Simultaneous femoral and tibial lengthening for severe limb length discrepancy in fibular hemimelia.

BACKGROUND: Fibular Hemimelia (FH) is the most common longitudinal limb deficiency. Significant limb length discrepancy (LLD) will necessitate long treatment times and multiple settings to compensate for LLD when associated with femoral shortening. This study evaluates the outcome of simultaneous femoral and tibial lengthening using the Ilizarov frame. METHODS: This retrospective study included the cases of 12 children with severe limb length discrepancy caused by combined FH and ipsilateral femoral shortening from May 2015 to August 2022. The total LLD ranged from 7 to 14.5 cm. All patients underwent single-session femoral and tibial lengthening using the Ilizarov ring external fixator technique. Additional procedures were performed in the same setting, including Achilles tendon lengthening, fibular anlage excision, peroneal tendons lengthening, and iliotibial band release. Follow-up ranged from 2 to 4 years. RESULTS: The planned limb lengthening was achieved in ten cases (83%). No cases of joint subluxation or dislocation were encountered. No neurovascular injury has occurred during the treatment course. In all cases, the bone healing index was better on the femoral side than on the tibia. Poor regeneration and deformity of the tibia occurred in two cases (16.6%). CONCLUSION: Simultaneous femoral and tibial lengthening using the Ilizarov fixator is a relatively safe procedure with the result of correction of total LLD in one session in a shorter time and less morbidity.

Carpal Tunnel Syndrome Secondary to Tuberculous Tenosynovitis With Rice Bodies: A Case Report.

CASE: We report the case of a 34-year-old African man who presented with severe symptoms of recurrent left carpal tunnel syndrome (CTS) and left hand swelling after previous open decompression. Considering the recurrent unilateral affection of the left hand in a patient working in a slaughterhouse in an area with a moderate burden for tuberculosis, tuberculous infection was suspected. Open surgery and biopsy revealed tuberculous tenosynovitis of flexor tendon sheath and shiny white rice bodies. CONCLUSION: Tuberculous tenosynovitis should be considered as a differential diagnosis of the CTS when there is evidence of proliferative tenosynovitis in patients from an endemic area for tuberculosis.

Minimally invasive K-wire fixation of displaced intraarticular calcaneal fractures through a minimal sinus tarsi approach.

BACKGROUND: Displaced intra-articular calcaneal fractures are challenging injuries, and there is debate regarding the best method of treatment. PATIENTS AND METHODS: Between January 2018 and January 2021, a prospective study was conducted on 46 patients with 56 displaced intraarticular calcaneal fractures that were treated with minimally invasive fixation using Kirschner wires (KWs) through the sinus tarsi approach. RESULTS: The mean follow-up period was 22.36 months. The American Orthopaedic Foot and Ankle Society (AOFAS) score was adopted as a method of clinical evaluation; the mean AOFAS score was 78.4. All cases showed radiographic evidence of adequate healing, with no collapse till the final follow-up. Complications included persistent pain, subtalar arthritis, deep infection and superficial pin site infection. CONCLUSION: The use of the sinus tarsi approach and percutaneous KWs represents a minimally invasive approach which expands the indications of surgery for displaced intra-articular calcaneal fractures with fewer treatment-related complications. Level of evidence (4) case series. Trial registration This study has been approved by the ethical research committee of the Faculty of Medicine, Tanta University, under the code: 35901/10/22.

Recurrent heel ulcers with calcaneal osteomyelitis in myelomeningocele: Treatment by partial calcanectomy and posterior transfer of tibialis anterior tendon.

OVERVIEW: Calcaneus deformity of the foot is common in patients with myelodysplasia, mainly due to muscle imbalance. This deformity, especially in ambulatory patients, can result in gait problems and development of pressure sores, which can be complicated by calcaneal osteomyelitis. MATERIAL AND METHODS: This retrospective cross-sectional study included 12 patients (18 feet), with calcaneus deformity due to myelomeningocele, and presented with penetrating heel ulcers complicated by calcaneal osteomyelitis. The mean age of the included cases was 11 years. The ulcers were unilateral in six patients and bilateral in six. Sensation was absent on the plantar aspect of the foot in all cases. The treatment was done in two stages; The first stage was eradication of infection and obtaining good soft tissue coverage, and the second stage was obtaining motor balance to achieve a more plantigrade and braceable foot. RESULTS: The average follow-up period was 19.2 months. In the final follow-up, twelve feet were graded as good, five as fair and one as poor according to Legaspi grading system. CONCLUSION: The combination of partial calcanectomy and subsequent transfer of tibialis anterior tendon, to improve the foot position and gait, can efficiently prevent ulcer recurrence in myelomeningocele patients with calcaneal deformity. LEVEL OF CLINICAL EVIDENCE: 4: Retrospective case series study.

