Undergoing Limb Lengthening Research Articles

Assessment of experience of treatment of patients with consequences osteomyelitis using the technique of intramedullary stressed reinforcement

Aim. Evaluation of the experience of treatment of patients with consequences of hematogenous osteomyelitis using the technique of intramedullary reinforcement. Materials and methods. The data treatment of 25 patients aged 12 to 17 years with a shortening of the humerus after hematogenous osteomyelitis. Patients were divided into two groups: the first (n = 15) – to extend the shoulder technique was used bifocal distraction osteosynthesis; the second (n = 10) – to extend the shoulder technique used bifocal distraction osteosynthesis using intramedullary reinforcement (IMR). Results. Applying the methodology IMR reduced the fixation index by an average of 4,6 days/cm (p <0,05). Long term recovery movement in the shoulder and elbow joints of patients in both groups after the treatment was not significantly different. In assessing the safety of the IMA revealed no differences in adverse events. Changes of biochemical parameters marked in patients with IMA group, were typical of patients undergoing limb lengthening by Ilizarov. Conclusion. According to clinical data, as well as according to other research methods, contraindications in terms of the safety of the IMR with the humerus lengthening in patients with consequences of osteomyelitis is not revealed.

Regenerate bone stimulation following limb lengthening: a meta-analysis.

BackgroundLimb lengthening with external fixation is performed to treat patients with leg length discrepancy or short stature. Although the procedure has a high rate of success, one potential drawback from limb lengthening is the amount of time spent in the fixation device while regenerate bone consolidates. Although some studies have assessed different treatment modalities, there has not been a study that has systematically evaluated whether low intensity pulsed ultrasound (LIPUS) or pulsed electromagnetic fields (PEMF) have significant effects on regenerate bone growth. The purpose of this study was to evaluate these two non-pharmacological treatment options to stimulate regenerate bone, and to assess whether they affect the treatment time in limb lengthening.MethodsUtilizing the electronic databases Medline, Embase and Ovid, we performed a literature search for studies describing the application of LIPUS or PEMF following limb lengthening. With the aid of a statistical software package, Forest-Plots were generated to compare the differences in bone healing index with and without the use of regenerate bone stimulation.ResultsA total of 7 studies assessed these two bone stimulation modalities in a cohort of 153 patients. Overall, the mean healing index was 11.7 days/cm faster when using bone stimulation that in the comparison cohorts (33.7 vs 45.4 day, standardized mean difference of 1.16; p = 0.003).ConclusionAmongst the drawbacks from limb lengthening is the relatively high rate of non- and delayed-union. Several methods, both pharmacological and non-pharmacological, have been investigated for their potential to stimulate the growth of regenerate bone. After systematically evaluating the limited and heterogeneous current literature, we found that LIPUS and PEMF both decreased the time for bone healing (healing index in days/cm) of the newly formed regenerate bone in an adequately selected cohort of patients that underwent limb lengthening. However, a high number of complications should be noted, which could be attributed to the lengthening procedure or to the additional bone stimulation.PROSPERO registration number CRD42016039024 Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-016-1259-5) contains supplementary material, which is available to authorized users.

Limb lengthening in achondroplasia.

Background:Stature lengthening in skeletal dysplasia is a contentious issue. Specific guidelines regarding the age and sequence of surgery, methods and extent of lengthening at each stage are not uniform around the world. Despite the need for multiple surgeries, with their attendant complications, parents demanding stature lengthening are not rare, due to the social bias and psychological effects experienced by these patients. This study describes the outcome and complications of extensive stature lengthening performed at our center.Materials and Methods:Eight achondroplasic and one hypochondroplasic patient underwent bilateral transverse lengthening for tibiae, humeri and femora. Tibia lengthening was carried out using a ring fixator and bifocal corticotomy, while a monolateral pediatric limb reconstruction system with unifocal corticotomy was used for the femur and humerus. Lengthening of each bone segment, height gain, healing index and complications were assessed. Subgroup analysis was carried out to assess the effect of age and bone segment on the healing index.Results:Nine patients aged five to 25 years (mean age 10.2 years) underwent limb lengthening procedures for 18 tibiae, 10 femora and 8 humeri. Four patients underwent bilateral lengthening of all three segments. The mean length gain for the tibia, femur and humerus was 15.4 cm (100.7%), 9.9 cm (52.8%) and 9.6 cm (77.9%), respectively. Healing index was 25.7, 25.6 and 20.6 days/cm, respectively, for the tibia, femur and humerus. An average of 33.3% height gain was attained. Lengthening of both tibia and femur added to projected height achieved as the 3rd percentile of standard height in three out of four patients. In all, 33 complications were encountered (0.9 complications per segment). Healing index was not affected by age or bone segment.Conclusion:Extensive limb lengthening (more than 50% over initial length) carries significant risk and should be undertaken only after due consideration.

