Residual Leg Length Discrepancy Research Articles

Comparison of "Human" and Artificial Intelligence Hand-and-Wrist Skeletal Age Estimation in an Epiphysiodesis Cohort.

We previously demonstrated that the White-Menelaus arithmetic formula combined with skeletal age as estimated with the Greulich and Pyle (GP) atlas was the most accurate method for predicting leg lengths and residual leg-length discrepancy (LLD) at maturity in a cohort of patients treated with epiphysiodesis. We sought to determine if an online artificial intelligence (AI)-based hand-and-wrist skeletal age system provided consistent readings and to evaluate how these readings influenced the prediction of the outcome of epiphysiodesis in this cohort. JPEG images of perioperative hand radiographs for 76 subjects were independently submitted by 2 authors to an AI skeletal age web site (http://physis.16bit.ai/). We compared the accuracy of the predicted long-leg length (after epiphysiodesis), short-leg length, and residual LLD with use of the White-Menelaus formula and either human-estimated GP or AI-estimated skeletal age. The AI skeletal age readings had an intraclass correlation coefficient (ICC) of 0.99. AI-estimated skeletal age was generally greater than human-estimated GP skeletal age (average, 0.5 year greater in boys and 0.1 year greater in girls). Overall, the prediction accuracy was improved with AI readings; these differences reached significance for the short-leg and residual LLD prediction errors. Residual LLD was underestimated by ≥1.0 cm in 26 of 76 subjects when human-estimated GP skeletal age was used (range of underestimation, 1.0 to 3.2 cm), compared with only 10 of 76 subjects when AI skeletal age was used (range of underestimation, 1.1 cm to 2.2 cm) (p < 0.01). Residual LLD was overestimated by ≥1.0 cm in 3 of 76 subjects by both methods (range of overestimation, 1.0 to 1.3 cm for the human-estimated GP method and 1.0 to 1.6 cm for the AI method). The AI method of determining hand-and-wrist skeletal age was highly reproducible in this cohort and improved the accuracy of prediction of leg length and residual discrepancy when compared with traditional human interpretation of the GP atlas. This improvement could be explained by more accurate estimation of skeletal age via a machine-learning AI system calibrated with a large database. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tension-band Plating for Leg-length Discrepancy Correction.

AimDual tension-band plates are used for temporary epiphysiodesis and longitudinal guided growth. The study aim was to assess rate of correction, to identify development of femoral and tibial intra-articular deformity during correction and to document resumption of growth after plate removal.Materials and methodsA retrospective study of 34 consecutive patients treated with dual tension-band plates between 2012 and 2020 was performed. Twenty-four patients had surgery at the distal femur, six at the proximal tibia and four at both. Twenty-five female patients were treated at a mean age of 11.6 (±1.4) years and nine male patients at 13.5 (±1.5) years. Measurements were performed on standardised long-leg radiographs and included leg-length discrepancy (LLD), joint line congruency angle (JLCA), tibial roof angle, femoral floor angle and notch-intercondylar distance. Measurements were taken pre-operatively, at the end of discrepancy correction and at skeletal maturity.ResultsThe LLD reduced by a mean of 12.9 mm (95% CI 10.2–15.5) with the mean residual difference 8.4 mm (95% CI 5.4–11.4). The mean correction rate for the proximal tibia was 0.40 (SD 0.33) mm/month and 0.68 (SD 0.36) mm/month for the distal femur. A significant mean change in residual LLD [−2.5 mm (95% CI −4.2 to −0.7)] was observed between plate removal and skeletal maturity at the femoral level only. After length discrepancy correction, the tibial roof angle showed a significant difference of 8.4° (95% CI 13.4–3.4) between legs. In femoral epiphysiodesis patients, no important differences were observed.ConclusionA significant reduction in LLD can be achieved using dual tension-band plating. A change in intra-articular morphology was observed only in the proximal tibia and not in the distal femur. In the authors’ opinion, tension-band plating is a useful tool for leg-length equalisation but should be reserved for younger patients or when residual growth is difficult to predict. It is one of the management strategies for limb-length difference prior to skeletal maturity.How to cite this articleTolk JJ, Merchant R, Calder PR, et al. Tension-band Plating for Leg-length Discrepancy Correction. Strategies Trauma Limb Reconstr 2022;17(1):19–25.

