. Methods: Seven consecutive patients who were treated with custom designed 3D printed implant cages for severe bone loss, deformity correction, and arthrodesis procedures were included in this study. A minimum of 1-year follow-up was required. No patients were lost to follow-up. Patients completed preoperative and most recent follow-up VAS for pain, FAAM, and SF-36 outcomes questionnaires. All patients had post-operative radiographs and CT scans to assess bony incorporation. Results: The mean age of these patients was 54.6 (35-73 years of age). The mean follow-up of these seven patients was 17.1 months (range 12 to 31). Radiographic fusion with cage ingrowth and integration occurred in all seven patients verified by CT scan. There was statistically significant improvement in all functional outcome score measures (VAS for pain, FAAM, and SF-36). All patients returned were satisfied with surgery. There were no failures. Case examples are demonstrated in Figure 1. Conclusion: This cohort of patients demonstrated the successful use of custom 3D printed implants to treat complex large bony defects, deformities and arthrodesis procedures of the lower extremity. These implants offer the surgeon a patient specific approach to treat both pain and deformity that is not necessarily available with allograft bone.

What's New in Limb Lengthening and Deformity Correction.

What's New in Limb Lengthening and Deformity Correction.

The computer-aided parallel external fixator for complex lower limb deformity correction.

Since parameters of the parallel external fixator are difficult to measure and calculate in real applications, this study developed computer software that can help the doctor measure parameters using digital technology and generate an electronic prescription for deformity correction. According to Paley's deformity measurement method, we provided digital measurement techniques. In addition, we proposed an deformity correction algorithm to calculate the elongations of the six struts and developed a electronic prescription software. At the same time, a three-dimensional simulation of the parallel external fixator and deformed fragment was made using virtual reality modeling language technology. From 2013 to 2015, fifteen patients with complex lower limb deformity were treated with parallel external fixators and the self-developed computer software. All of the cases had unilateral limb deformity. The deformities were caused by old osteomyelitis in nine cases and traumatic sequelae in six cases. A doctor measured the related angulation, displacement and rotation on postoperative radiographs using the digital measurement techniques. Measurement data were input into the electronic prescription software to calculate the daily adjustment elongations of the struts. Daily strut adjustments were conducted according to the data calculated. The frame was removed when expected results were achieved. Patients lived independently during the adjustment. The mean follow-up was 15 months (range 10-22 months). The duration of frame fixation from the time of application to the time of removal averaged 8.4 months (range 2.5-13.1 months). All patients were satisfied with the corrected limb alignment. No cases of wound infections or complications occurred. Using the computer-aided parallel external fixator for the correction of lower limb deformities can achieve satisfactory outcomes. The correction process can be simplified and is precise and digitized, which will greatly improve the treatment in a clinical application.

Case report: rare skeletal manifestations in a child with primary hyperparathyroidism

BackgroundPrimary hyperparathyroidism (PHPT) is uncommon among children with an incidence of 1:300,000. This diagnosis is often missed in children in contrast to adults where it is detected at a pre symptomatic stage due to routine blood investigations. Etiology of PHPT can be due to adenoma, hyperplasia or rarely carcinoma.Case presentationA 12 year old Sri Lankan girl presented with progressive difficulty in walking since 1 year. On examination she had bilateral genu valgum. Skeletal survey revealed valgus deformity of knee joints, bilateral subluxation of upper femoral epiphysis(SUFE), epiphyseal displacement of bilateral humeri, rugger jersey spine and subperiosteal bone resorptions in lateral aspects of 2nd and 3rd middle phalanges. There were no radiological manifestations of rickets. Metabolic profile revealed hypercalcemia with hypophosphatemia. Intact parathyroid hormone levels were elevated at 790 pg/ml. Vitamin D levels were deficient. She had low bone mineral density with Z score of −3.4. Vitamin D supplementation resulted in worsening of hypercalcemia without reduction in PTH levels. Tc 99 Sestamibi uptake scan showed abnormal tracer retention in left inferior pole of thyroid. A large parathyroid gland was removed with histology favoring parathyroid adenoma. Post operatively she developed hypocalcemia. Bilateral osteotomy was done for SUFE and further surgeries for correction of limb deformities planned.ConclusionPHPT in children is usually diagnosed late when irreversible organ damage has occurred. Children can present with non specific symptoms involving gastrointestinal, musculoskeletal, renal and neurological systems. PHPT can cause disarray in bone and epiphysis in children during pubertal growth spurt. Genu valgum and SUFE are rare skeletal manifestations in PHPT and only 10 cases of genu valgum and 9 cases of SUFE have been reported up to now. So far no cases have been reported on epiphyseal displacement of humeri. Awareness regarding the occurrence of these rare skeletal manifestations especially during puberty is important for early diagnosis to prevent irreversible outcomes.

