Tibial Lengthening Research Articles

Effect of elastic intramedullary nailing on lower limb lengthening in acquired shortenings: a prospective study

Introduction Lengthening and correction of limb deformities using Ilizarov external fixation is a frequent standard operation. However, the risk of complications associated with limb lengthening, including superficial or deep infection, contractures, secondary deformity, and fractures after device removal associated with delayed bone consolidation, remains significant.The purpose of the work was to identify the features of bone lengthening with an external fixator in combination with elastic intramedullary nails, titanium or titanium with a composite hydroxyapatite coating, in the conditions of shortening of the lower extremities of acquired etiology.Materials and methods The study included 64 patients, of which 31 patients underwent monofocal lengthening of the femur, 33 patients underwent monofocal lengthening of the tibia.Results The mean external fixation indices (EFIs) of the groups compared for similar lengthening types (femoral or tibial lengthening) did not differ significantly for the types of intramedullary nails implanted. In femoral lengthening, a significant effect on the EFI had the nail type and the ratio of “nail diameter / medullary canal diameter”. The dependence of EFI on the nail type in tibial lengthening was associated with the ratio “nail diameter / internal diameter at the osteotomy site” (p = 0.023). Two-way ANOVA showed that the effect of the nail type on EFI depended on the nail diameter/ internal diameter at osteotomy site ratio in the tibial lengthening group (p = 0.034).Discussion In acquired shortening of the lower extremities, there is no difference in EFI by using titanium elastic nails or intramedullary nails coated with composite hydroxyapatite. The use of a combined technique, in any case, has advantages: it provides good and excellent results without serious complications during lengthening in patients with shortening of acquired etiology. The strong positive correlation between the bone diameter/internal cortical distance ratio at the osteotomy site, coupled with the significant influence of the nail type and nail diameter on EFI, suggests that both factors should be considered together in future studies.Conclusion In shortening of the lower extremities of acquired etiology, the use of a combined bone lengthening technique, comprising an external fixator in combination with elastic intramedullary nailing, provides good and excellent results without serious complications.

PRECICE nail bending in femur lengthening

IntroIntramedullary nails (ILNs) are commonly used in orthopedic surgery for the fixation of long bone fractures and limb lengthening. Understanding the structural mechanics (i.e. nail bend) of an ILN device is crucial in determining its performance under various loading conditions. Furthermore, nail diameter was found to play a key role in an ILN's susceptibility to plastic deformity. This study aims to investigate the degree of nail bending and incidence of plastic deformity in patients receiving antegrade femoral ILNs (PRECICE, NuVasive, Inc.). MethodsRetrospectively evaluated 130 ILNs (PRECICE, NuVasive, Inc.) in 100 adult patients who underwent limb lengthening done in a single center. Patients who had concomitant osteotomies, tibial lengthening, malunion, non-union, mechanical failure, or revision surgery for any reason were excluded. All nails were inserted through the greater trochanter or piriformis. Patients’ age, weight, height, and body mass index (BMI)were extracted. Radiologic assessments involved analyzing long lower limb standing X-rays before, during, and at consolidation for total distraction and nail bend. Naildiameter and patient characteristics were directly sourced from medical records. ResultsNail bend at consolidation averaged 2.4° (SD 2.4), ranging from 0 to 9. Additionally, total femoral lengthening was assessed, with a mean value of 5.3 cm (SD 2.1). A significant positive association was observed in the nail bend and weight (weight in kg/nail diameter in mm) coefficient (P < 00.01). Bilateral limb lengthening was also correlated to increase nail bend (P < 00.05). ConclusionPatient's weight to nail diameter ratio and bilateral limb lengthening were found to be significant factors affecting nail bend. These findings advance our understanding of the interrelation between the nail biomechanical profile and the patient's physical attributes, offering important implications for limb lengthening. Level of evidenceIII.