Staged reconstruction of unilateral neglected hip dislocation through total hip arthroplasty and subsequent intramedullary femoral lengthening

Background and purposeTotal hip arthroplasty (THA) is a successful approach to treat unilateral symptomatic neglected hip dislocation (NHD). However, the extensive leg length discrepancy (LLD) can hereby only be partially corrected. In case of residual LLD of more than 2 cm, subsequent femoral lengthening can be considered.Patients/material/methodsRetrospective analysis of clinical data and radiographs of five patients (age 38.1 (28–51) years) with unilateral NHD who underwent THA with (n = 3) or without (n = 2) subtrochanteric shortening osteotomy (SSO) and secondary intramedullary femoral lengthening through a retrograde magnetically-driven lengthening nail (follow-up 18.4 (15–27) months).ResultsLLD was 51.0 (45–60) mm before and 37.0 (30–45) mm after THA. Delayed bone union at one SSO site healed after revision with autologous bone grafting and plate fixation. Subsequent lengthening led to leg length equalisation in all patients. Complete consolidation was documented in all lengthened segments.ConclusionStaged reconstruction via THA and secondary femoral lengthening can successfully be used to reconstruct the hip joint and equalise LLD. The specific anatomical conditions have to be taken into consideration when planning treatment, and patients ought to be closely monitored.

Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures

Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage. This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded. Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10-20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation. Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

Outcome of Congenital Pseudoarthrosis Tibia Treated with Illizarov Fixator in Children

OBJECTIVES : To determine the outcome of congenital pseudoarthrosis tibia (CPT) managed with illizarov fixator. METHODS : This prospective cross-sectional study was done from 20 th March 2008 to 19 th March 2018. All patients presenting to the Orthopaedic out patient department (OPD) with pseudoarthrosis tibia belonging to either gender aged up to 12 years were included. All patients underwent excision of tapering ends and illizarov fixator application. Outcome was assessed in terms of complications. Data regarding age, gender, side, type of CPT and any complication was noted and analyzed using SPSS version 23. RESULTS : 16 patients were included in the study. 10 (62.5%) were males and 6 (37.5%) females. Mean age was 4 years. 10 (62.5%) patients were type-1 and 6 (37.5%) were type-2. Evidence of neurofibromatosis was seen in 9 (56.2%) patients. Most common complications were residual leg length discrepancy (LLD), mal-alignment and delayed consolidation which was seen in 8 (50%) patients. CONCLUSION : CPT is a periosteal disease with variable results. The study concludes that good results are achieved in 50% patients.

Traumatic Composite Bone and Soft Tissue Loss of the Leg: Region-Specific Classification and Treatment Algorithm

The management of traumatic composite bone and soft tissue loss (TCBSTL) requires a classification system and decision-making algorithm for the purpose of description, prognosis and choice of treatment method. between the year 2000 and 2017 a series of 254 cases of TCBSTL were treated using distraction histogenesis and external fixation techniques. The tissue loss was due to either the initial injury or debridement of infection. Adjunctive procedures included split thickness skin grafting and ICBG when indicated. A classification system was designed by the author. The classification is based on factors that influence management and prognosis; (1) stability of the host bone (intact tibia or a well-fixed fracture), (2) presence or absence of infection in the fracture site, (3) size of bone defect, and (4) contamination (infection) of the medullary cavity. A flowchart and decision-making algorithm was subsequently developed. Ilizarov external fixator was used in all cases. Ten cases (4%) had combined Masquelet - Ilizarov technique. One hundred seventy five cases (68.9%) had gradual distraction-compression (GDC) technique; while 79 cases (31.1%) had acute shortening and re-lengthening (ASRL) technique. Seventy-two cases (28.3%) had autogenous iliac crest bone graft (ICBG). All cases (100%) had complete clinical and radiological fracture union. All patients completed the follow up that ranged from 24 to 118 months (mean 43.3 ± 23). The results were satisfactory in 212 cases (83.5%) and unsatisfactory in 42 (16.5%) cases due to residual leg length discrepancy, joint stiffness, and persistent pain. the proposed classification is simple, applicable, recallable and includes most scenarios of reconstructable TCBSTL. The classification provides a basis for communication, description and evaluation of such cases. The algorithm, based on our classification, provides a guideline for management without over/under treatment.

