Tibial Shortening Research Articles

Depletion of b-series ganglioside prevents limb length discrepancy after growth plate injury

IntroductionGrowth plate damage in long bones often results in progressive skeletal growth imbalance and deformity, leading to significant physical problems. Gangliosides, key glycosphingolipids in cartilage, are notably abundant in articular cartilage and regulate chondrocyte homeostasis. This suggests their significant roles in regulating growth plate cartilage repair.MethodsChondrocytes from 3 to 5 day-old C57BL/6 mice underwent glycoblotting and mass spectrometry. Based on the results of the glycoblotting analysis, we employed GD3 synthase knockout mice (GD3-/-), which lack b-series gangliosides. In 3-week-old mice, physeal injuries were induced in the left tibiae, with right tibiae sham operated. Tibiae were analyzed at 5 weeks postoperatively for length and micro-CT for growth plate height and bone volume at injury sites. Tibial shortening ratio and bone mineral density were measured by micro-CT.ResultsGlycoblotting analysis indicated that b-series gangliosides were the most prevalent in physeal chondrocytes among ganglioside series. At 3 weeks, GD3-/- exhibited reduced tibial shortening (14.7 ± 0.2 mm) compared to WT (15.0 ± 0.1 mm, P = 0.03). By 5 weeks, the tibial lengths in GD3-/- (16.0 ± 0.4 mm) closely aligned with sham-operated lengths (P = 0.70). Micro-CT showed delayed physeal bridge formation in GD3-/-, with bone volume measuring 168.9 ± 5.8 HU at 3 weeks (WT: 180.2 ± 3.2 HU, P = 0.09), but normalizing by 5 weeks.ConclusionThis study highlights that GD3 synthase knockout mice inhibit physeal bridge formation after growth plate injury, proposing a new non-invasive approach for treating skeletal growth disorders.

Ipsilateral Healthy-segment Response to Leg Length Discrepancy.

Few studies address frequency or magnitude of healthy lower-extremity segment response to ipsilateral companion segment shortening. We sought to document and quantify this occurrence in a variety of pediatric etiologies. We reviewed the medical record and radiographs of patients undergoing epiphysiodesis to manage leg length discrepancy. Inclusion criteria for this study were leg length discrepancy of a single lower-extremity segment by identifiable cause and adequate scanograms to allow accurate measurement of all 4 lower-extremity segments before any surgical treatment for the discrepancy. We recorded the etiology of shortening, age of onset of disorder, the length of the lower-extremity segments on scanograms, and age at the time of radiographs. We considered ipsilateral healthy-segment difference from the contralateral ≥ 0.5cm. as clinically significant. Two hundred nine patients met inclusion criteria (126 boys, 83 girls). The average age was 12.5years. 16/60 patients with avascular necrosis of the hip demonstrated ipsilateral tibial shortening averaging 1.2cm whereas 6/60 demonstrated ipsilateral tibial overgrowth averaging 0.6cm. 11/30 Legg-Perthés patients demonstrated ipsilateral tibial shortening averaging 0.7 cm; none had ipsilateral tibial overgrowth. 10/42 posteromedial bow patients had ipsilateral femoral shortening averaging 0.8cm, whereas 6/42 had ipsilateral overgrowth averaging 0.8cm. 13/48 with distal femoral physeal injury demonstrated ipsilateral tibial shortening averaging 1.2cm, whereas 6/48 demonstrated ipsilateral tibial overgrowth averaging 0.8cm. 8/29 tibial physeal injuries (proximal or distal) demonstrated ipsilateral femoral shortening averaging 1.1cm. whereas 7/29 demonstrated ipsilateral femoral overgrowth averaging 0.7cm. Although there are individual exceptions, the ipsilateral healthy segment does not grow appreciably more than the contralateral in patients with avascular necrosis of the hip, Legg-Perthés disease, or physeal trauma. The femur is not a significant component of shortening in patients with posteromedial bow. Level III, retrospective review.

Predicting tibial plateau angles following four different types of cranial closing wedge ostectomy.