Lengthening for functional acetabular dysplasia due to limb length discrepancy: A report of two cases

Osteoarthritis of the hip joint as a complication of limb length discrepancy (LLD) caused by lower extremity deformity is rarely reported in the literature. We report two such cases of osteoarthritic changes of the long leg hip joint due to severe LLD but no developmental dysplasia of the hip. Both underwent limb lengthening, and the symptoms were improved without further treatment. The osteoarthritic changes are secondary to functional acetabular dysplasia resulting in insufficient acetabular coverage of the femoral head and lateral inclination of the pelvis caused by LLD. Thus, lengthening treatment may be one option for such patients with osteoarthritis due to functional acetabular dysplasia.

Safety and Efficacy of Botulinum Toxin A in Children Undergoing Lower Limb Lengthening and Deformity Correction: Results of a Double-blind, Multicenter, Randomized Controlled Trial.

Lengthening of the lower limb is a complex procedure in which pain management and complications such as pin-site infections and muscle contractures impact the family and affect the child's quality of life. As a result, the paralytic and antinociceptive actions of neurotoxins may be indicated in managing these complications; however, few studies have explored ways to improve outcomes after lengthenings. The objective of this study was to evaluate the safety and efficacy of botulinum toxin A (BTX-A) in children undergoing lower limb lengthenings and deformity correction. Participants with a congenital or acquired deformity of the lower extremity requiring surgery to one limb were randomized to receiving either BTX-A as a single dose of 10 units per kilogram body weight, or an equivalent volume of saline solution. Pain, medication, quality of life, and physical function were assessed at different time-points. Adverse events were recorded in all participants. T test and χ tests were used to compare potential differences across both groups. Mean age of the 125 participants was 12.5 years (range, 5 to 21 y), and lengthenings averaged 4.2 cm. Maximum pain scores on day 1 postoperatively were lower in the BTX-A group (P=0.03) than in the placebo group, and remained significant favoring botox when stratifying by location of lengthening (femur vs. tibia). Clinical benefits for BTX-A were found for 3 quality of life domains at mid-distraction and end-distraction. When stratifying according to location of lengthening, there were significantly fewer pin-site infections in the tibia favoring botox (P=0.03). The amount of adverse events and bone healing indices were no different in both groups. The clinical differences in quality of life, the lower pain on the first postoperative day, and the lower number of pin-site infections in the tibia favoring BTX-A support its use as an adjunctive treatment to the lengthening process. The detailed analyses of pain patterns help inform families on the pain expectations during lower limb lengthenings. The amount of adverse events were no different in both groups, and bone healing rates were similar, indicating that the use of BTX-A in children undergoing limb lengthening and deformity correction is safe. Level I.

Achondroplasia and limb lengthening: Results in a UK cohort and review of the literature

AimsWe aim to review the results, complications and outcomes of a single surgeon's series of lower limb lengthening in patients with achondroplasia. MethodsTen achondroplastic children underwent limb lengthening. The patients, medical records and radiographs were reviewed. ResultsThe average age at the time of the index operation was 7.8 years. A single surgeon undertook all procedures. The average total length gain was 20.5 cm. The commonest complication was a fractured femur after removal of the frame. ConclusionAlthough complication rates were high (70%), none were left with any long-term sequelae and all were pleased with the results.