Outcome of Congenital Pseudoarthrosis Tibia Treated with Illizarov Fixator in Children

OBJECTIVES : To determine the outcome of congenital pseudoarthrosis tibia (CPT) managed with illizarov fixator. METHODS : This prospective cross-sectional study was done from 20 th March 2008 to 19 th March 2018. All patients presenting to the Orthopaedic out patient department (OPD) with pseudoarthrosis tibia belonging to either gender aged up to 12 years were included. All patients underwent excision of tapering ends and illizarov fixator application. Outcome was assessed in terms of complications. Data regarding age, gender, side, type of CPT and any complication was noted and analyzed using SPSS version 23. RESULTS : 16 patients were included in the study. 10 (62.5%) were males and 6 (37.5%) females. Mean age was 4 years. 10 (62.5%) patients were type-1 and 6 (37.5%) were type-2. Evidence of neurofibromatosis was seen in 9 (56.2%) patients. Most common complications were residual leg length discrepancy (LLD), mal-alignment and delayed consolidation which was seen in 8 (50%) patients. CONCLUSION : CPT is a periosteal disease with variable results. The study concludes that good results are achieved in 50% patients.

Does the intra-operatively measured leg length correction compare to the post-operative radiograph in total hip replacement surgery?

ABSTRACT BACKGROUND: This study aims to analyse the accuracy of the Vertical Measurement System™ (VMS) in assessing the leg length correction (LLC) during total hip arthroplasty (THA) by comparing the intra-operative measurements to the radiographic measurements obtained six weeks post-operatively Patients and methods: A prospective cohort study was conducted in which patients undergoing primary THA were enrolled at two centres in Cape Town, over a period of 19 weeks. THAs were performed by four surgeons. Pre-operative leg length discrepancy (LLD) measurements were obtained in 92 patients. The VMS was used to predict intra-operative LLC, and this measurement was compared to the post-operative LLC measured on the six-week follow-up X-ray. These measurements were statistically compared using the Mann-Whitney U test. RESULTS: The difference between the intra-operative VMS calculation and the six-week radiological measurement was not significant (p&gt;0.05), with the difference in their mean values being 0.1±3.3 mm. In the cohort, 82% of the patients (n=75) were within 5 mm of the target LLC, and 96% of patients (n=88) were within 10 mm of the target LLC. The mean absolute residual LLD at six weeks was 3.2±3.1 mm. CONCLUSION: The intra-operative LLC measurement obtained using the VMS accurately predicts the six-week post-operative radiographic LLC measurement Level of evidence: Level 4 Keywords: total hip replacement, leg length discrepancy, leg length correction, vertical measurement system, comparative study, longitudinal study

Comparison of Moseley and Rotterdam straight-line graphs in predicting leg lengths and leg-length discrepancy at maturity.

PurposeOne method of predicting leg-length discrepancy at maturity is the Moseley straight-line graph. Beumer et al developed an alternative graph, using a more modern Dutch population. The purpose of this study was to compare the prediction accuracy of these two graphs in a cohort of patients treated at our institution using epiphysiodesis.MethodsWe identified 76 patients treated using epiphysiodesis for leg-length discrepancy who were followed to maturity and had adequate preoperative radiographic assessment for straight-line graph construction. We compared predicted long leg length (after epiphysiodesis), short leg length, and residual leg-length discrepancy to actual outcome for both methods, using both chronological and skeletal ages.ResultsBoth methods were more accurate using skeletal age rather than chronological age. The Rotterdam graph showed modest improved accuracy compared to the Moseley graph in developmental aetiologies and in Hispanic patients. Using a difference of one centimetre in prediction error as clinically relevant (long leg [after epiphysiodesis], short leg, and leg-length discrepancy in each of the 76 patients, 228 predictions), we found comparable predictions in 171, more accurate prediction using the Rotterdam in 32, and using the Moseley in 25 predictions.ConclusionsStraight-line graphs provide a generally more accurate prediction of leg lengths at maturity by virtue of multiple preoperative evaluations. The Rotterdam straight-line graph was equal to or superior to the Moseley graph in most patients in this cohort. Use of skeletal age resulted in more accurate predictions than chronological age. Clinicians should remain familiar with the concept and use of the straight-line graph.Level of evidenceIII, case-control study.