Masquelet-Ilizarov technique for the management of bone loss post debridement of infected tibial nonunion.

PURPOSE: Masquelet and Ilizarov techniques have their advantages and shortcomings in the reconstruction of bone defects. The aim of this study was to evaluate the effectiveness of the combination of both techniques for the management of infected tibial nonunion to combine the advantages of both techniques with avoidance of shortcomings of both of them. PATIENTS AND METHODS: A prospective single-centre study was performed during the period from 2012 to 2019. Patients with the infected nonunion of the tibia with bone defect were included. Patients with pathological fractures or non-infected bone loss were excluded. Management protocol for all patients consisted of two stages. The first stage was Masquelet induced membrane technique and the second stage was Ilizarov bone transport. The results were assessed based on both objective (clinical and radiographic evaluation) and subjective criteria (limb function and patient satisfaction). RESULTS: Thirty-two patients were included in this study. The mean size of the defect was 6 cm. Ilizarov bone transport was done through the induced membrane chamber in all cases with an average follow-up of 28 months. Successful reconstruction without recurrence of infection was achieved in 30 cases (94%). No other bone or soft tissue procedure was needed with satisfactory functional outcome in 27 out of 30 cases (90%). Three cases had unsatisfactory results due to leg length discrepancy, joint stiffness, and persistent pain. CONCLUSIONS: Masquelet-Ilizarov technique can be used for the management of infected nonunion tibia with high satisfactory results without the need for complex soft tissue procedures.

Congenital segmental tibial dysplasia and late onset pseudarthrosis of the tibia.

Background: Congenital pseudarthrosis of the tibia represents a continuum of dysplasia. Most cases develop pseudarthrosis during the first two years of life. Only a few cases with tibial dysplasia present after the age of two years, with or without pseudarthrosis. This under-reported form of Congenital segmental Tibial Dysplasia (CSTD) was investigated to evaluate its distinctive features and possibly predict the disease progression. Methods: Of the 46 cases presented to our institute over a 20-year period, 17 patients had CSTD. 13 patients developed pseudarthrosis after the age of two years, the average follow up period was four years. Four patients did not break their tibiae until the time of last follow up. Radiological criteria were evaluated by plain x-rays. Results: According to the radiological criteria, late-presenting CSTD was divided into resolving CSTD (R-CSTD), and pre-pseudarthrosis-CSTD (P-CSTD). In all cases of the R-CSTD group, the tibia had a canalized medullary cavity with anterolateral bowing and segmental cortical sclerosis. While in the P-CSTD group, there was anterolateral bowing, segmental cortical sclerosis, and any of the following: 1) medullary obliteration, 2) cystic changes, 3) hour-glass appearance, 4) Impending fracture, and 5) progressive deformity. Conclusion: A simple classification of prognostic value has been proposed for cases that did not sustain a fracture until after the age of two years. This differentiation would assist in decision making, and in preoperative counseling for patients. Level of evidence: IV, Retrospective case series.

Salvage arthrodesis for infected ankle fractures with segmental bone-loss using Ilizarov concepts: a prospective study.