Screening for spinal stenosis in achondroplastic patients undergoing limb lengthening

The need for a screening programme for spinal stenosis in children with achondroplasia undergoing limb lengthening was identified in a tertiary limb reconstruction service. The aim of this study was to evaluate whether screening would identify the 'at risk' group. A total of 26 achondroplastic patients underwent our screening programme. Canal diameters were measured by MRI. Neurosurgical interventions were recorded. Of the patients, 13 had severe foramen magnum narrowing. Six patients required single or multiple surgical decompressions. We identified female sex, delayed milestones and a tight cervicomedullary junction as high risks. We stress upon the importance of developing a nationalized screening programme with guidelines to identify a high-risk group.

Limb lengthening in children with Russell-Silver syndrome: a comparison to other etiologies.

Russell-Silver syndrome (RSS) is the combination of intrauterine growth retardation, difficulty feeding, and postnatal growth retardation. Leg length discrepancy (LLD) is one of four major diagnostic criteria of RSS and is present in most cases. We aimed to ascertain whether pediatric RSS patients will adequately consolidate bony regenerate following leg lengthening. We retrospectively reviewed pediatric RSS patients who underwent limb lengthening and compared them to a similar group of patients with LLD resulting from tumor, trauma, or congenital etiology. The primary outcome measurement was the bone healing index (BHI). The RSS group included seven lengthened segments in five patients; the comparison group included 21 segments in 19 patients. The groups had similar lengthening amounts (3.3 vs. 3.9cm, p=0.507). The RSS group healed significantly faster (lower BHI) than the control group (BHI 29 vs. 43days/cm, p=0.028). Secondary analysis showed no difference between RSS and trauma patients in terms of the BHI (29 vs. 31); however, the BHI of the RSS group was significantly lower than both of the other congenital etiologies (29 vs. 41, p=0.032) and tumor patients (29 vs. 66, p=0.019). The RSS patients had fewer and less significant complications than the controls. The limb lengthening regenerate healing of RSS patients is faster than the healing of patients with other congenital etiologies and tumor patients, and is as fast as the regenerate healing of patients with posttraumatic LLD. Although all RSS patients were treated with human growth hormone (hGH), we are unable to isolate the hGH contribution to the regenerate bone healing. We conclude that RSS patients can have safe limb lengthening.

Elastic intramedullary nailing as a complement to Ilizarov's method for forearm lengthening: A comparative pediatric prospective study

Most of the techniques for forearm lengthening involve external fixation to achieve stability and provide progressive distraction. We introduce the use of elastic stable intramedullar nailing (ESIN) in combination with external circular assembly for the procedure. The purpose of this prospective study was to compare Ilizarov's classical technique with this combined technique. Fifty-seven patients, with forearm length discrepancies or deformities either congenital or acquired, were prospectively followed-up. Patients were divided in two groups: 35 had only external fixation, and 22 had external fixation-ESIN combined techniques. Patients were assessed for clinical and radiographic outcome with a mean follow-up of 21 months after external device removal. Overall lengthening was 45.0mm. Healing index (HI) was 22.2d/cm with the combined technique, and 32.0 d/cm with external fixation. HI was 30% better when ESIN was used, for congenital and for overall cases. Combined technique has a lower complication rate. Although forearm lengthening still remains a time-consuming procedure, ESIN can shorten external fixator wearing time. No additional complication occurred and bony complications seem to be limited by the nails. We recommend this technique, which we now use for most of our patients undergoing limb lengthening. Level IV.