Percutaneous femoral shortening over a nail using on-site smashing osteotomy technique.

Closed femoral-shortening osteotomy over an intramedullary nail for the treatment of leg length discrepancy (LLD) is a demanding surgical technique, classically requiring specialized instrumentation (intramedullary saw and chisel). Herein, we describe our experience with shortening osteotomy over a nail, using a percutaneous multiple drill-hole osteotomy technique to perform the bone section with the osteotomized bone smashed and let on-site. We operated on six patients with LLD due to: hemihypertrophy syndrome (three patients), congenital short femur, hemiplegic cerebral palsy, and growth plate injury. Mean femoral shortening was 4.2cm. Osteotomy was performed via a multiple drill-hole technique, and femurs were stabilized using an intramedullary nail. Post-operative clinical and radiological data were recorded. Residual LLD was assessed through long-standing teleroentgenography. Shortening was achieved, with a final LLD of < 1cm in all patients. All patients were satisfied and considered the lengths of the lower limbs to be equal. Our technique did not require special surgical skill or specialized instrumentation. Moreover, we did not record intraoperative and post-operative complications. Percutaneous femoral-shortening osteotomy over a nail using the on-site smashing osteotomy technique was effective and safe in treating LLD in this initial case series.

The Delta of Correction: a novel, more reliable variable than limb-length discrepancy at predicting outcome after total hip arthroplasty.

Leg-length discrepancy (LLD) is a frequent and recurring issue after total hip arthroplasty (THA). It can lead to discomfort and litigation due to the patient's perception of this inequality. The aim of this study was to evaluate the functional impact of postoperative LLD and length correction in patients after primary THA. We hypothesised that clinical outcomes are inversely correlated to length correction and residual discrepancy. In a prospective cohort, we included 121 patients undergoing unilateral primary THA. Patients were categorised into 3 groups based on their residual LLD using routine EOS imaging; Shorter (<-5 mm); Equal (-5 mm to +5 mm); and Longer (>+5 mm). Delta of Correction (DC) was defined as the difference between pre- and postoperative discrepancy measured on EOS imaging. Functional scores (HHS, Postel Merle d'Aubigné, and WOMAC) were measured preoperatively and at last follow-up. The average follow-up was 24 months. We evaluated the clinical and radiographic outcomes regarding the residual LLD and DC. All patients had improvement in their functional scores at last follow-up. There was no difference in clinical outcomes, regardless of preoperative or residual LLD. The highest scores were found in the population with the smallest variations (DC -5 to +5 mm, HHS 96). Conversely, poorer results were found in shortened patients (DC <-5 mm), HHS 86, and lengthened patients, corrected by > 15 mm, with HHS of 83, p < 0.005. Patient perception of postoperative LLD correlated with the DC (p = 0.004). The DC measurement is a more effective assessment than arthroplasty.

Arthroscopic versus open, medial approach, surgical reduction for developmental dysplasia of the hip in patients under 18 months of age

Background and purpose — The value of arthroscopic surgical reduction in developmental hip dysplasia is poorly known. We compared the clinical and radiographic efficacy of arthroscopic and medial open surgical reduction in patients less than 18 months of age with developmental hip dysplasia.Patients and methods — 54 patients with a mean age of 11 months who were treated by Ludloff’s medial open reduction technique (28 hips, Group L) or arthroscopic surgical reduction technique (26 hips, Group A) were evaluated in this case series. Data on age, sex, preoperative Tönnis grade, operative time, estimated blood loss, residual leg length discrepancy, range of motion (ROM), acetabular index (AI) angle, coverage ratio of the femoral head, continuity of Menard–Shenton line, re-dislocation rate, McKay classification, and Kalamchi–MacEwen avascular necrosis (AVN) classification were collected.Results — Preoperatively, the mean AI angle was 39° in Group L and 37° in Group A. At the latest follow-up, the mean AI was 26° in both groups. The mean femoral head coverage ratio was 79% in Group L and 80% in Group A. The Menard–Shenton line was intact in all patients. Residual leg length discrepancy or limited ROM was not detected in any patients. 4 patients in Group L and 2 in Group A were diagnosed with type 2 AVN.Interpretation — Arthroscopic surgical reduction in patients aged 6–18 months revealed promising clinical and radiographic outcomes similar to medial open reduction using Ludloff’s technique.