PURPOSE: Complex ankle fractures accompanied with infection and segmental bone loss are a worrying issue. This prospective study was conducted to explore the effectiveness of using Ilizarov concepts in achieving salvage arthrodesis and reconstructing post-debridement defects in such complicated scenarios. METHODS: A total of 44 consecutive patients (mean age 35.61 ± 8.57 years, 30 males, 44 feet) of post-traumatic infected ankle fractures, who met our selection criteria, were enrolled and subjected to radical debridement and salvage arthrodesis using the bifocal bone transport concepts of Ilizarov. All patients were treated between 2012 and 2017 either by acute shortening compression of the arthrodesis site with re-lengthening (ASRL) through the created proximal metaphyseal osteotomy (group I, n = 20) or by gradual bone transport (BT) through the proximal osteotomy with gradual closure of the distal ankle defect (group II, n = 24). Plain-radiographs were used for radiological assessment. Clinically, the outcomes were objectively graded according to the Hawkins criteria, while subjectively the patients reported their satisfaction on a 1-5 points acceptance scale. RESULTS: The mean follow-up was 37.16 ± 5.31 (30-48 months). Successful fusion was achieved in 43/44 patients, with a significantly (P < 0.05) lesser needs for bone-grafting in favour of group II. The results were good in 32 cases, fair in 11, and poor in a single case with no significant difference between the two groups. The acceptance scores were significantly (P < 0.05) superior in group II (3.08 ± 1.1 points) than that group I (2.25 ± 1.4 points). CONCLUSIONS: Bifocal bone transport is effective in salvaging troublesome infected ankle fractures with bone loss. BT is more comprehensive and acceptable than ASRL with lesser needs for bone grafting.

Talectomy for the Management of Resistant Talipes Equinovarus Deformity; Does Adding Ilizarov External Fixator Provide Extra Advantages?

BACKGROUND: The management of resistant talipes equinovarus (TEV) is challenging. Residual deformity and recurrence are among the most feared complications. This study was conducted to evaluate the effectiveness of talectomy in the management of arthrogrypotic TEV and to investigate the value of adding a simplified Ilizarov fixator (SIF). PATIENTS AND METHODS: A total of 42 resistant TEV feet among 23 arthrogrypotic children were operated between January 2012 and 2016. The average age was 6.7 ± 1.67 years. The feet were divided into 2 groups; group A (Casting group) included 20 feet (11 children) that were managed by talectomy and casting, while group B (Fixator group) included 22 feet (12 children) that were treated using a SIF concomitant with talectomy. The results were evaluated morphologically by Dimeglio grading system and functionally by Legaspi system. RESULTS: The average follow-up was 36.62 ± 3.88 months. With the numbers available in this study, there was significant improvement (p ≤ .05) in the Dimeglio scores in both groups, which was significantly more evident (p ≤ .05) among the fixator group. The majority of the good functional results were reported among the fixator group, while the poor feet were observed mainly in the casting group (p ≤ .05). The functional end results were significantly affected (p≤ .05) by the final Dimeglio scores. The age had also statistically significant effect (p≤ .05) on the functional end results in group A only. CONCLUSION: Talectomy is an effective procedure for salvaging arthrogrypotic TEV. Supplementation of the procedure by SIF was associated with more satisfactory morphological and functional results particularly in older children.

Distally Based Medial Hemisoleus Muscle Flap for Wound Coverage in the Distal Third of the Leg.

Wound healing and coverage of soft tissue defects of distal tibia are challenging. Free tissue transfer is treatment of choice for distal tibial defects. However, resources for free tissue transfer are not readily available and they increase morbidity to host. Local and regional flaps play a key role in management of these defects with less demanding or specialized requirements. The soleus muscle flap is the workhorse flap for midtibia soft tissue defects and is used in reverse fashion to reach the distal third of the tibia. Despite minor complications, distally based medial hemisoleus flap is reliable in limb salvage cases.

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

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

Congenital pseudarthrosis of the tibia: the outcome of a pathology-oriented classification system and treatment protocol.

Congenital pseudarthrosis of the tibia is defined as a non-union of a tibial fracture that develops in a dysplastic bone segment of the tibial diaphysis. Pathologically, a fibrous hamartoma surrounds the bone at the congenital pseudarthrosis of the tibia site. The cases of 25 children, who have congenital pseudarthrosis of the tibia, were included in this study. Their ages ranged from 15 months to 15 years at the time of treatment. Neurofibromatosis-1 was present in 24 children. They were managed according to our classification system and treatment protocol. The treatment for mobile pseudarthrosis (types 1 and 2) included complete excision of the pathological periosteum, insertion of autogenous iliac crest bone graft, and combined fixation using intramedullary rod and Ilizarov external fixator. For type 3 pseudarthrosis (stiff pseudarthrosis), a pre-constructed Ilizarov fixator was applied for simultaneous distraction of the pseudarthrosis and deformity correction without open surgery. Evaluation of results was mainly radiological and included achievement of union, leg length equalization, deformity correction and prevention of refracture. Consolidation of the pseudarthrosis and osteotomies was achieved in all cases (100%). Refracture occurred in one case (4%) at the site of previous pseudarthrosis. Residual limb length discrepancy more than 2.5 cm occurred in two cases (8%). Valgus deformity of the ankle was present in 12 cases (48%) and was treated by supramalleolar osteotomy. Follow-up ranged from 24 to 48 months (average 36.9 months) after fixator removal. The results of our treatment protocol, based on our classification system, have been consistently good and predictable in all cases of congenital pseudarthrosis of the tibia. Mobility of the pseudarthrosis is an important factor in choosing the type of interference.