Functional results of lower extremity lengthening by motorized intramedullary nails

The aim of this study was to evaluate the outcome of patients undergoing limb lengthening using motorized intramedullary nails. This study included eleven femora and 4 tibiae from 14 patients (9 male, 5 female; mean age: 26.9 years; range: 14 to 51 years) who underwent limb lengthening using motorized intramedullary femoral nails (Fitbone(®) TAA). Average preoperative limb shortening was 4.9 (range: 2.5 to 7.5) cm. Distraction was initiated on the seventh postoperative day. Serial radiographs and Paley's bone and functional outcome scoring systems were used to evaluate the results. Mean follow-up period was 33.5 (range: 7 to 88) months. Mean distraction index value was 1.2 (range: 0.7 to 2.1) days/mm and mean bone-healing index value was 43.7 (range: 13.8 to 144) days/cm. The average lengthening achieved was 51.7 (range: 25 to 75) mm. The distraction mechanism of the nail did not function properly in two patients, restricted transient knee motion was observed in four patients, and delayed consolidation was observed in four patients. Other complications included valgus deformities and superficial infections surrounding the antenna of the intramedullary nail, as well as femur fractures at the proximal end of the nail. Bone scores were excellent in 11 segments and were good in one segment. Functional scores were excellent for all 12 patients. While usual complications related to the external fixators, such as pin-track infections and mobilization difficulties were not encountered, the development of additional complications such as dysfunction of the distraction mechanism should be monitored with the use of motorized intramedullary nails in limb lengthening.

Antimicrobial Gauze as a Dressing Reduces Pin Site Infection: A Randomized Controlled Trial

Pin site infection is a common problem in external fixation. Plain gauze wetted with normal saline is commonly used for a pin site dressing owing to the simplicity and low cost. Evidence to support adding an antimicrobial agent in the dressing material is lacking. We compared the rate of pin tract infection using plain gauze and gauze impregnated with polyhexamethylene biguanide in patients undergoing limb lengthening procedures. We included 38 patients (40 limbs) undergoing limb lengthening or deformity correction using an external fixator between July 2009 and June 2010. There were 23 male patients and 15 female patients, with a mean age of 26.3 years (range, 5-68 years). The patients were randomized into two groups: a polyhexamethylene biguanide group (22 limbs) and a control group (18 limbs). The metal-skin interfaces were assessed by a researcher blinded to the type of gauze at 2, 4, 8, and 12 weeks after surgery for the pin site infection based on a predetermined grading system. There were a total of 483 metal-skin interfaces, with 1932 total observations. Infection rates were compared using the chi square test and relative risk with 95% confidence interval. The infection rate was lower (χ(2) [1, n = 1932] = 23.00) and the risk for infection was lower (relative risk, 0.228; 95% confidence interval, 0.118, 0.443) for the polyhexamethylene biguanide group (n = 1068; 1.0%) than for the control group (n = 864; 4.5%). Use of polyhexamethylene biguanide-impregnated gauze can reduce the risk of pin tract infection in external fixation. Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Recurrence of axial malalignment after surgical correction in congenital femoral deficiency and fibular hemimelia

Recurrent genu valgum deformity complicates treatment of congenital femoral deficiencies (CFD) and fibular hemimelia (FH). We analysed factors influencing recurrence. Patients who underwent limb lengthening or deformity correction for CFD and/or FH were reviewed. Radiographs after surgery and after a minimum of a further sixmonths were analysed. Change in parameters of mechanical axis deviation per month (∆ MAD/month) and of angle per month were calculated. These parameters were tested against cofactors patient age, baseline MAD, type of CFD and FH, severity of ball-and-socket joints, ankle-joint stiffness, absence of cruciate ligaments and resection of the fibular anlage. Recurrent valgus deformity was found in 23 of the 42 limbs included with a mean change of MAD of 23.4mm (5-60mm). There was no significant difference between patients with ∆ MAD/month <0.5mm versus >1mm regarding MAD in the first radiograph and patient age. CFD cases Pappas types VII and VIII showed a ∆ MAD/month of 1.6mm, whereas milder cases of Pappas IX showed a ∆ MAD/month of 0.8. Mild FH (type Ia) showed a mean ∆ MAD/month of 0.39mm, whereas mean ∆ MAD/month for FH type Ib/II was 0.72mm. In FH type II cases, mean ∆ MAD/month was 0.79mm after resection of the fibular anlage compared with 1.98mm in those without resection. Recurrence in FH and CFD was not dependent on patient age but partly on FH and CFD type. Limbs with more severe ball-and-socket knee joints showed more recurrence. Overcorrection depending deformity type should be performed.