To investigate how tibial long axis (TLA) shift affects the postoperative tibial plateau angle (TPA) in four cranial closing wedge ostectomy (CCWO) techniques. In silico study. A total of 15 client-owned dogs. Computed tomography (CT) scans of 15 client-owned dogs were reviewed using an open-source 3D computer graphics editor. Each computer-generated 3D tibia model underwent a CCWO, with cranial cortex alignment, in 10° increments up to 70° using each of the four previously described techniques. The TLA shift, TPA and mechanical tibial length (mTL) were calculated, using trigonometry, for each model. Equations for predicting final TPA were generated with linear regression. A total of 433 3D computer generated tibial models were analyzed. With each technique, the TPA varied in a linear fashion within the studied range of wedge angles. The TLA shift and tibial shortening magnitude varied between the four different CCWO techniques, with maximum mTL reduction of ranging from 7.5% to 40.9%. All predicted TPAs using the generated equations were within the target range of 4-6°. A linear relationship between ostectomy wedge angle and TPA correction was observed in this study, which allowed for generation of accurate corrective equations. These results allow extrapolation of the wedge angle required to reach a postoperative TPA of 5°, by considering the TLA shift. The use of the generated corrective equations may thus increase CCWO planning precision.

Morphologic impact of four surgical techniques to correct excessive tibial plateau angle in dogs: A theoretical radiographic analysis.

To determine morphologic differences between four tibial osteotomy techniques used to correct excessive tibial plateau angle (eTPA). Retrospective radiographic analysis. Sixteen dogs (27 tibias) with eTPA. Virtual corrections of eTPA were performed on sagittal plane radiographs of canine tibia using four tibial osteotomy techniques and categorized into respective groups. Group A represented the center of rotation of angulation (CORA)-based leveling osteotomy (CBLO) and coplanar cranial closing wedge ostectomy (CCWO), Group B the tibial plateau leveling osteotomy (TPLO) and CCWO, Group C the modified CCWO (mCCWO), and Group D the proximal tibial neutral wedge osteotomy (PTNWO). Pre- and post-correction TPA, tibial length and mechanical cranial distal tibial angle (mCrDTA) were measured and compared. Mean TPA prior to correction was 42.67 ± 6.1°. Post-correction mean TPAs were 10.47 ± 2.1°, 6.77 ± 1.6°, 4.76 ± 1.5°, and 7.09 ± 1.3° for Groups A, B, C, and D, respectively. TPA correction accuracy in Groups A and D varied least from target TPAs. Tibial shortening was documented in Group B in contrast to other groups. The greatest mechanical axis shift was identified in Group A. Each technique achieved TPA < 14° despite having different effects on tibial morphology including alteration of tibial length, mechanical axis shift and variation in correctional accuracy. Despite all methods being able to correct eTPA, the choice of technique will affect morphology in unique ways and should be considered prior to surgery to consider the implications in a given patient.

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.

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.

Hybrid Lateral Closed-Wedge High Tibial Osteotomy Showed Similar Accuracy in Angular Correction and Reduction of Posterior Tibial Slope Compared to Opening-Wedge High Tibial Osteotomy: A Correction Angle Matched Cohort Study

BackgroundWe aimed to compare the accuracy of applied correction angle between hybrid lateral closed wedge high tibial osteotomy (hybrid HTO) and medial open wedge high tibial osteotomy (OWHTO), and verify previous reports on hybrid HTO by matching correction angle between groups. Change in various radiological parameters including union rate were also compared. MethodsA total of 50 OWHTO patients were selected for 2:1 propensity matching with 25 hybrid HTO patients. Rate of correction error was calculated by dividing the difference between the change in medial proximal tibial angle and preoperatively planned correction angle (PRD) by planned correction angle. Accuracy of angular correction was assessed using PRD and correction error rates. Hip-knee-ankle axis, mechanical lateral distal femoral angle, medial proximal tibial angle, joint line convergence angle, and length of the entire lower limb and tibia were measured. The Caton-Deschamps index (CDI) was used to assess change in patellar height. Serial postoperative radiographic analysis was performed to assess the union rate. ResultsThe discrepancy between planned correction angle and real correction angle was 0.8 ± 2.3° in hybrid HTO and 1.1 ± 3.4° in OWHTO (P > .05), and the rate of error in osteotomy was similar between the groups approximately 6%. Postoperatively, posterior tibial slope (PTS) (P < .001), tibia length, and CDI (P < .001) were significantly different between groups. The amount of change in PTS (P < .001), tibia length in hybrid HTO (P < .001), and CDI (P < .001) were significantly different between groups. Union rate of osteotomy site was significantly faster in hybrid HTO than in OWHTO (P < .001). ConclusionHybrid HTO showed similar accuracy in angular correction compared to correction angle-matched OWHTO. Reduction in PTS, tibial shortening, maintained patellar height relative to the proximal tibia, and faster osteotomy site union were also confirmed in hybrid HTO.