Efficacy and safety of electrophysical agents in tibial lengthening by the Ilizarov method: a protocol of systematic review

Introduction: The Ilizarov method, a circular external fixator, is the most commonly used approach to assist in bone union for tibial fractures. Electrophysical agents play a crucial role in rehabilitation, offering significant benefits in speeding up the recovery process and reducing treatment time. Objective: To evaluate the efficacy and safety of using electrophysical agents as adjunct treatment in the rehabilitation of tibial lengthening with the Ilizarov method. Methods: A systematic review of randomized clinical trials (RCTs) will be conducted. The review protocol has been registered on the PROSPERO platform (CRD42023432698). Adults aged 18 years and older undergoing tibial lengthening using the Ilizarov method will be included. Searches will be performed in the following databases: Medical Literature Analysis and Retrieval System Online (Medline) via PubMed, Brazil Scientific Eletrononic Library Online (SciElo), Latin American and Caribbean Health Sciences Literature (LILACS) via Virtual Health Library, Physiotherapy Evidence Database (PEDro), Web Of Science, Sciverse Scopus and Excerpta Medica dataBASE (Embase) via Elsevier, with no language or publication year restrictions. The methodological rigor and certainty of evidence of the included studies will be assessed using the Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, respectively. Study selection, data extraction, and methodological quality assessment will be conducted by two independent researchers. Expected outcomes: To provide robust information on how rehabilitation through electrophysical agents can impact bone lengthening using the Ilizarov method. Keywords: Ilizarov Technique; Rehabilitation; Systematic Review.

Fibular hemimelia: reconstruction of difficult cases with tibial lengthening and ankle arthrodesis.

Management of fibular hemimelia includes either prosthetic care with or without a suitable amputation or tibial lengthening. Many studies have documented the success of both procedures. Most parents of these children refuse an amputation or have no access to good prosthetic care. The author presents a limb-salvage procedure with tibial lengthening and ankle stabilization. Twelve children of fibular hemimelia with 14 extremities had been subjected to limb lengthening after lateral leg release. To correct the valgus procurvatum, double oblique diaphyseal osteotomy (DODO) of the tibia was performed in 11 extremities. The age of the patients ranged from two to 15years with the median of fiveyears. All were male. The proposed procedure included three stages of loosening, lengthening, and stabilization with ankle arthrodesis at a later stage. All patients returned for follow-up for the first fouryears and had been walking on their sensate feet. With DODO followed by fixator/traction could straighten and lengthen the tibia simultaneously and correct the valgus procurvatum. Ankle stabilization provided stability and a plantigrade foot. A follow-up of six to30years with a median of tenyears has been reported. A new procedure of loosening, lengthening, and stabilization of the leg with ankle arthrodesis has been proposed. A follow-up of 30years with a median of tenyears of the said procedure has been reported. The procedure provides a long-lasting plantigrade and painless foot that has sensation and proprioception. An amputation at any level has not been recommended.

A RETROSPECTIVE REVIEW OF THE THERAPEUTIC MANAGEMENT OF SOFT TISSUE AND JOINT RANGE OF MOTION DURING LOWER LIMB LENGTHENING IN CHILDREN

IntroductionSheffield Children's Hospital specialises in limb lengthening for children. Soft tissue contracture and loss of range of motion at the knee and ankle are common complications. This review aims to look at therapeutic techniques used by the therapy team to manage these issues.Materials &amp; MethodsA retrospective case review of therapy notes was performed of femoral and tibial lengthening's over the last 3 years. Included were children having long bone lengthening with an iIntramedullary nail, circular frame or mono-lateral rail. Patients excluded were any external fixators crossing the knee/ankle joints.Results20 tibial and 25 femoral lengthening's met the inclusion criteria. Pathologies included, complex fractures, limb deficiency, post septic necrosis and other congenital conditions leading to growth disturbance. All patients had issues with loss of motion at some point during the lengthening process. The knee and foot/ankle were equally affected. Numerous risk factors were identified across the cohort. Treatment provided included splinting, serial casting, bolt on shoes, exercise therapy, electrical muscle stimulation and passive stretching.ConclusionsLoss of motion in lower limb joints was common. Patients at higher risk were those with abnormal anatomy, larger target lengthening's, poor compliance or lack of access to local services. Therapy played a significant role in managing joint motion during treatment. However, limitations were noted. No one treatment option gave preferential outcomes, selection of treatment needed to be patient specific. Future research should look at guidelines to aid timely input and avoid secondary complications.

