Advances in deformity correction, limb lengthening and reconstruction.

This article summarizes the content of this special issue of the journal about: deformity correction, limb lengthening and reconstruction.

Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame.

This retrospective review assesses 55 tibial nonunions with bone loss to compare union achieved with combined Ilizarov and Taylor spatial frames (I-TSF) versus a conventional circular frame with the standard Ilizarov procedure. Seventeen (31 %) of the 55 nonunions were infected. Thirty patients treated with I-TSF were compared with 25 patients treated with a conventional circular frame. In the I-TSF group, an average of 7.6 cm of bone was resected and the lengthening index (treatment time in months divided by lengthening amount in centimeters) was 1.97. In the conventional circular frame group, a mean of 6.5 cm was resected and the lengthening index was 2.1. Consolidation at the docking site and at the regenerate bone occurred in 49 (89 %) of 55 cases after the first procedure. No statistically significant difference was shown between the two groups. Superiority of one modality of treatment over the other cannot be concluded from our data. Application of combined Ilizarov and Taylor spatial frames for bone transport is useful for treatment of tibial nonunion with bone loss. Level of evidence Case series, Level III.

Safe Cosmetic Leg Lengthening for Short Stature: Long-term Outcomes.

It is well known that limb lengthening is performed to treat limb-length discrepancies resulting from congenital anomalies and developmental problems. However, few studies discuss lengthening for cosmetic purposes. The current authors conducted a prospective study with long-term follow-up. From July 2002 through June 2007, 133 patients requested that their height be increased. Fifty-two were approved to undergo limb-lengthening surgery. Two were lost to final follow-up, leaving 50 in the study group. For all patients, the Ilizarov ring external fixator was applied with a maximum-stability technique that achieved frame stability and allowed patients to ambulate with a walker from the first week postoperatively. The method requires close follow-up for early detection of problems. Physiotherapy improved ankle function and prevented plantar flexion deformity, which can occur during lengthening. Excellent final outcomes were achieved in all patients except one, who required additional surgery. The Ilizarov device is a safe tool for limb lengthening in individuals of short stature when applied with the authors' maximum stability technique. To the authors' knowledge, this is the first article on this topic to report long-term results (minimum 5-year follow-up for all patients). Many factors influence the outcome of lengthening surgery performed with Ilizarov devices: the material of the rings, the use of a hybrid technique combining pins and wires, the diameter and number of pins over each bone segment, the size of the rings around the limb, the surgical technique for pin insertion, and the use of hydroxyapatite-coated pins or regular stainless pins.

Taylor spatial frame fixation in patients with multiple traumatic injuries: study of 57 long-bone fractures.

OBJECTIVE: To evaluate the Taylor spatial frame (TSF) for primary and definitive fixation of lower limb long-bone fractures in patients with multiple traumatic injuries. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Consecutive series of 52 patients, 57 fractures (25 femoral and 32 tibial), treated between 2005 and 2009. Forty-nine fractures (86%) were open. Injury Severity Score ≥16 for all patients. INTERVENTION: Fifty-four fractures (95%) underwent definitive fixation with the TSF and 3 were treated primarily within 48 hours of injury. In 22 cases (39%), fractures were acutely reduced with the TSF, fixed to bone and the struts in sliding mode without further adjustment, and in 35 cases (61%), the total residual deformity correction program was undertaken. MAIN OUTCOME MEASURE: Clinical and radiological. RESULTS: Complete union was obtained in 52 fractures (91%) without additional surgery at an average of 29 weeks. Four nonunions and 1 delayed union occurred. Results based on Association for the Study and Application of the Method of Ilizarov criteria: 74% excellent, 16% good, 4% fair, and 7% poor for bone outcomes and 35% excellent, 47% good, and 18% fair for functional outcomes. Eighty-eight percent of patients returned to preinjury work activities. CONCLUSIONS: Primary and definitive fixation with the TSF is effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of primary defect caused by bone loss, easy and accurate application, convertibility and versatility compared with a monolateral fixator, and improved union rate and range of motion for lower extremity long-bone fractures in patients with multiple traumatic injuries.

Treatment of a fibular autograft non-union with a resulting deformity by stabilization, progressive correction and callotasis using an Ilizarov fixator: a case study.

Bone tumours present a challenge to reconstructive surgery when the tumour breaches the physeal and periphyseal region of the growing bone. Though a host of options are available, these are not without complications. We report one such case of osteosarcoma of the tibia treated initially with wide resection of the tumour and intercalary fibular strut grafting using plate and screws. The operation was complicated by a non-union at the proximal tibio-fibular autograft junction. This leads to a multiplanar deformity with severe procurvatum at the proximal tibio-fibular graft junction, which was successfully treated by callotasis using an Ilizarov fixator. Appropriate consent was obtained from the patient and parents to publish this case report.

Correction of poliomyelitis foot deformities with Ilizarov method.

Poliomyelitis is an infectious disease caused by a neurotrophic virus targeting anterior horn cells of lower motor neurons resulting in flaccid paralysis and represents a common condition in developing countries, and even nowadays, most of both treated and untreated cases result in foot deformities. Between 1994 and 2007, 27 patients were treated by classic ring Ilizarov fixator, aiming at producing a stable plantigrade and cosmetically acceptable foot and followed up for meanly 7.17 years. Additional procedures were performed if needed. The mean time in frame was 4.2 months. All the patients were satisfied with their gait, compared to preoperative status. A painless and plantigrade foot was obtained in all patients, and limb-length discrepancy was always corrected where present. No major complications were encountered. In conclusion, the Ilizarov method allows simultaneous progressive correction of all components of severe foot deformities associated with limb-lengthening discrepancy with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding important shortening of the foot.