AO distractor and manual traction reduction techniques repair in distal tibial fractures: a comparative study

BackgroundMinimally invasive plate osteosynthesis (MIPO) via percutaneous plate placement on the distal medial tibia can be performed with minimizes soft tissue injury and produces good clinical results. However, the difficulty with MIPO lies in how to achieve satisfactory fracture reduction and maintain that reduction via indirect reduction techniques to facilitate internal fixation. The purpose of this study was to compare the effects of AO distractor and manual traction reduction techniques combined with MIPO in the treatment of distal tibia fractures.MethodsBetween January 2013 and December 2019, 58 patients with a distal tibia fracture were treated using MIPO. Patients were divided into two groups according to the indirect reduction method that was used: 26 patients were reduced with manual traction(group M), and 32 were reduced with an AO distractor (group A).Time until union and clinical outcomes including AOFAS ankle-rating score and ankle range of ankle motion at final follow-up were compared. Mean operative time, incision length, blood loss and postoperative complications were recorded via chart review. Radiographic results at final follow-up were assessed for tibial angulation and shortening by a blinded reader.ResultsMean operative time, incision length, and blood loss in group A were significantly lower than in group M(p = 0.019, 0.018 and 0.016, respectively).Radiographic evidence of bony union was seen in all cases, and mean time until union was equivalent between the two groups (p = 0.384).Skin irritation was noted in one case(3.1%) in group A and three cases(11.5%)in group M, but the symptoms were not severe and the plate was removed after bony union. There was no statistically significant difference in postoperative complications between the two groups(p = 0.461). Mean AOFAS score and range of ankle motion were equivalent between the two groups, as were varus deformity, valgus deformity, anterior angulation and posterior angulation. No patients had gross angular deformity. Mean tibial shortening was not significantly different between the two groups, and no patients had tibial shortening > 10 mm.ConclusionBoth an AO distractor and manual traction reduction techniques prior to MIPO in the treatment of distal tibial fractures permit a high fracture healing rate and satisfying functional outcomes with few wound healing complications. An AO distractor is an excellent indirect reduction method that may improve operative efficiency and reduce the risk of soft tissue injury.

Poliomyelitis - Related Deformities Successfully Treated with Reconstructing and Lengthening Lower Limb Surgeries and Followed up 11 Years: Challenging Approaches in a Limited - Resources Country

Poliomyelitis is a viral infection that may lead to paralysis or death. Paralysis can lead to skeletal and joint deformities. Typical manifestations include equinoscavus and tibial shortening. We report a polio case presented with right equinus foot, clawing in the right great toe, and shortening in the right tibia.

Outcomes of intralesional osteotomy and distraction osteogenesis for limb length equalization in Ollier's disease.

Limb length discrepancy and deformities resulting from Ollier's disease are challenging to treat and have increased complications. We aimed to assess the safety of intralesional osteotomy for distraction osteogenesis and report the results of guided growth as a method of deformity correction in such conditions. We retrospectively reviewed 13 patients (eight boys and five girls), 28 segments (12 femora and 16 tibias), treated using Ilizarov circular ring fixator in one center. Nine patients had an oblique plane deformity, whereas four had a coronal plane deformity. Femoral shortening ranged from three to 11 cm. Tibial shortening ranged from 3.5 to 12 cm. Intralesional osteotomy was carried out in all patients, and guided growth (hemiepiphysiodesis) was used in seven segments (25%). The median age was 11 years (6-14 years) at surgery, with a median follow-up of 4.5 years (3-18 years). The median achieved lengthening in the femur was 7 cm (5-11 cm) and in the tibia was 5 cm (3-9 cm). The average Bone Healing Index (BHI) for the femur was 32 days/cm (28-38 days/cm), and for the tibia was 36 days/cm (28-40 days/cm). Before frame removal, the mechanical axis was restored to the knee joint center in all cases. Normal radiographic bone regeneration was evident in all cases. Hemiepiphysiodesis successfully corrected the angular deformities. Intralesional osteotomy for distraction osteogenesis is well-tolerated and reliable in Ollier's disease. Radiological normal bone was formed at the distraction site. Guided growth is also a reproducible method for deformity correction in Ollier's disease, similar to other conditions.