Debridement Technique and Dead Space Management For Infected Non-Union of the Tibia

Infected non-union of the tibia represents a major challenge to orthopaedic surgeons. Wide resection of infected tissues decreases the recurrence rate of infection in post-osteomyelitis reconstruction. Such radical debridement results in bone and soft tissue defects making the challenge more difficult with creation of a dead space. Elimination of the dead space is a necessity using antibiotic-impregnated cement as a staged technique for further reconstruction of bone and soft tissue. The objective of this series is to assess the efficacy of our integrated protocol for management of infected non-union of the tibia. This prospective study included 23 patients with infected non-union of the tibia with medullary contamination managed by staged debridement and insertion of antibiotic-impregnated cement spacer with later distraction histogenesis using Ilizarov frame for bone and soft tissue reconstruction. The mean age of the patients was 24 years (19 to 52). The mean size of the defect after debridement was 6 cm (range 4–10 cm). The average follow up period was 28 months (range 16–36 months). Successful reconstruction with no recurrence of infection was achieved in all cases (100%) without the need for bone or soft tissue grafts. External fixator index ranged from 35 to 60 days/cm (average 45 days/cm). The functional results were satisfactory in 20 cases (86.9%) and unsatisfactory in 3 cases (13.1%) due to residual leg length discrepancy, joint stiffness, and persistent pain. The proposed staged protocol represents a valid option for successful bone and soft tissue reconstruction and elimination of the infection without the need of bone grafting nor soft tissue procedures.

Lengthening of free fibular grafts for reconstruction of the residual leg length discrepancy

BackgroundWe evaluated our results of lengthening of free vascularized fibular grafts using a unilateral external fixator in patients with residual leg length discrepancy after free vascularized fibular graft for lower limb reconstruction.Cases presentationTwo patients were administrated to our hospital with residual tibial length discrepancy after vascularized free fibular graft surgery. Lengthening of the free vascularized fibular graft with a unilateral external fixator was performed to correct the leg length discrepancy. Both patients recovered well with no difficult in activities of daily living at the last follow-up.ConclusionsThis study shows that lengthening of free vascularized fibular grafts with an external fixator is an effective treatment for massive residual leg shortening after vascularized free fibular graft surgery.

Timing of Epiphysiodesis to Correct Leg-Length Discrepancy: A Comparison of Prediction Methods.

The purpose of this study was to compare the accuracy of different methods used to predict ultimate leg lengths and residual leg-length discrepancy in a group of patients treated with epiphysiodesis at our institution. Seventy-seven patients with adequate preoperative radiographs, no postoperative complications, and follow-up to skeletal maturity composed the study group. We compared the predicted lengths of both legs and residual leg-length discrepancy at maturity with actual outcomes using the White-Menelaus, Anderson-Green, Moseley, and multiplier methods. Skeletal age varied >1 year from chronological age in 61 (26%) of 231 observations, including 19 patients (25%) whose average skeletal age from 3 determinations differed by >1 year from chronological age. The prediction accuracy of each method was improved by using skeletal, rather than chronological, age. Error in prediction of the length of the short leg varied from a mean (and standard deviation) of 1.8 ± 1.2 cm for the straight-line graph to 2.5 ± 2.0 cm for the multiplier method. Prediction error for the long leg (after epiphysiodesis) varied from a mean of 1.2 ± 1.1 cm for the straight-line graph to 1.7 ± 1.5 cm for the multiplier method. Leg-length-discrepancy prediction error ranged from a mean of 0.7 ± 0.6 cm for the White-Menelaus method incorporating a growth inhibition factor to 1.1 ± 0.9 cm for the multiplier method. The multiplier method was the least accurate of all. All differences were significant. Determination of skeletal age is clinically relevant in patients being considered for epiphysiodesis to manage leg-length inequality. The multiplier method was the least accurate of the prediction methods in this patient population, which may have implications in calculating the appropriate timing of epiphysiodesis.