Fixator-assisted Percutaneous Plate Fixation of Complex Diaphyseal Tibial Fractures.

AIM: The purpose of this study is to evaluate the results of indirect reduction and fixation of comminuted diaphyseal tibial fractures using temporary simplified external fixator and plate osteosynthesis through a limited incision approach with special consideration of the duration of surgery and rate of complications. MATERIALS AND METHODS: In this prospective case series study, 41 cases of comminuted diaphyseal tibial fractures were included. Twenty-two were closed fractures, 15 grade I open fractures, and four were grade II open fractures. Patients were evaluated clinically according to the lower extremity functional scale (LEFS). RESULTS: Of the 41 cases, 38 were followed up for at least 1 year. Using the LEFS, final scores ranged from 67-80 (mean 75). Union was achieved in all cases except one which united after bone grafting. The mean time to radiological healing was 12 weeks. Operative time from skin incision to closure ranged between 65 minutes and 100 minutes (mean of 80 minutes). There were four cases of superficial infection. CONCLUSION: Treatment of comminuted tibial fractures through use the of a simplified external fixator to aid and maintain the reduction of comminuted tibial fractures whilst limited incisions are then used for minimally-invasive plate osteosynthesis in an effective and time-saving method with a low complication rate. HOW TO CITE THIS ARTICLE: Nada AA, Romeih M, El-Rosasy M. Fixator-assisted Percutaneous Plate Fixation of Complex Diaphyseal Tibial Fractures. Strategies Trauma Limb Reconstr 2019;14(1):25-28.

Midterm results of Ilizarov hip reconstruction for late sequelae of childhood septic arthritis.

The management of hip instability as a consequence of septic arthritis in childhood is difficult. Ilizarov hip reconstruction is a double-level femoral osteotomy with the objective of eliminating hip instability, through a proximal valgus-extension-derotation osteotomy and a distal varization-lengthening osteotomy for mechanical axis correction and equalization limb length. Ilizarov hip reconstruction was performed for 16 adult patients with complaints of hip pain, leg-length discrepancy, limping, reduced activity and limited abduction of the hip as a result of childhood septic arthritis. Their ages ranged from 19 to 32 years (mean 23.2 ± 4.2). Ilizarov external fixator was used in all cases. At the time of last follow-up that ranged from 60 to 132 months (mean 85.6 ± 23.5), the Harris hip score (HHS) showed excellent functional outcome in two cases (12.50 %), good in 13 cases (81.25 %) and fair in one case (6.25 %). There was no poor functional outcome in any case. Preoperatively, the mean HHS was 56.18 points, and at the time of last follow-up, it improved to a mean of 84.62 points. Pain subsided in all patients, the Trendelenburg sign became negative in all but three (19 %) patients, no patient had limb-length discrepancy, and the alignment of the extremity was reestablished in all cases. No additional operations were required. Ilizarov hip reconstruction is a valuable and durable solution for the late sequelae of childhood septic arthritis of the hip presenting in adult patients.

Late onset tibia vara. Acute correction strategy: proper case selection and a simple external fixation technique.

Following proximal tibial osteotomy for cases of late onset tibia vara, both acute and gradual correction strategies were described, where each has its pros and cons. The aim of this study was to verify the proper selection criteria of cases with late onset tibia vara amenable to successful acute correction strategy using a homogenous patient group with clear inclusion criteria; all the cases were fixed by a low profile semicircular fixator module. Thirty legs in 20 patients (11 boys, nine girls) with late onset tibia vara, treated in our department between January 2005 and February 2008, that complied well with the assigned inclusion criteria constituted the material of this prospective study. Their mean age was 10.4 years (range, 6-14 years). They were all managed using the same modality that was acute correction based on the osteotomy rule II concept and fixed by a low profile miniature Ilizarov fixator module. After a mean follow up period of 5.9 years (range, 5-7) only (13%) of the cases showed recurrence. Proper selection of cases with late onset tibia vara undergoing acute correction strategy is of utmost importance for the sake of a successful outcome. On the other hand, the low profile simplified fixator module used is a handy and a compliant osteotomy fixation tool.