Infection rates and risk factors with magnetic intramedullary lengthening nails

IntroductionSurgical site infection (SSI) related to magnetic intramedullary lengthening nails (MILNs) can lead to delayed consolidation or loss of limb function, resulting in deleterious effects to a patient's quality of life. With the rise of MILNs, we sought to determine the incidence rate and risk factors for infection during limb lengthening with MILNs. MethodsWe reviewed a consecutive series of patients who underwent femoral and/or tibial lengthening with an MILN at a single institution between 2012 and 2020 (n = 420). SSI was defined according to CDC-NHSN criteria (including superficial and deep infections) with postoperative surveillance time of 12 months. Demographic, health metrics, comorbidities, limb- and surgery-related factors, were assessed as potential risk mediators of SSI. ResultsIncidence of SSI was 3.3 % (14/420). This was divided into superficial (0.5 %,2/420) and deep (2.9 %, 12/420) infections. Of deep infections, 75 % (9/12) were osteomyelitis. Of the 14 limbs that developed SSI, 57 % (8/14) had a history of prior external fixation in the same limb and 38 % (5/14) had a previous infection of the same limb. A subanalysis of patients with a history of prior external fixation in the same bone was associated with SSI, as compared to those without previous external fixation. None of the surgery-related infection risk factors reached statistical significance. Discussion and conclusionThe total incidence of infection with MILNs was 3.3 % at 24 months follow-up. The risk of deep infection was 2.9 %. Patients with a history of previous external fixation and prior infection show an independent association with increased rate of infection recurrence in the same bone. These patients could be considered a high-risk group for developing deep tissue infection. Potential algorithms include prolonged oral antibiotics after MILN insertion or simultaneous injection of absorbable antibiotic at the time of the nail insertion.

Distraction osteogenesis in combined sequential use of external fixation and nailing (lengthening and then nailing): An experimental study in rabbits.

Limb lengthening relies on the process of distraction osteogenesis. The active periosteal bone formation has been detected in clinical practice with a lengthening and then nail (LATN) technique but has not been confirmed by experimental studies to date. The aim of this study is to compare the tissue regeneration of the distraction regenerate during tibial lengthening in rabbits using a LATN technique. This study was performed on 54 mature rabbits of the Soviet Chinchilla breed, which were divided into three groups of 18 animals. In group 1 (control), the tibia was lengthened in an external fixator. In group 2, the LATN technique was modeled and in group 3, lengthening over nail (LON) was modeled. The total duration of the experiment was 45 days. On the 10th, 15th, 20th, 30th, and 45th day X-ray, computed tomography and morphological studies were performed. In the experimental groups (2 and 3), a more pronounced periosteal bone formation in the area of regenerate was noted when compared to group 1. In group 2 (LATN), wide cortical plates were formed from the intermediate and periosteal areas. In this group, the maximum densitometric density values were noted. Endosteal bone formation was preserved in all groups. The LON and LATN techniques, when compared with the classical Ilizarov lengthening, do not demonstrate any deficiency in the tissue regeneration of the bone tissue at the regenerate sites. The most powerful bone structures are formed with the sequential use of the external fixation and nailing (LATN).

Limb salvage reconstruction of the lower limb with complex ankle arthrodesis and magnetic internal lengthening nail.