Continuous Force Measurement in Limb Lengthening

Complications of limb lengthening include stress on soft tissue, premature consolidation, and bone non-union. This study reports on the development and testing of instrumentation that continually measures distraction forces in rabbits with the aim of relating the forces developed to bone growth and muscle physiology. A full bridge strain gage resistor set mounted to a unilateral distractor measured distraction force and stored the data on a self-contained logger attached to a jacket worn by the rabbit. Two rabbits underwent limb lengthening on one hind leg. Lengthening was set at 0.5 mm/ day, twice per day for a total of 12 mm. Tibialis anterior muscle and proximal and distal tibial growth plates from the operated and control legs were harvested after euthanasia for histomorphometric analysis. Radiographs were taken periodically throughout lengthening. Force data show characteristic overall increase in force. Force steadily decays after each lengthening. Peak forces appear to correlate with time between lengthenings. Histologic data show that the operated leg had an increased preponderance of type I muscle fibers, a decrease in type-I and type-II muscle fiber diameters, and a decrease in endogenous bone growth at the distal growth plate. Histomorphometric analysis showed that the lengthening paradigm employed altered distal bone growth and muscle fiber physiology during lengthening.

Ollier's disease limb lenghtening: Should intramedullary nailing be combined with circular external fixation?

During progressive lower limb lengthening in the management of Ollier's disease, the mean bone-healing index usually reported in the literature stands around 35 days/cm. One of the therapeutic objectives is to reduce the duration of the external fixation. The use of an elastic stable intramedullary nailing system (ESIN) combined with a circular external fixator significantly reduces the healing index. Two groups of patients were compared. In group I, seven patients were operated on for progressive limb lengthening using a circular external fixator associated with an ESIN system: four monosegmental femoral lengthenings, one monosegmental tibial lengthening and two polysegmental femorotibial lengthenings. Nailing was performed via two intramedullary nails already used in traumatology. The date of external fixator removal coincided with that of radiographic healing. The nails were left in place. Group II included 37 patients who underwent limb lengthening by means of an external fixator only. The healing index was calculated and complications were analysed in both groups. The mean healing index (HI) values were: in group I: 23.3 days/cm for the femur, 22.4 days/cm for the tibia and 11.6 days/cm for polysegmental lengthenings ; in group II: 31.6 days/cm for the femur, 35.7 days/cm for the tibia and 19.9 days/cm for polysegmental lengthenings. Group I demonstrated a statistically significant decrease in the HI for monosegmental femoral lengthenings. A substantially reduced duration of external fixation, limited postoperative complications and prevention of later pathologic fractures are the reported advantages of the associated use of a circular external fixator with an ESIN system in the management of Ollier's disease. Level III, comparative retrospective study.

Distraction osteogenesis induces endothelial progenitor cell mobilization without inflammatory response in man