Adolescent Tillaux Fractures: A Systematic Review of the Literature.

The Tillaux fracture is an uncommon injury to the anterolateral distal tibial epiphysis. It occurs during a distinct time period when adolescent patients are transitioning to skeletal maturity. Owing to its rarity, the optimal management strategy for this fracture is not well-described. The aim of this review was to assess the outcomes of operatively and nonoperatively managed displaced adolescent Tillaux fractures. We analysed articles from The Cochrane Library, PubMed, MEDLINE, and EMBASE databases that met our predetermined inclusion and exclusion criteria according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statements. A descriptive data analysis was performed. A total of 461 articles were identified from the data search, of which 13 articles were included for full-text analysis. Five of these studies reported recognised patient outcome measures and the remaining eight reported on radiographic follow-up. The reported studies included a total of 114 patients with Tillaux fractures; 58.8% of patients were female and 34.2% were male. Mean ages ranged from 12.5 to 15 years, with the youngest patient being 12 years old and the oldest 17 years old. Overall mean follow-up was 42.8 months. Of the patients, 40.4% were treated with open reduction internal fixation (ORIF), 14.9% with closed reduction internal fixation (CRIF), and 1.8% arthroscopically. The remainder were treated nonoperatively. Outcome measures were excellent for all patients irrespective of operative management choice. Follow-up radiographic deformity was only evident in Tillaux fractures that were managed nonoperatively; deformity included poor joint congruity, angular deformity, and tibial shortening. These nonoperative patients have a residual fracture displacement of 2 mm. There were no reported instances of premature physeal closure for any patient. This review shows that excellent patient outcomes have been reported for different methods of operative fixation, however, study sizes are small and data is sparse. Further robust comparative studies are required to identify definitive conclusions. The use of established clinical and radiographic outcome measures will help improve the quality of future studies for this relatively rare injury.

Surgical management of a severe congenital deformity of the hind limb in a Shetland pony foal – a case report

This case report describes the surgical management of a severe congenital deformity in a Shetland pony. A two-week-old foal was presented with the right hind limb showing a 90-degree torsion of the tarsal region towards the medial side and the metatarsophalangeal joint forced in a 90-degree extension behind the right tarsus. As assessed through radiography, the tibial malleoli and the trochlea of the talus were poorly developed, the flexor tendons inserted topographically correctly on the phalanges but due to articular torsion, the tenaculum of long and lateral digital extensor tendons were projected laterally and the common digital extensor tendon on the medioplantar aspect. At the age of one month, a corrective ostectomy of the tibial malleoli, trochlear ridge, and talus was performed to reposition the adjacent bones. The tarsal bones were repositioned through an arthrotomy and subsequently the tarsal region fused by means of two cortex screws inserted in a lag fashion. Complete correction of the torsion was achieved through metatarsal osteotomy. A 20-hole 3.5-mm reconstruction plate was used for stabilization of the tibia and metatarsus, resulting in a pantarsal arthrodesis. Partial tibia shortening was performed to improve angulation of the tarsal region. At nine months after surgery, the pony was keeping the right limb hoof sole on the ground.