Hybrid grafting of post-traumatic bone defects using ß-tricalcium phosphate and demineralized bone matrix.

OBJECTIVES: Management of post-traumatic bone defects continues to be a substantial clinical challenge in orthopaedic trauma. This retrospective study evaluates the results of primary hybrid grafting of residual bone defects or voids, in displaced and comminuted long-bone fractures treated by plate fixation, using ß-tricalcium phosphate and demineralized bone matrix. MATERIALS AND METHODS: Fifty-four patients having 62 fractures were included. Their mean age was 40.7±10.7 years; femoral and tibial fractures were the commonest (70.9%) in this study. Eight fractures (12.9%) were open injuries; 13 fractures had critical-sized defects that averaged 3.4±0.9 cm. Cortical bone defects occurred in 51 cases, and cancellous bone voids in eleven. Eleven patients (20%) were polytraumatized. Tobramycin powder was added to the graft in all open fractures. The functional outcome was evaluated according to a modified Karlström and Olerud criteria. RESULTS: All fractures (100%) had solid union without any implant failure. There was a significant delayed union (P<0.001) in all critical-sized defects. The mean healing time showed a highly significant difference (P<0.001) between closed and open fractures. The functional outcome was excellent in 28 fractures, good in 21 fractures, fair in nine fractures and poor in four fractures. CONCLUSIONS: We believe that the ideal bone graft substitute for all situations does not exist; however, this hybrid grafting is a very good alternative to autogenous grafts especially in polytraumatized patients and when massive bone grafting is needed to reconstruct more than one bone in absence of segmental defects.

Realignment-lengthening osteotomy for malunited distal fibular fracture.

PURPOSE: Persistent displacement of ankle fractures increases the stresses on the articular cartilage and leads to degenerative arthritis. Correction of the ankle mortise restores the normal ankle biomechanics and should prevent the development of degenerative joint disease. METHODS: Seventeen patients were treated for symptomatic ankle joint due to malunited distal fibular fracture. There were eleven male and six female patients. Their ages ranged from 23 to 54 years (median 34 years). The procedure included transverse fibular osteotomy for restoration of the lateral malleolar alignment, acute distraction of the osteotomy to restore the fibular length with interpositional graft and reduction of subluxation of the distal tibio-fibular articulation. Internal fixation of the osteotomy was performed with plate and screws and trans-syndesmotic screws. RESULTS: Fibular lengthening was performed in all cases and ranged from six to 12 mm (median eight millimetres). The American Orthopaedic Foot and Ankle Society score preoperatively ranged from 40 to 74 (median 60) and at follow up ranged from 50 to 95 (median 79). Progression of ankles arthrosis occurred in one patient leading to ankle arthrodesis as a secondary procedure. Results were satisfactory in 12 cases (70.6%), and unsatisfactory in five cases (29.4%) due to stiffness and pain in the ankle joint. The follow-up ranged from 24 to 45 months (median 31 months). CONCLUSION: Corrective osteotomy of fibular malunion produces considerable improvement provided that the patient does not have significant degenerative changes before surgery. The use of athrodiastasis of the ankle as a secondary procedure may be of value to improve the outcome.

Ilizarov treatment for pseudarthrosis of the tibia due to haematogenous osteomyelitis.

Haematogenous osteomyelitis is associated with poverty and overcrowding. The infection may extend through the entire length of a long bone and as a part of debridement, the sequestrum may be removed, resulting in a defect. Infection of tibial growth plates would result in altered growth rates of the tibia and fibula and produce deformities and shortening. Fourteen children were treated for pseudarthrosis of the tibia because of haematogenous osteomyelitis. Their ages ranged from 4 to 13 years. There were nine male and five female children. The treatment included the use of Ilizarov techniques in the form of distraction of a stiff pseudarthrosis (n=5) and acute shortening and relengthening for bone defects (n=9). No active infection was present at the time of treatment. In all cases, the bone defects were bridged and consolidated. No residual infection was present. Transient palsy of the common peroneal nerve occurred in two cases during deformity correction and lengthening. Refracture occurred in one case at the site of a previous wire. Residual leg shortening of more than 1 inch was present in two cases. The results were satisfactory in 12 cases (86%) and unsatisfactory in two cases (14%) because of residual shortening and ankle joint fusion. Ilizarov techniques comprehensively address the problems associated with chronic haematogenous osteomyelitis of the tibia in children despite the difficulties in their application because of the nature of the illness.