IntroductionDistraction osteogenesis (DO) is a unique postnatal bone formation process, which is characterized by a profuse increase in vascularization. Recently endothelial progenitor cells (EPCs) have been reported to circulate in substantial numbers under physiologic conditions and to contribute to bone regeneration. The authors investigated EPC mobilization in patients undergoing limb lengthening. Materials and methodsThirteen of 24 consecutive patients who underwent limb-lengthening procedures on weight-bearing long bones (femur and tibia) were included in this study. Peripheral blood samples were taken at four different time points from each patient, that is, before operation (pre-Op), 2 or 3 days after osteotomy (early-PO), before the start of distraction (pre-Dist), and at 7 to 14 days after the start of distraction (during-Dist). Numbers of leukocytes and levels of plasma C-reactive protein (CRP) were determined. After isolating mononuclear cells (MNCs) by centrifugation, we performed FACS analysis on freshly isolated MNCs using antibodies to the cell surface markers; CD34, CD133, vascular endothelial growth factor receptor 2 (VEGFR2), and alkaline phosphatase. MNCs were also cultured in endothelial cell growth medium and numbers of EPC colony-forming units were counted. Plasma levels of EPC-mobilizing cytokines, such as, VEGF, SDF-1, and MCP-1, were determined by ELISA. ResultsNumbers of leukocytes and CRP plasma levels increased significantly during the early-PO period (p<0.01) but were maintained within normal range in the during-Dist period. FACS analysis of freshly isolated MNCs showed that EPC-enriched cell fractions increased after distraction, but that alkaline phosphatase-positive cell numbers were unchanged. Numbers of EPC colony-forming units significantly increased in the during-Dist period (p<0.01). Plasma levels of VEGF and SDF-1 significantly increased in the during-Dist period (p<0.05). In femoral lengthening patients whose healing index was less than 30 days/cm, the number of CFUs was 46.8 in the during-Dist period, whereas it was 12.7 in patients whose healing index was more than 30 days/cm (p=0.088). ConclusionsThis study demonstrates a mobilization of EPC population during distraction osteogenesis in human limb-lengthening patients. Distraction strain provoked increases in the plasma levels of EPC-mobilizing cytokines, such as, VEGF and SDF-1. These findings suggest a possibility that therapeutical approaches which modulate EPC mobilization may speed bone healing by angiogenesis–osteogenesis coupling during distraction osteogenesis.

Botulinum Toxin Type A Injection in Alleviating Postoperative Pain and Improving Quality of Life in Lower Extremity Limb Lengthening and Deformity Correction: A Pilot Study

The Ilizarov technique is commonly used for lengthening and deformity corrections of the lower limbs in children. Postoperative pain can be significant, affecting quality of life and functional mobility, and often requiring prolonged medication use. Several studies have investigated the antinociceptive actions of botulinum toxin type A (BtX-A), yet evidence for its use in this population is limited. The objectives were to (1) establish the feasibility of a randomized clinical trial in children undergoing limb lengthening or deformity correction and (2) provide preliminary evidence of the beneficial effects of BtX-A in this population. Fifty-two patients with a mean age of 13.7 years (range, 5 to 21 y) were randomized to receive either BtX-A or an equivalent volume of sterile saline solution (placebo group), as a single dose during the surgical procedure. Pain, medication use, quality of life, and functional mobility outcomes were assessed in all patients. Adverse events were reported for all patients and classified as minor or major. Differences between groups did not reach statistical significance; however, pain at mid-distraction was found to be slightly lower in the BtX-A group, as compared with the placebo group. Patients in the BtX-A group used less parenteral pain medication in the first 4 days after the surgery, had higher quality of life scores at 3 of the 5 time points assessed, and slightly higher functional mobility scores. All adverse events were expected complications of the lengthening process. No event was considered to be a serious adverse event related to the BtX-A injection itself. There was a trend toward fewer major adverse events in the BtX-A group. This pilot study established the feasibility of a randomized controlled trial design for in this population. Its findings indicate that BtX-A injections appear to be safe and effective for reducing pain and improving the quality of life and functional mobility of children undergoing lengthening or deformity corrections of the lower limbs. A larger-scale study is currently underway to confirm these preliminary findings.

Acute correction using focal dome osteotomy for deformity about knee joint

Correction of deformities about knee joint may prevent or delay the onset of osteoarthritis or mitigate its effects. Accurate correction of such deformities without production of secondary deformities depends on precise localization and quantification of the deformities. We corrected deformities around the knee using acute correction with focal dome osteotomy in 21 segments (15 patients). Five segments underwent limb lengthening postoperatively. The mean correction angle was 16.0 degrees . We were able to correct all segments. In the five lengthening cases, the mean external fixation index (EFI) was 70.9 days/cm, which is much higher than the generally reported EFI. There were eight complications, all but one of which occurred in lengthening cases. We believe that acute correction with focal dome osteotomy is very useful for cases of alignment correction, but is not indicated for cases of alignment correction with lengthening, due to a high risk of complications related to poor callus formation.