The effects of tubular structure on biomaterial aided bone regeneration in distraction osteogenesis

Long duration of bone consolidation in distraction osteogenesis (DO) has been regarded as a major disadvantage. Porous bone substitutes have been long used in aiding bone formation. However the effects of geometric tubular structure of the porous scaffolds on bone formation in DO remains unknown. This study investigated the effects of porous scaffolds with three different geometric structures on bone regeneration in a rabbit DO model. β-tricalcium phosphate (β-TCP) was fabricated into no tubular, single tubular, or multi-tubular structure constructs. The microstructure of the three types of β-TCP constructs was determined by scanning electron microscope (SEM). Unilateral tibial osteotomy was made at the midshaft with 1 cm tibial shaft removed, fixed with an external lengthener in adulkt New Zealand white rabbits. After acute tibial shortening of 0.5 cm, the remaining 0.5 cm defect was implanted with β-TCP constructs with no tubular, single tubular, or multi-tubular structure. Five days after surgery, the tibia was lengthened at 0.5 mm/12 h for 5 days. After further 28 days of consolidation, the animals were terminated. Bilateral tibial specimens were collected for X-ray, micro-computed tomography examination, four-point bending mechanical test and histological analysis. SEM results showed that pore sizes and pore interconnectivity in all three types of β-TCP constructs were identical. 38 days after surgery (4 weeks after lengthening), the new bone formation and mechanical properties were significantly enhanced in the groups implanted with multi-tubular and single tubular constructs, comparing to the group implanted with no tubular constructs. Furthermore, the group implanted with multi-tubular constructs had significantly better mechanical properties comparing to the group implanted with single tubular constructs. Histological results confirmed that group implanted with multi-tubular constructs had the most advanced bone formation and remodelling in the defect gap. The current study confirmed that β-TCP constructs with multi-tubular structure was the best choice as scaffold aid for bone regeneration in DO, indicating a novel fabrication approach of multi-tubular constructs for rapid bone formation together with DO procedure. Porous β-TCP scaffold with a multi-tubular structure used in combination with DO procedure can significantly shorten the bone consolidation duration. The tubular shaped porous β-TCP scaffold may be used to fill bone defect and to aid bone formation, consolidaiton and remodelling in DO.

Preoperative and postoperative radiomorphological changes in the bones forming the knee joint of patients with tibial shortening and deformities of different etiology

Introduction. Tibial lengthening is one of highly popular surgical procedures that can be associated with complications of the knee joint related to surgical intervention or baseline changes in the bones forming the knee. Objective. To explore preoperative and postoperative changes in the bones forming the knee joint of patients with tibial shortening of different etiology. Material and methods. Radiography and multislice computed tomography (MSCT) were performed for 48 achondroplasia patients, 15 subjects with subjectively low height, 25 patients with vitamin-D resistant rickets (MRI produced for 20 patients), 56 patients with Blount’s disease (MSCT produced for 10 cases) before and after tibial lengthening or deformity correction. Results. The findings showed that tibial lengthening was accompanied by limited function of the knee even in absence of evident articular changes. Good results could be ensured with adequately performed lengthening technique and proper control of muscle condition and rehabilitation program to be meticulously followed. Patients with baseline problems in the joints were shown to have progressive changes in the knee joints during tibial lengthening, however, they were not critical and could provide a normal function at a long-term follow-up. Conclusion. Tibial lengthening as a complicated biomechanical and morphological process is accompanied by changes in the knee joint and can be successfully accomplished with adequate technique applied and rehabilitation program performed. Chnages in the knee were more evident in patients with baseline disorders in the anatomy and architechtonics of the femoral and tibial condyles, however, improved biomechanical parameters of the limb allowed us to obtain positive outcomes and good function in almost all the cases.

Moment arm function dictates patella sagittal height anatomy: Rabbit epiphysiodesis model alters limb length ratios and subsequent patellofemoral anatomical development.