Distal tibial hypertrophic nonunion with deformity: treatment by fixator-assisted acute deformity correction and LCP fixation.

Distal tibial hypertrophic nonunion with angular deformity has been successfully treated by circular external fixator. The inconvenience of the bulky external fixator and frequent pin tract infection would not be accepted in certain cases. This study included thirteen patients (mean age 39 years) with angular deformity of the distal dia-/metaphyseal tibial shaft. Five patients were originally treated by interlocking nail, three were treated by plate and screws fixation, four treated conservatively and one had deformity secondary to fracture of a lengthening regenerate. All patients were treated by osteotomy and acute correction of the deformity using temporary unilateral fixator and internal fixation by a locking compression plate (LCP). The external fixator was removed at the end of surgery. The results were evaluated both clinically and radiologically. All osteotomies healed within 3 (2-4) months. All patients were able to work within an average of 2.3 months. The function of the upper ankle joint was unrestricted in twelve cases, and in 1 case there was a mild functional deficit. The mean follow-up was 60 months (24-120). The frontal plane alignment parameters (the mechanical axis deviation, the lateral distal tibial angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior proximal tibial angle and the anterior distal tibial angle) were within normal values postoperatively. No cases of deep infection or failure of fixation were encountered. Acute correction of distal tibial shaft hypertrophic nonunion with deformity and LCP fixation is a reliable option in well-selected cases.

Nonunited humerus shaft fractures treated by external fixator augmented by intramedullary rod.

BACKGROUND: Nonunion of humeral shaft fractures after previously failed surgical treatment presents a challenging therapeutic problem especially in the presence of osteoporosis, bone defect, and joint stiffness. It would be beneficial to combine the use of external fixation technique and intramedullary rod in the treatment of such cases. The present study evaluates the results of using external fixator augmented by intramedullary rod and autogenous iliac crest bone grafting (ICBG) for the treatment of humerus shaft nonunion following previously failed surgical treatment. MATERIALS AND METHODS: Eighteen patients with atrophic nonunion of the humeral shaft following previous implant surgery with no active infection were included in the present study. The procedure included exploration of the nonunion, insertion of intramedullary rod (IM rod), autogenous ICBG and application of external fixator for compression. Ilizarov fixator was used in eight cases and monolateral fixator in ten cases. The monolateral fixator was preferred for females and obese patients to avoid abutment against the breast or chest wall following the use of Ilizarov fixator. The fixator was removed after clinical and radiological healing of the nonunion, but the IM rod was left indefinitely. The evaluation of results included both bone results (union rate, angular deformity and limb shortening) and functional outcome using the University of California, Los Angeles (UCLA) rating scale. RESULTS: The mean follow-up was 35 months (range 24 to 52 months). Bone union was obtained in all cases. The functional outcome was satisfactory in 15 cases (83%) and unsatisfactory in 3 cases (17%) due to joint stiffness. The time to bone healing averaged 4.2 months (range 3 to 7 months). The external fixator time averaged 4.5 months (range 3.2 to 8 months). Superficial pin tract infection occurred in 39% (28/72) of the pins. No cases of nerve palsy, refracture, or deep infection were encountered. CONCLUSION: The proposed technique is effective in treating humeral nonunion especially in the presence of osteoporosis and short bone segments. The inclusion of intramedullary rod as internal splint improves stability of fixation and prevents refracture after fixator removal.

Acute correction of proximal tibial deformities in adolescents using Ilizarov external fixator: focal-dome versus straight-cut osteotomy.

Straight-cut osteotomy was compared with focal-dome osteotomy in two similar groups of patients with proximal tibial deformities. Acute correction of deformity was carried out for 27 patients with a total of 36 bone segments. Ilizarov external fixator was used in all cases. No significant difference was found between the two groups in terms of bone healing, external fixation time and stability of osteotomy. The follow-up ranged from 24 to 63 months. In this study, the focal-dome osteotomy was not found to be superior to straight-cut osteotomy, which is simpler to perform and more versatile for deformity correction.