Intérêt de la surveillance électrophysiologique des allongements de membre par fixateur externe : à propos de 25 enfants et adolescents

Objective To evaluate neurological tolerance during limb lengthening in children and adolescents. Material and methods Retrospective study of 25 children and adolescents [15 girls, 10 boys; mean age 11.3 years, range 5–18 years] undergoing limb lengthening. Limbs involved were the femur [11 cases], tibia [10 cases], radius [3 cases] and humerus [1 case], and lengthening was 1 mm/day, adjusted depending on clinically and electrophysically observed alterations during weekly surveillance. Results Lengthening in 8 cases was accompanied by electrophysiological deterioration and in 1 by clinical alteration without electrophysiological anomaly. Eight of 25 lengthenings had to be slowed and 1 discontinued. Discussion This work confirms poor neurological tolerance with limb lengthening. It shows the interest of clinical and electrophysiological monitoring in preventing severe neurological accidents with such lengthening.

Predicting the loss of knee flexion during limb lengthening using inherent muscle length

Limb lengthening procedures can be associated with loss of range of knee movement, although the amount of knee flexion lost varies markedly between patients. The exact aetiology of this problem is not fully understood. This study investigates whether the amount of joint range that is lost during limb lengthening might be affected by the inherent passive compliance and length of the patients' soft tissues determined preoperatively. A simple mathematical model has been developed to calculate the inherent length and 'spare' length of the hamstring and quadriceps muscle groups in 28 patients undergoing limb lengthening procedures. The range of knee motion was recorded preoperatively and loss of movement recorded during follow-up. The results show a strong correlation between predicted 'spare' length of quadriceps and loss of knee flexion. An association was noted between loss of knee extension and the straight leg raise and correlation of knee extension and the spare length of the hamstrings. The straight leg raise test, and calculation of spare quadriceps length using our formula, as part of the preoperative assessment, can help predict which patient is at risk of a reduced range of motion of the knee.

Primary Shortening with Secondary Limb Lengthening for Gustilo IIIB Open Tibial Fractures: A Report of Six Cases

The treatment of type IIIB open tibial fractures remains a challenge for orthopedic surgeons, particularly with respect to the soft-tissue and subsequent bony reconstruction. The primary shortening and limb lengthening (PSLL) simplifies wound closure for severe open injuries without requiring microsurgical procedures as a main advantage. This method is thought to be also useful for type IIIB patients with polytrauma and other life-threatening injuries because it helps to control both wound sepsis and their general state. In the present study, we attempted to assess the problems, long-term functional outcome, and quality of life (QOL) of patients who were treated by PSLL for Gustilo type IIIB open tibial fractures in our facility. Six patients with type IIIB open tibial fractures treated with PSLL were retrospectively reviewed. The mean shortening length was 7.4 cm (range, 4.5-10.3 cm). The mean percent shortening of the entire bone was 18.7% (range, 12.3-29.7%). Limb lengthening started at a mean interval of 10.3 months (range, 3-18 months) after the original injury. The mean healing index was 56.5 days/cm (range, 31.3-86.7 days/cm). The complications, functional outcome, and quality of life were evaluated for all cases. One superficial infection at the initial corticotomy, one deep infection around the shortening site, one refracture at the healed docking site, several wire breaks in external frames in two cases, and two severe equinovarus deformities occurred as complications of these procedures. Regarding functional outcome, three patients showed good outcome, two showed fair outcome, and one showed poor outcome. The percent shortening of the entire bone in the two fair cases were more than 25%. The median scale of physical health summary, mental health summary, and total general health summary in Short Form-36 (QOL) were lower than the standard scale in age-matched individuals. This PSLL treatment was thought to be a useful option for severe open fracture of the tibia, which had bony defect in more than 4.5 cm in length after serial debridement, although several complications occurred in this regimen. However, it is difficult to achieve an excellent function and QOL using these techniques. In addition, it is difficult for patients who underwent limb lengthening after shortening more than 25% of the total length of bone to gain good function.