Minimizing Leg Length Discrepancy After Intramedullary Nailing of Comminuted Femoral Shaft Fractures: A Quality Improvement Initiative Using the Scout Computed Tomography Scanogram.

To prevent leg length discrepancy (LLD) after locked femoral nailing in patients with comminuted femoral shaft fractures. Prospective consecutive case series aimed at quality improvement. Level 1 Trauma Center PATIENTS:: Ninety-eight consecutive patients with a comminuted femoral shaft fracture underwent statically locked intramedullary nailing, with a focused attempt at minimizing LLD during surgery. A computed tomography scanogram of both legs was performed on postoperative day 1 to assess for residual LLD. Patients were offered the option to have LLD >1.5 cm corrected before discharge. LLD >1.5 cm. Twenty-one patients (21.4%) were found to have an LLD >1.5 cm. An LLD >1.5 cm occurred in 10/55 (18%) antegrade nail patients and 11/43 (26%) retrograde nail patients (P = 0.27). No difference was noted based on the mechanism of injury, surgeon training and OTA/AO type B versus C injury. Ninety of 98 patients left with <1.5 cm LLD, 13/21 had a correction all to ≤0.6 cm, and 8 decided to accept the LLD and declined early correction. No patient left the hospital with an LLD >1.5 cm after locked intramedullary nailing for a comminuted femoral shaft fracture without being informed and the option of early correction. We recommend using a full-length computed tomography scanogram after IM nailing of comminuted femur fractures to prevent iatrogenic LLD. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The use of a non-invasive extendable prosthesis at the time of revision arthroplasty.

The use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses. All patients who had a noninvasive growing endoprosthesis inserted at the time of a revision procedure were identified from our database. A total of 21 patients (seven female patients, 14 male) with a mean age of 20.4 years (10 to 41) at the time of revision were included. The indications for revision were mechanical failure, trauma or infection with a residual leg-length discrepancy. The mean follow-up was 70 months (17 to 128). The mean shortening prior to revision was 44 mm (10 to 100). Lengthening was performed in all but one patient with a mean lengthening of 51 mm (5 to 140). The mean residual leg length discrepancy at final follow-up of 15 mm (1 to 35). Two patients developed a deep periprosthetic infection, of whom one required amputation to eradicate the infection; the other required two-stage revision. Implant survival according to Henderson criteria was 86% at two years and 72% at five years. When considering revision for any cause (including revision of the growing prosthesis to a non-growing prosthesis), revision-free implant survival was 75% at two years, but reduced to 55% at five years. Our experience indicates that revision surgery using a noninvasive growing endoprosthesis is a successful option for improving leg length discrepancy and should be considered in patients with significant leg-length discrepancy requiring a revision procedure. Cite this article: Bone Joint J 2018;100-B:370-7.

Clinical Results and Complications of Lower Limb Lengthening for Fibular Hemimelia: A Report of Eight Cases.

Fibular hemimelia is a rare but the most common congenital long bone deficiency, encompassing a broad range of anomalies from isolated fibular hypoplasia up to substantial femoral and tibial shortening with ankle deformity and foot deficiency. Most cases of fibular hemimelia manifest clinically significant leg length discrepancy (LLD) with time that requires adequate correction by bone lengthening for stable walking. Bone lengthening procedures, especially those for pathological bones, are sometimes associated with severe complications, such as delayed consolidation, fractures, and deformities of the lengthened bones, leading to prolonged healing time and residual LLD at skeletal maturity. The purpose of this study was to review our clinical results of lower limb lengthening for fibular hemimelia.This study included 8 Japanese patients who diagnosed with fibular hemimelia from physical and radiological findings characteristic of fibular hemimelia and underwent single or staged femoral and/or tibial lengthening during growth or after skeletal maturity. LLD, state of the lengthened callus, and bone alignment were evaluated with full-length radiographs of the lower limb. Previous interventions, associated congenital anomalies, regenerate fractures were recorded with reference to medical charts and confirmed on appropriate radiographs. Successful lengthening was defined as the healing index <50 days/cm without regenerate fractures.A significant difference was observed in age at surgery between successful and unsuccessful lengthening. The incidence of regenerate fractures was significantly correlated with callus maturity before frame removal. LLD was corrected within 11 mm, whereas mechanical axis deviated laterally.Particular attention should be paid to the status of callus maturation and the mechanical axis deviation during the treatment period in fibular hemimelia.