With advances in orthopedic implants, the use of intramedullary lengthening devices has gained increasing popularity as an alternative technique compared to lengthening with external fixators, with alleged comparable or better outcomes. The aim of this study is to report our single-center technique and outcomes of combined ankle arthrodesis and proximal tibial lengthening using external fixator with a motorized intramedullary nail, respectively. Fourteen patients with post-traumatic advanced ankle arthritis underwent staged ankle arthrodesis with external fixator and proximal tibial lengthening using the PRECICE® ILN. Amount of shortening, length achieved, bone healing index, infection rate, ankle fusion rate, and ASAMI score were evaluated. The average age was 44 years old (range, 30-62). The mean follow up is 70 months (range, 43-121.4). The average amount of limb shortening for patients after ankle fusion was 36.7 mm (18-50) while lengthening was 35.9 mm (range, 18-50). Patients had the nail implanted for an average of 479 days (range, 248-730). Ankle fusions were healed in an average of 178.3 days. There were no surgical infections. All osteotomy-lengthening sites healed after an average 202 days (106-365). The mean bone healing index (BHI) was 56.0 days/cm (21.2-123.6) among the whole cohort. There were no cases of nonunion. ASAMI bone scores were excellent or good among all patients. Ankle arthrodesis with external fixation along with proximal tibial lengthening using motorized IMN yielded high rates of fusion and successful lengthening. This technique could be offered as a reasonable alternative to using external fixation for both purposes. Level IV, Retrospective cohort study.

Magnetically driven antegrade intramedullary lengthening nails for tibial lengthening.

As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated.

Limb lengthening and deformity correction in patients with severe fibular hemimelia: experience of the children's university hospital in Belgrade

Background Fibular hemimelia (FH) is a congenital disease manifested by valgus deformity and instability of the knee joint, shortening and deformity of the tibia, hypoplasia and deformities of the foot and ankle.The aim of this paper was to determine the efficacy of the strategy of separate reconstruction of the foot along with correction of tibia deformity, and then tibial lengthening in patients with FH of types 3 and 4 according to Paley.Methods This retrospective study is based on an analysis of the treatment of 12 children with severe FH. The patients, aged no older than 24 months, were treated for foot reconstruction along with correction of tibial deformity followed by a separate stage of tibial lengthening. Tibial lengthening was performed in the age 4.6 ± 1.2 years. The long-term result of treatment was evaluated at least 1 year after the end of tibial lengthening. Evaluation criteria after tibia lengthening were external osteosynthesis index, amount of lengthening, assessment of outcomes according to Lascombes. Walking ability was assessed using Gillette questionnaire.Results The approach we used gave excellent and good results in 83 % of cases after the first reconstructive stage. Complications and recurrences of deformities encountered during the first stage were eliminated during subsequent planned limb lengthening. The average magnitude of lengthening was 6.4 ± 2.4 cm (37.2 ± 12.4 % of the initial segment length). The index of external osteosynthesis was 22.9 ± 12.2 days/cm. Monofocal distraction osteosynthesis was used in 9 cases and bifocal osteosynthesis in three cases. The results of lengthening were classified by Lascombes as IA in 7 cases, IB in four cases, 2B in one case.Discussion In severe FH, the question of reconstruction or early amputation remains open. There are two opinions on the staging of reconstructive orthopedic surgery and tibial lengthening in young children with severe FH.Conclusion The strategy of reconstruction of the foot and ankle joint at an early age (16-24 months) in children with severe FH followed by lengthening of the lower leg (at the age of 4-6 years) proved to be effective and can be used when it is chosen by the patient's parents. In 3C type cases, the use of external fixation to correct the deformity and simultaneously lengthen the tibia at the first stage is an alternative reasonable strategy option.

Characteristics of terminal hemimelia: What is the difference between terminal hemimelia and classic fibular hemimelia?