Enhancing bone healing during distraction osteogenesis with platelet-rich plasma.

UNLABELLED: Gradual limb lengthening with external fixators using distraction osteogenesis principles is the gold standard for treatment of limb-length discrepancy. However, long treatment time is a major disadvantage of the current lengthening procedures. Efforts to decrease the treatment include biological and biomechanical factors. Injection of platelet-rich plasma (PRP) is a biological method to enhance bone healing during distraction osteogenesis. We hypothesised that PRP can enhance bone healing during limb lengthening. We report our experience with the use of PRP during distraction osteogenesis. This retrospective study included 19 patients divided into the standard group of 10 patients who did not receive PRP and the PRP group of nine patients who received PRP at the end of the distraction phase. The study variables included external fixator time, external fixation index, and complications during treatment. The PRP group had statistically significantly shorter treatment time (p=0.0412). Injection of PRP into regenerate bone might be an effective method to shorten treatment time during limb lengthening and lead to better functional outcomes and improved patient satisfaction. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The new "dual osteotomy": combined open wedge and tibial tuberosity anteriorisation osteotomies.

The high frequency with which medial compartment osteoarthritis is associated with patellofemoral osteoarthritis makes the addition of tibial tuberosity anteriorisation to high tibial osteotomy an appealing solution, despite the discouraging previously reported long-term results when tubercle anteriorisation was combined with a Coventry closed wedge technique. We conducted a prospective study of a new osteotomy combination: "the dual osteotomy". An open wedge high tibial osteotomy was combined with 1- to 1.5-cm Maquet-like tibial tuberosity anteriorisation. Thirty-four knees in 30 patients underwent surgery, including ten knees in nine male patients and 24 knees in 21 female patients with a mean age of 45 years (age range 34-58 years). All patients had varus medial compartment osteoarthritis and patellofemoral osteoarthritis with preoperative anatomical tibiofemoral angle exceeding 5 degrees . Twenty-four months after surgery, final evaluation detected improvement in the Knee Society clinical rating system function score from a mean of 61.3 (range 30-80) preoperatively to a mean of 87.3 (range 50-100) postoperatively and in the knee pain score from 27.3 (range 10-30) to 47 (range 30-50) postoperatively. Based on the rating system, at final follow-up, 70% of patients experienced no pain, 13% had mild or occasional pain, 10% had pain on stairs only, and 7% had pain during walking and on stairs. Anatomical tibiofemoral angles from 0 to 10 degrees valgus were achieved in 91% of operated knees, and union was achieved in all cases within six to twelve weeks after surgery. The dual osteotomy was effective in the short term in cases of medial compartment osteoarthritis associated with patellofemoral osteoarthritis.

Deformity correction with an external fixator: ease of use and accuracy?

The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a hexapod frame that differs from the well-known Ilizarov fixator in that it works in conjunction with special software programs and can simultaneously correct 6 axes of deformity. The aim of this study was to evaluate the ease of use and accuracy of the Taylor spatial frame. We used the Taylor spatial frame with the older software, Version 2, and the newer Internet-based program, Version 3.1, to achieve our treatment goals in 29 cases. We herein report our results achieved by using the Taylor spatial frame to treat deformity and trauma of the lower limb from November 1999 through May 2005. The hybrid advanced technique of frame application with the use of wires and half-pins was applied in all cases. Included in this study were only those patients whose frames had been removed and whose final results were available. All patients were treated and followed by the senior author (Y.E.). We found that the Taylor spatial frame is easy to apply and that application can be accomplished quickly. The results were clinically and radiographically excellent in all cases at the time of final assessment, and the treatment goals were 100% successful. The only drawbacks we noted are that the Taylor spatial frame is more cumbersome than the conventional Ilizarov frame and the financial cost is comparatively high.

Treatment of traumatic forearm bone loss with Ilizarov ring fixation and bone transport.

Bone loss in the forearm results from high-energy trauma or follows non-union with infection. Ilizarov methodology provides stable fixation without implantation of permanent foreign bodies while permitting wrist and elbow movement. We are reporting our experience using distraction osteogenesis in the treatment of traumatic bone loss in the forearm. From 1991 to 2000, 11 consecutive patients with traumatic forearm bone loss were treated with Ilizarov ring fixation. Records were reviewed retrospectively. All patients were contacted 2-10 years after surgery at the Ilizarov Clinic in Lecco, Italy. Eleven atrophic non-unions with bone loss were treated. The time from injury to Ilizarov treatment averaged 2.1 years. Follow-up averaged 6.2 years. The union rate with Ilizarov treatment alone was 64%. Thirty-six percent of the patients were converted to a hypertrophic non-union and underwent compression plating. The overall rate of union was 100%. There were four unplanned reoperations and no refractures, neurovascular injuries or deep infections. Three patients had significant limitations of wrist function. Nine patients described their function as excellent. Ilizarov fixation with bone transport is a viable treatment option for atrophic forearm non-unions with bone loss. Treatment resulted in ablation of infection, healing of atrophic non-unions with minimal complications and early extremity use.