Patellofemoral anatomical dysplasia is associated with patellofemoral instability and pain. The closure of the knee physis occurs at the same age as the peak incidence of patellofemoral dislocation. This study determined the effect on the patellofemoral anatomical development in a rabbit epiphysiodesis model. Twenty-four skeletally immature New Zealand White rabbits were divided into three groups (a) distal femur epiphysiodesis (FE) (b) proximal tibia epiphysiodesis (TE) (c) control; no epiphysiodesis (C) performed at 6 weeks of age. The primary endpoint was shape analysis using three-dimensional reconstructions of micro-computed tomographys (CTs) performed at 30 weeks of age. The limb length ratios (femur:tibia) were significantly different for both FE (mean 0.72, SD 0.0381, P < .001) and TE (mean 0.91, SD 0.0383, P < .001) treatment groups compared to control (mean 0.81, SD 0.0073). Patella height, as measured from the most distal point of the patella to the tibial joint surface (modified Caton-Deschamps measurement), was lower (baja) in the FE and higher (alta) for the TE, compared with the control group. Our findings suggest femoral and tibial shortening can influence the development of the patellofemoral joint, which may be dictated by moment arm function and is potentially responsible for the etiology of patella alta. Future studies are warranted to explore this association further with the view for the development of treatment options for patella alta in human patients.

Blade expandable intramedullary nails for fixation of tibial shaft fractures

This study is aimed to compare the clinical and radiological differences between classic locked intra- medullary nailing ( LIN) and blade expandable intra- medullary nailing (BEIN) at tibia shaft fractures. Operation time, exposing of radiation time and fracture healing times were recorded. Pain visual anolog scale (VAS), shortening of tibia and angulation of fracture line were compared. All patients healed. In LIN group operation time, exposing of radiation time was longer (statistically significant). Because of shorter operation time and lower radiation exposure we recommend the BEIN technique as a preferable technique in tibia intramedullary nailing.

Bone and Joint Reconstruction Using Ilizarov Circular External Fixation Device

Introduction: Ilizarov circular external fixation device is a versatile external fixation device which can be used for bone and joint reconstruction such as fracture fixation, bone transport, lengthening, shortening, and correction of deformity and contracture. It is a complex procedure and requires patients understanding, motivation, pin site care and rehabilitation to ensure successful treatment and avoiding complication. The aim of this study was to review cases of bone and joint reconstruction using Ilizarov external fixation device. Materials and Methods: From 2006 till 2018, 59 patients with the mean age of 34.8 (10-69) years old underwent these procedures. There were 49 tibias, three femurs, one humerus, three elbows, two knees and one ankle reconstruction. 18 open fractures, 16 non- union, seven tibial plateau fractures, 10 implant related infections, one valgus mal-union and one shortening. There were also 4 dislocations and two flexion contracture. The procedure that were done include 31 bone transport, 18 fracture fixation, three joint reduction, two correction of flexion contracture, two shortening of tibia and one each for lengthening, deformity correction and arthrodesis. Results: Forty seven (80%) patients achieved the objective of operation: 41 fractures united, three joints were reduced, two achieved knee extension and one deformity corrected. Five developed non-union, of which two not compliant to treatment, two had failed bone transport and one died during the treatment due to medical problem not related to the Ilizarov fixation. Conclusion: Ilizarov circular external fixation is an effective device for joint and bone reconstruction in majority of patients.

Change in limb length after high tibial osteotomy using computer-assisted surgery — A comparative study of closed and open wedge osteotomies

Purpose Generally, a closed-wedge HTO tends to shorten the tibial length, while an open-wedge HTO tends to lengthen it. Overall limb length changes were evaluated after closed- and open-wedge high tibial osteotomies (HTOs) using computer-assisted surgery. The hypothesis was that the overall limb length of the corrected extremity does not change much after closed-wedge HTO because the effect of extremity realignment on limb length counterbalances the effect of tibial shortening caused by the metaphyseal bone loss of the proximal tibia. After an open-wedge HTO, the overall limb length would increase within a certain range. Methods A total of 78 closed- and 30 open-wedge HTOs were performed. The changes in limb length were evaluated on a navigation system and radiographs. The correction angle was defined as the difference between the pre- and postoperative mechanical axis on the navigation system. The change in limb length with respect to the correction angle was analyzed. Results Following the closed-wedge HTOs, the mean changes in limb length based on the navigation system and radiographs were −1.3 ± 1.9 and −1.3 ± 10.7 mm, respectively, versus 6.2 ± 2.6 and 7.8 ± 2.9 mm after the open-wedge HTOs. The mean correction angle was 11.6 ± 3.2° for closed-wedge HTOs and 11.5 ± 1.9° for open-wedge HTOs. The correction angle did not affect the change in limb length after closed-wedge HTO, while the larger the correction angle required, the greater the increase in limb length after open-wedge HTO. Conclusions The change in limb length was negligible after closed-wedge HTO, while the limb length was slightly increased in every knee after open-wedge HTO. The greater the correction angle required in the open-wedge HTO, the greater limb length increased. The possibility of limb lengthening must be considered carefully when determining whom to perform open-wedge HTO on, especially when a large correction angle is required.