Fibular hemimelia has denoted a spectrum of postaxial longitudinal deficiency with fibular aplasia/hypoplasia; the term "terminal hemimelia" is reserved for patients with postaxial longitudinal deficiency having a normal fibula. We aimed to delineate the characteristics of terminal hemimelia. In total, 30 patients with postaxial longitudinal deficiency who had a normal or hypoplastic fibula and visited our institution between 1992 and 2022 were reviewed. Patients were divided into terminal hemimelia and classic fibular hemimelia groups, and their demographic characteristics and clinical and radiographic findings were compared. Femoral shortening, knee valgus, and tibial spine hypoplasia were less common in terminal hemimelia (n = 13) than in classic fibular hemimelia (n = 17) (p = 0.03, p < 0.001, and p = 0.003, respectively). None of the patients in the terminal hemimelia group exhibited knee instability, whereas 12% of patients with classic fibular hemimelia did. Ball-and-socket ankle and absence of lateral rays were commonly observed in both groups. However, tarsal coalition was observed less frequently in terminal hemimelia (p = 0.004). All terminal hemimelia patients exhibited a painless plantigrade foot without ankle instability. Despite limb-length discrepancy at maturity averaging 40.4 mm for terminal hemimelia and 67.0 mm for classic fibular hemimelia (p < 0.001), patients with terminal hemimelia, except for one, exhibited > 20 mm of limb-length discrepancy. However, 46% of them underwent limb-length equalization procedures, mostly single-stage tibial lengthening, at a mean age of 11.2 years. Terminal hemimelia may present with a milder phenotype than classic fibular hemimelia. It mainly overlaps with the symptoms of fibular hemimelia below the ankle joint and manifests as limb-length discrepancy. However, a considerable number of patients with terminal hemimelia required limb-length equalization procedures, for example single-stage tibial lengthening. level IV.

Chronic knee pain following infrapatellar/suprapatellar magnetic intramedullary lengthening nails versus external fixators in limb length discrepancy: A retrospective review

Aims & objectivesPrior to the popularization of magnetic intramedullary nails (MILNs), gradual deformity correction using external fixation was the norm in limb lengthening. Trauma literature has shown MILN via a suprapatellar approach (SP) to be associated with less knee pain than either an infrapatellar entry (IP) or external fixation. Yet, no research has investigated chronic knee pain and MILNs. We assessed differences in chronic knee pain following lengthening via an IP or SP approach with an MILN versus external fixation. Materials & methodsWe reviewed 147 limbs (55 MILN/IP, 22 MILN/SP, 71 external fixator) in 124 patients who underwent tibial lengthening with ≥12 months follow-up between February 2012 and July 2020. Knee pain was assessed pre- and postoperatively at 6 and 12 months, with the Lysholm Knee Scoring Scale (LKSS) and numeric pain scale (0-10). Differences in knee pain outcomes were compared across methods, with subgroup analysis of MILN/SP and MILN/IP. ResultsMean LKSS was 96.3 for external fixation and 88.5 for MILN (P = .011). In the MILN subgroups, mean LKSS was 91.7 for IP and 85.3 for SP. The IP group reported a lesser mean pain score (0.6 versus 2.1) at 12 months. Bilateral nail recipients demonstrated no knee pain differences versus unilateral. At 12 months postoperative, external fixation had better knee outcomes. ConclusionTibial lengthening with external fixation was associated with less chronic anterior knee pain and better functional outcomes than MILN overall. In terms of MILN approach, IP surpassed SP on subjective pain scores. Larger tibial lengthening and knee pain studies are warranted.

A Case of Cavus: Tackling Post Operative Recurrence

Pes cavovarus deformities of the foot and ankle pose significant challenges for patients and clinicians, often leading to debilitating symptoms and sequelae. This case study presents a 67-year-old female patient who underwent multiple surgical corrections for recurrent cavus foot deformity. The initial surgery involved Tendo-Achilles Lengthening, Dwyer Calcaneal Osteotomy, and Total Ankle Arthroplasty. However, over time, the deformity migrated to the forefoot and midfoot, necessitating further interventions, including dorsiflexory wedge osteotomy and IPJ fusion. Despite these efforts, the cavus deformity recurred in the rearfoot in 2022, leading to a comprehensive surgical approach. The procedures included soft tissue and osseous corrections, such as posterior tibial tendon lengthening, deltoid release, hardware removal, lateral calcaneal sliding osteotomy, and polyethylene replacement of the ankle arthroplasty. The patient experienced pain relief and improved function following this intervention. The study highlights the challenges associated with managing cavovarus deformities and the importance of a systematic approach to address both soft tissue contractures and osseous abnormalities. Furthermore, it underscores the potential for recurrence in such cases, necessitating vigilant postoperative monitoring and adaptable treatment strategies. While the patient achieved positive outcomes twelve months postoperatively, this case emphasizes the need for careful pre-operative planning and consideration of various surgical techniques to effectively manage pes cavovarus deformities and their recurrent nature.