Lower limb kinematics following pelvic support osteotomy for unilateral avascular necrosis of the femoral head

Introduction: Avascular necrosis of the femoral head (AVN) has devastating long term consequences for hip joint mobility and lower limb function. Management is complex, there is no accepted gold standard treatment and there has been only limited evaluation of the gait characteristics of this group [1–3]. To evaluate the management of this condition functionally, a twostage study has been undertaken. Stage one, a retrospective cohort study of the gait of young people with femoral head AVN (presented previously) and stage two, evaluation of these patients post pelvic support osteotomy PSO (current paper). Patients/materials and methods: A standard threedimensional gait analysis was performed post operatively on 17 patients following PSO for femoral head AVN using a 6camera Vicon® 370 system, Kistler® force platform and Plug in Gait® software. From a representative cycle for each patient, mean ± 1 standard deviation were calculated for waveform throughout the cycle for affected and unaffected sides. These were compared to the laboratory normal adult dataset (Figure 1.). Paired t-tests were performed where data were normally distributed. Results: The cohort comprised 11 males and 6 females, mean age 17 years (range 15-19). Initial analysis of the data revealed increased hip excursion and shift towards normal range with associated improvements in pelvic excursion and alignment. Therewas a shift towards normal timing and magnitude of knee flexion in stance. Length discrepancy persisted in all cases although compensatory equinus was reduced. Discussion & Conclusions: Analysis of three dimensional gait analysis post pelvic support osteotomy for unilateral avascular necrosis of the femoral head, revealed significant improvements in lower limb kinematics. Although residual leg length discrepancy was evident in themajority of the cohort, PSOappears to represents a functionally beneficial surgical option for this group of patients. Further comparative evaluation is required to establish the optimal surgical intervention for this group of patients.

Proximal Tibial Osteotomy and Taylor Spatial Frame Application for Correction of Tibia Vara in Morbidly Obese Adolescents

Four percent of children and adolescents in the United States are morbidly obese. Treatment for tibia vara includes proximal tibial osteotomy and correction with a Taylor Spatial Frame (TSF). There are no reports that specifically examine the success of this technique in morbidly obese adolescents. A retrospective review was conducted of patients between 12 and 18 years of age with a body mass index for age at or above the 99th percentile who had undergone gradual correction of tibia vara with proximal tibial osteotomy and application of a TSF at our institution between 2005 and 2009. Deformity analysis was performed on full-length standing anteroposterior radiographs of both lower extremities and lateral radiographs of the involved tibia obtained preoperatively and at latest follow-up. All complications were recorded. Fourteen patients met the inclusion criteria. The mean age was 13 years. The average body mass index was 45 kg/m. Preoperative deformity analysis demonstrated a mean mechanical axis deviation of 90 mm, mean mechanical medial proximal tibial angle of 66 degrees, and mean posterior proximal tibial angle of 80 degrees. Analysis at an average follow-up of 14 months demonstrated a mean mechanical axis deviation of 10 mm, mean mechanical medial proximal tibial angle of 88 degrees, and mean posterior proximal tibial angle of 81 degrees. Complications specifically related to the TSF occurred in 2 patients. Both experienced strut disengagement and loss of osteotomy position. This was treated with refastening of the strut and a new program of deformity correction. Complications related to the deformity correction occurred in 3 patients. One had premature fibular consolidation requiring repeat osteotomy, 1 developed a transient partial deep peroneal nerve palsy, and 1 experienced thigh soft tissue irritation from the proximal ring necessitating early TSF removal. One patient had a residual leg-length discrepancy that required tibial lengthening. Correction of tibia vara with proximal tibial osteotomy and application of a TSF is an effective treatment option in morbidly obese adolescents. Associated complications are minimal. Level IV-therapeutic study.