Evaluation of the external fixator TrueLok Hexapod System for tibial deformity correction in children

BackgroundTibial deformities are common in paediatric orthopaedic practice. Correcting multiplanar tibial deformities associated with lower limb length discrepancy can be challenging. Hexapod external fixation with gradual correction has been proven effective in this situation. ObjectiveTo assess clinical and radiological outcomes of gradual tibial deformity correction using the external fixator TL-HEX™ (Orthofix) in children. HypothesisTL-HEX™ is effective in correcting tibial deformities in children. Patients and methodsThis multicentre retrospective study collected data from the medical files of 26 patients with 31 tibial deformities treated by gradual correction using TL-HEX™. The tibial deformities were due to congenital defects in 11 (35%) cases, Blount's disease in 9 (29%) cases, pseudo-achondroplasia in 4 (13%) cases, and other causes in 7 (23%) cases. Mean age at surgery was 11.9 years. In each patient, antero-posterior long leg radiographs obtained pre-operatively and at last follow-up were used to measure parameters including the mechanical axis deviation (MAD), medial proximal tibia angle (MPTA), and leg length discrepancy (LLD). ResultsThe mean healing index was 39.3 days/cm (range, 32–58 days/cm). The overall complication rate was 61%, with 11 unplanned visits. Superficial pin tract infection was the most common complication. Significant decreases between the pre-operative and post-operative assessments occurred in mean MAD (from 32.1mm to 10.2mm, P<0.001) and mean LLD (from 36.8mm to 9.1mm, P<0.001). Patients who underwent proximal tibial osteotomy had a significant improvement in MPTA, from 80.6° to 88.5° (P=0.006). DiscussionThis is the first clinical study specifically designed to assess outcomes of TL-HEX™ limb lengthening and deformity correction. MAD, MPTA, and LLD were significantly improved at last follow-up. MAD was greater than 10mm at last follow-up in only 11patients. The complication rate was similar to those reported with other external fixators. TL-HEX™ is effective in the management of tibial deformities in children. Level of evidenceIV (retrospective study).

Tibio-talo-calcaneal fusion after limb salvage procedures—A retrospective study

BackgroundThe treatment of limb threatening trauma on the distal tibia or hindfoot often results in posttraumatic osteoarthritis requiring tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to present a case series of patients undergoing various techniques of joint fusion after bone reconstruction and deformity correction as a salvage procedure. The study should help trauma surgeons making decisions in limb salvage and deformity correction in complex lower leg and foot injuries by presenting options and treatment strategies. Patients and methodsEight patients (4 male, 4 female) after TTC arthrodesis as a definitive procedure after polytrauma or monotrauma involving the distal tibia or hindfoot were the subject of this retrospective analysis. We included patients treated by external ring fixation (1 case), external fixation+wires (1 case), external fixation+screws (1 case) and intramedullary nailing (1 ante- and 5 retrograde; 1 bilateral, 4 unilateral). Initial trauma included open fractures, subtotal foot amputations and closed fractures with failed osteosynthesis and failed ankle joint replacement. Bone defects were treated with callus distraction or segment transport in 5 cases. Various angles were measured to assess foot deformities in the lateral radiographic view and clinical results were presented. ResultsIndependent, pain-free mobilisation with full weight bearing was achieved in all 8 patients. In terms of subjective outcome, all patients reported a highly satisfying result. Complete consolidation at the fusion site was achieved in 8 out of 9 cases with a high rate of adjacent joint arthritis. Angles measures in the lateral radiographs showed values typical for a pes cavus tendency. ConclusionTibio-talo-calcaneal (TTC) arthrodesis is a viable treatment option for severe post traumatic arthritis and deformity of the ankle and subtalar joint. Despite bad bone quality retrograde intramedullary nailing does provide acceptable results providing stability, low invasiveness and low infection rate. Simultaneous TTC-fusion and tibial lengthening using the Ilizarov ring fixator may be necessary when the surgeon is confronted with large bone defects – often followed by a nailing after lengthening procedure. This study shows that limb preservation after limb threatening trauma with hindfoot injury and multiple fractures of the lower extremity is recommenced as the method of choice with reasonable clinical results.Level of Evidence: IV, Case series

Limb lengthening and deformity correction of congenital and acquired deformities in children using the Taylor Spatial Frame

Background and purpose — Hexapod ring fixators such as the Taylor Spatial Frame (TSF) have shown good outcomes. However, there have only been a few studies comparing the use of TSF with various etiologies of the deformity. We compared the use of TSF in congenital and acquired deformities in children.Patients and methods — We reviewed 213 lower extremity reconstructive procedures with the TSF in 192 patients who were operated between October 2000 and October 2015. 128 procedures (67 proximal tibiae, 51 distal femora, and 10 distal tibiae) in 117 children (median age 14 (4–18) years; 59 girls) fulfilled the inclusion criteria. 89 procedures were done in children with congenital deformities (group C) and 39 were done in children with acquired deformities (group A). Outcome parameters were lengthening and alignment achieved, lengthening index, complications, and analysis of residual deformity in a subgroup of patients.Results — Mean lengthening achieved was 3.9 (1.0–7.0) cm in group C and 3.7 (1.0–8.0) cm in group A (p = 0.5). Deformity parameters were corrected to satisfaction in all but 3 patients, who needed further surgery for complete deformity correction. However, minor residual deformity was common in one-third of the patients. The mean lengthening index was 2.2 (0.8–10) months/cm in group C and 2.0 (0.8–6) months/cm in group A (p = 0.7). Isolated analysis of all tibial and femoral lengthenings showed similar lengthening indices between groups. Complication rates and the need for secondary surgery were much greater in the group with congenital deformities.Interpretation — The TSF is an excellent tool for the correction of complex deformities in children. There were similar lengthening indices in the 2 groups. However, congenital deformities showed a high rate of complications, and should therefore be addressed with care.