Bone Defect Replacement in Diabetic Neuropathic Osteoarthropathy (Charcot Foot): Review

Background. The number of patients with diabetes mellitus, including those with its severe complications such as Charcot neuropathic osteoarthropathy, is increasing worldwide. Restoration of weight bearing ability and creation of conditions for ulcer healing is challenging for trauma and orthopedic surgeons, especially because of the need to restore bone tissue defects.&#x0D; Aim of the review to compare modern methods of replacement of large bone tissue defects of the distal segment of the lower limb in patients with Charcot neuropathic osteoarthropathy.&#x0D; Methods. The articles were searched in PubMed/MEDLINE, Google Scholar, Scopus, eLIBRARY, CyberLeninka databases. The search was performed using the following keywords and word combinations: Charcot foot, diabetic neuropathic osteoarthropathy and bone grafting. Full-text articles in Russian and English were selected. The search was carried out without chronological limitations due to the small number of published studies and specific subject of research.&#x0D; Results. The possibilities of bone defect replacement in Charcot foot are poorly described in the world literature. The narrow specificity and relative infrequency of this pathology is the probable reason for the small number of publications and the lack of studies with a high level of evidence.&#x0D; Conclusion. Bone autografting for lesions of the medial or lateral midfoot column and Ilizarov tibial lengthening to compensate for limb shortening after reconstructive surgeries at the level of the hindfoot and ankle joint are the most commonly used methods of bone defect replacement in patients with Charcot foot. Free bone autografting (possibly with demineralized bone matrix) is the method of choice for small defects of the lateral or medial column of the midfoot.

Comparative fixation devices for preventing migration of the proximal tibiofibular joint during tibial lengthening: a tether versus screw fixation

BackgroundWhen lengthening the tibia segment using motorized internal lengthening nails (MILN), undesired distal migration of the proximal fibula segment is prevented by tibiofibular stabilization, traditionally using a screw. A tightened cortical suspensory fixation rope (tether) is an alternative option, but its appropriateness has never been studied. The primary outcome was comparing the amount of proximal fibular migration between patients who were stabilized with either a tether or a screw. The secondary outcome was to evaluate the effect of fibular migration on the clinical outcome between both groups.MethodsA retrospective study was conducted on patients who underwent tibial lengthening with MILN between April 2016 and June 2022. Two cohorts were compared: 18 limbs with tether fixation versus 29 limbs with screw fixation. Data on the patient's age, sex, etiologies, and clinical outcomes were collected. Radiographic measurements included the lengthening distance and the amount of proximal fibular migration.ResultsIn total, 47 limbs from 41 patients, with average age 35.01 ± 13.72 years old. There were 28 males (68.29%) and 13 females (31.71%). The tether group demonstrated a statistically significant greater distance of migration than the screw group (p < 0.001), with an average migration distance of 8.39 ± 5.09 mm and 2.59 ± 3.06 mm, respectively. No correlation was found between the amount of tibial lengthening and the distance of proximal fibular migration in both the tether group (p = 0.96) and the screw group (p = 0.32). There was no significant difference in the change of knee extension between both groups (p = 0.3), and no patients reported knee pain or tightness.ConclusionA screw provides better resistance to proximal tibiofibular joint migration during MILN lengthening, but the difference appears clinically inconsequential. Either option appears suitable.