Effect of distraction osteogenesis in patient with tibial shortening after initial union of congenital pseudarthrosis of the tibia (CPT)

Background: This is a Retrospective study which was conducted with the purpose of evaluating the preliminary result of distraction osteogenesis in patients with tibial shortening after initial union of Congenital Pseudarthrosis of the Tibia (CPT). Methods: Identification of all the CPT cases with tibial shortening after initial union managed by proximal tibia lengthening using Ilizarov technique was done. All the patients charts and radiograms were reviewed. Results: 11 CPT cases were included between March 2013 and January 2018 with an average follow up of 41 months (range, 34-51 months). 8.5 years was the mean age at surgery. The average length of discrepancy was 5.6 cm (range, 2.0-8.2 cm). Radiological findings of proximal tibial dysplasia were found in eight cases while three other cases had no radiological findings. The average distraction length gained was 5.3cm (range, 3.5 -8.0 cm) with a mean elongation rate of 21.4% (range, 15-30%). The Healing Index (HI) was 63.1 d/cm (range, 47–77 d/cm). The Findings seen in the eight patients with proximal tibial dysplasia was that out of eight cases, five cases had lateral callus, three had central callus and poor bone regeneration was seen in all of them. In the three patients who had no radiological findings concave shaped callus was identified with an average HI of 52.7 d/cm. None of the patients had refracture, non-union, axis deviation or angulation of the distraction area. Two of the patients were found to have ankle stiffness. There was no evidence of knee contracture in any of the patients. There were five cases with pin tract infection which was managed by regular dressing and oral antibiotics. Conclusions: We concluded that proximal tibial lengthening after initial union of CPT was effective for management of tibial shortening, however poor bone regeneration with various types of callus from normal, greater healing index and prolonged fixator wearing was seen. We recommended that when the limb length discrepancy (LLD) was more than 4 cm in younger children after primary union of CPT, tibia lengthening could be considered.

Modified cranial closing wedge ostectomy in 25 dogs.

To describe the planning of a modified cranial closing wedge ostectomy (mCCWO) and determine the accuracy of execution without intraoperative jigs or alignment guides. Retrospective study. Twenty-five client-owned dogs (32 stifles) with cranial cruciate ligament disease. Medical records of dogs treated with mCCWO between July 2014 and December 2016 were reviewed. Preoperative, postoperative, and 8-week-recheck radiographs were reviewed to measure changes in the conformation of the proximal tibia. The accuracy of execution was assessed by comparing planned and actual postoperative tibial plateau angle (TPA) and the lengths of bone contact along osteotomy lines. Radiographic healing and clinical outcome were subjectively evaluated 8 weeks after surgery. Preoperative planning of mCCWO decreased the cranial wedge length by a mean of 23% compared with the traditional CCWO planning. Mean TPA decreased from 40.69 ° (range 28-63) to 6.94 ° (range 2-20) after surgery (P < .001). Mean tibial length decreased by 0.5 mm (±0.16, P = .003), from 138 mm (range 65-267) to 137.5 mm (range 65-265) after mCCWO. The tibial long axis (TLA) shifted by a mean of 3.47 ° (range 0-10). Planned and actual postoperative TPA differed by -0.66 ° (±0.47, P = .034). The proximal and distal apposing osteotomies differed in length by 1.81 mm (±0.35). No bone healing complications or implant failures were diagnosed, and all dogs returned to subjectively satisfactory function by 8 weeks after surgery. The preoperative planning and methods of execution of the mCCWO resulted in differences in target TPA and postoperative TPA, differences in lengths of proximal and distal osteotomies, and tibial shortening that did not appear clinically significant in this study. mCCWO can be planned and accurately executed without consideration of TLA shift or the intraoperative use of alignment guides or jigs.