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

Hexapod external fixator systems allow simultaneous deformity correction in multiple planes as well as limb lengthening. The aim of this study is to evaluate the accuracy of a hexapod frame (smart correction frame) in different types of tibial deformities requiring correction with or without lengthening. A total of 54 tibial angular deformities and limb length discrepancies operated with a hexapod frame between January 2015 and January 2021 were classified into four groups: "Group A (n = 13): only lengthening," "Group B (n = 14): lengthening and uniplanar correction," "Group C (n = 16): only uniplanar correction," and "Group D (n = 11): biplanar correction." The accuracy of angular deformity correction/lengthening was calculated by dividing the actual correction/lengthening achieved after frame removal by the preoperative planned lengthening/correction. The lengthening accuracy in Group A and Group B was 96.3 ± 7.1% and 95.7 ± 5.9%, respectively (P = 0.685). The angular deformity correction accuracy was 85.1 ± 9.9% for Group B, 85.2 ± 13.9% for Group C, and 80.2 ± 18.4% for Group D (P = 0.852). A revision program was performed in six cases (1 in Group B, 1 in Group C, and 4 in Group D) for full correction of the deformities. The accuracy of tibial lengthening is high with the hexapod frame and is minimally affected by simultaneous deformity correction; however, the accuracy of angular correction slightly reduces as the deformity becomes more complex. Surgeons should be aware that reprogramming may be required after complex deformity correction.

Simultaneous tibio-talar fusion and tibial lengthening for end-stage ankle arthritis.

Arthrodesis of the ankle joint is an accepted treatment option in patients with end-stage ankle arthritis. The goal is to achieve fusion between the tibia and the talus, thereby stabilizing the joint and alleviating pain. There might be associated limb length discrepancy, especially in post-traumatic and post-infectious cases. These patients require limb lengthening and arthrodesis. The purpose of this study is to report our experience with simultaneous ankle arthrodesis and lengthening using external fixation in adolescent and young adult patients. This retrospective case series included all patients treated in our hospital by concomitant ankle arthrodesis and tibial lengthening procedures on the same limb, using ring external fixation system. All surgeries included distal tibial joint surface resection and the talar dome, thereby correcting any associated deformity at the ankle. The arthrodesis was fixed and compressed using ring external fixator. A concurrent proximal tibial osteotomy was done, and limb lengthening, or bone transport was performed. Eight patients operated between the years 2012-2020 were included in this study. Median patient age was 20.4years (range 4-62years), 50% women. Median limb lengthening was 20mm (range 10-55mm), and median final leg length discrepancy (LLD) was 7.5mm (range 1-72mm). The most common complication recorded was pin tract infection, which resolved with empiric antibiotics in all cases. Based on our experience, combined arthrodesis and proximal tibial lengthening is efficient solution that provides stable ankle and restores length of the tibia even in complex and challenging situations.

Radiographic Comparison of Virtual Surgical Corrective Options for Excessive Tibial Plateau Angle in the Dog.

The main aim of this study is to compare the impact of six proximal tibial osteotomies on the geometry and alignment of tibias with and without excessive tibial plateau angle (TPA). Mediolateral radiographs of 30 canine tibias were divided into three groups (n = 10/group): moderate TPA (≤34 degrees), severe TPA (34.1-44 degrees) and extreme TPA (>44 degrees). Six proximal tibial osteotomies were simulated on each tibia using orthopaedic planning software: cranial closing wedge ostectomy (CCWO), modified CCWO (mCCWO), isosceles CCWO (iCCWO), neutral isosceles CCWO (niCCWO), tibial plateau levelling osteotomy with CCWO (TPLO/CCWO) and coplanar centre of rotation of angulation-based levelling osteotomy (coCBLO). All tibias were reduced to a standard target TPA. Pre- and postoperative measurements were obtained for each virtual correction. Compared outcome measures included tibial long axis shift (TLAS), cranial tibial tuberosity shift (cTTS), distal tibial tuberosity shift (dTTS), tibial shortening and osteotomy overlap. Across all TPA groups, TPLO/CCWO had the lowest mean TLAS (1.4 mm) and dTTS (6.8 mm); coCBLO had the largest TLAS (6.5 mm) and cTTS (13.1 mm); CCWO had the largest dTTS (29.5 mm). CCWO had the largest degree of tibial shortening of 6.5 mm, while mCCWO, niCCWO and coCBLO resulted in minimal tibial lengthening (1.8-3.0 mm). These trends were generally conserved across different TPA groups. All findings had a p-value less than 0.05. mCCWO balances moderate alterations to tibial geometry while preserving osteotomy overlap. The TPLO/CCWO has the least effect on tibial morphology alteration, whereas the coCBLO results in the largest alteration.

Allongement combiné des inégalités de longueur des membres inférieurs acquises : est-ce que l’utilisation de clous élastiques avec hydroxyapatite a des avantages ?

IntroductionThe aim of this multicenter prospective study was to analyze the outcomes of bone lengthening by external fixator associated with flexible intramedullary nailing (FIN) in acquired limb length discrepancy (LLD). HypothesisHydroxyapatite(HA)-coated FIN enables reduced External Fixation Index in limb lengthening for acquired leg length discrepancies in comparison to non-HA-coated FIN. Material and MethodsThis study included 54 patients (mean age, 17.9 years) operated on for femoral or tibial lengthening by combined technique (External fixator with FIN) for acquired length discrepancy. Titanium non-HA-coated FIN (29 cases) or HA-coated FIN (25 cases) were used. The factors that might influence external fixation index, complication occurrence and outcome were analyzed: age, amount of lengthening, nail diameter, HA-coating vs. non-HA-coated nails. ResultsThe mean External Fixation Indexes (EFI) of groups compared for non-HA-coated nails vs. HA-coated nails were not significantly different: 26.5 d/cm and 27.2 d/cm in femoral lengthening and 34.9 d/cm and 31.7 d/cm in tibial lengthening. Positive correlation between the “Nail diameter/inner distance between cortices at osteotomy site” ratio and EFI in tibial lengthening was revealed (p=0.034). The nail types and the “nail diameter/medullary canal diameter” ratio interact and have significant simultaneous effect on EFI in femoral lengthening (p=0.021). DiscussionThe results of this study revealed no differences with regards to EFI using HA-coated or non-HA-coated titanium FIN in lengthening for acquired leg-length discrepancies. Combined technique allowed reduced EFI and avoided major complications. Both non-HA-nail and HA-coated nail lengthening provided good and excellent outcomes. Level of EvidenceIII; (controlled trial without randomization) prospective comparative study.

Is physeal distraction osteogenesis a good choice to treat CPT patients with tibial shortening?

The purpose of this study was to evaluate the healing index and complications of distraction osteogenesis through the physis in children with Congenital pseudarthrosis of the tibia (CPT) using Ilizarov external fixation device. Nine children with CPT who underwent distraction osteogenesis through the physis surgery with an Ilizarov external fixation device between June 2018 and August 2020 were included in the study. The average follow-up time was 36.1 months. X-ray examination was performed 1 month after physis lengthening, and the callus quality was evaluated using the Li classification. Any complications and the quality of the callus after tibial lengthening were followed up. The average age at the time of operation was 9.4 years, and the average follow-up time was 36.1 months. The average lengthening length of children with CPT was 6.6 cm. The incidence of good callus morphology was 100%, and the healing index was 51.1 d/cm. The average fixation time of the external fixation device was 316 days. Needle tract infection occurred in one case, ankle stiffness occurred in one case, ankle plantar flexion 20° deformity occurred in one case, angular deformity of the tibial lengthening segment occurred in one case (7°) and limited movement of knee joint occurred in one case (0-20°-70°). The osteogenic quality of the patients of distraction osteogenesis through the physis with tibial shortening and small diameter of the proximal tibia is good, which provides a choice of operation for the children with CPT.