Combined lengthening for acquired leg length discrepancy: Are there advantages of hydroxyapatite-coated intramedullary nails?

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

Comparison of Intramedullary Magnetic Nail, Monolateral External Distractor, and Spatial External Fixator in Femur Lengthening in Adolescents with Congenital Diseases.

The aim of this study is to evaluate the course of the treatment and clinical and functional outcomes of femur lengthening in adolescents with congenital disorders by the application of different surgical methods. This retrospective study comprised 35 patients (39 procedures). A total of 11 patients underwent femur lengthening with the use of the intramedullary magnetic nail (IMN) Precise 2 (NuVasive, San Diego, CA, USA), 7 patients (11 procedures) with the use of the monolateral external distractor Modular Rail System (MRS) (Smith and Nephew, Memphis, TN, USA), and 17 with the use of the computer-assisted external fixator Taylor Spatial Frame (TSF) (Smith and Nephew, Memphis, TN, USA). The inclusion criteria were as follows: (1) congenital femoral length deficiency without any axial deformities and (2), independently of the finally applied treatment, the technical possibility of use of each of the analyzed methods. The distraction index did not differ significantly between the groups (p = 0.89). The median lengthening index was the lowest in the IMN group (24.3 d/cm; IQR 21.8-33.1) and statistically different in comparison to the MRS (44.2 d/cm; IQR 42-50.9; p < 0.001) and the TSF groups (48.4 d/cm; IQR 38.6-63.5; p < 0.001). Similarly, the consolidation index in the IMN group (12.9 d/cm; IQR 10.7-21.3) was statistically lower than that in the MRS (32.9 d/cm; IQR 30.2-37.6; p < 0.001) and the TSF (36.9 d/cm; IQR 26.6-51.5; p < 0.001) groups. This study indicates that IMN is a more valuable method of treatment for femoral length discrepancy without axial deformity than MRS and TSF in complication rate and indexes of lengthening and consolidation.

Limb Lengthening for Congenital Deficiencies Using External Fixation Combined With Flexible Intramedullary Nailing: A Multicenter Study.

BACKGROUND: Hydroxyapatite (HA) coated flexible intramedullary nailing (FIN) stimulates osteogenic activity. The role of HA-coated intramedullary nails remains unclear in normal bone lengthening. The goal of this study was to quantify the influence of FIN on the External Fixation Index (EFI) in patients with congenital lower limb discrepancy. METHODS: Patients with femoral deficiency and fibular hemimelia underwent lengthening by the combined technique of external fixation with titanium (Ti) FIN or HA coated FIN and returned for follow-up at least 12 months after frame removal. RESULTS: Seventy patients (mean age of 12.6 y) were included: 19 monofocal femoral lengthenings, 35 tibial monofocal lengthenings, 16 tibial bifocal lengthenings. The mean EFI's for those treated with and without HA-coated nails were not significantly different. The Conover posthoc analysis did not reveal a significant influence of the type of FIN on EFI in any subgroup. However, 2-way analysis of variance revealed simultaneous effects of nail types and age on the EFI in tibial bifocal lengthening.Significant positive correlation between the ratio "nail diameter/medullary shaft diameter" and EFI in tibial bifocal non-HA-coated FIN lengthening, and a significant positive correlation between age and EFI for femoral non-HA-coated FIN lengthening, tibial monofocal and bifocal HA-coated FIN lengthening were revealed.There were 4 cases of fracture at lengthening site required unscheduled surgery. In the non-HA-coated group, there was a statistically significant negative correlation between nail diameter and fracture occurrence at the lengthening site after frame removal. A ratio of <0.15 likely does not ensure required mechanical stability and support. CONCLUSIONS: Both Ti-nail and HA-coated nail lengthening provide good and excellent outcomes for femoral and tibial monosegmental lengthening procedures and ensure reduced EFI. In congenital disorders which were not associated with abnormal bone, there are no differences with regard to EFI using HA-coated or non-HA-coated FIN. The ratio of "elastic Ti-nail diameter/medullary canal diameter at narrowest site" <0.15 seems to be associated with higher risk of fracture at the lengthening site after frame removal.

Inter-observer and intra-observer reliability in the radiographic measurements of paediatric forefoot alignment.

BACKGROUND: Foot bones in children have more rounded shapes in radiograms than adults. Thus, the goal of this work was assessing inter- and intra-observer reliability in paediatric forefoot angle measurements. MATERIAL AND METHODS: Six forefoot angles in 34 AP standing paediatric foot radiographs were measured by 5 researchers. A classic statistical analysis with use of IBM SPSS Statistics 25 was performed and a new method with two-way analysis of variance was applied. RESULTS: Results of statistical analysis revealed the properties of a subjective assessment related to specific angles. Kilmartin's angle, calcaneus-fifth metatarsal angle and first ray angle are the most reliable; metatarsus adductus angle should be used with great caution in pediatric population. Engel's angle is the most difficult for measuring and measurement error is the highest. CONCLUSION: The power of paediatric forefoot measurements is various. Several angles are reliable, while Engle's angle is the most doubtful.

Radiological Outcomes of Overhead Traction Therapy for Developmental Dysplasia of the Hip in Non-ambulatory Children.

BACKGROUND: Infants with a dislocated and unstable hip that does not lend itself to stabilisation may be treated using overhead traction to achieve gradual reduction of the hip joint. The aim of this paper was to analyse the radiological outcomes of overhead traction therapy and the effect of duration of traction on the occurrence of complications and final treatment outcomes. Material and methodd. A retrospective analysis of medical records of 26 children (34 affected hips) involved three independent observers assessing radiological parameters before the surgery and at follow-up visits at least two years after the therapy. RESULTS: Overhead traction was used for an average of 35 days (range: 15-43 days). Twenty six hips were treated solely with reduction and immobilisation in a 'human position' plaster cast. Three hips were qualified for surgery immediately after a preliminary traction period. Five hips showed a suboptimal result following the immobilisation period. A MANOVA model revealed that the following factors had a significant effect on the treatment outcome: superior centring ratio of Smith (with the lowest values recorded in patients with residual hip dysplasia, p = 0.001) and acetabular angle of Sharp (with the lowest values found in patients requiring surgery, p = 0.01). Statistical tests did not show a correlation between the duration of traction and disturbance of proximal femoral metaphysis growth assessed according to Bucholz and Ogden classification. Fifteen hips were classified as type I, eight hips were graded as type II and also eight hips as type III. CONCLUSIONS: The lowest values of acetabular angle of Sharp were recorded in patients requiring surgery and the lowest superior centring ratio of Smith was found in those with residual hip dysplasia. The duration of overhead traction did not directly correlate with the final outcome; it only seemed to be an indicator of the severity of hip dysplasia. Routine use of overhead traction before undertaking closed reduction does not probably decrease the incidence of proximal femoral growth disturbance.

[Precocious puberty due to hypothalamic hamartoma]. / Przedwczesne dojrzewanie plciowe w przebiegu guza hamartoma podwzgórza.

INTRODUCTION: Central precocious puberty is usually idiopathic. Appearance of the precocious puberty symptoms in early childhood or pre-school period indicate that also it could be caused by organic disorder of the central nervous system. The aim of this work is to present the case of the 4-year-old girl, diagnosed with precocious puberty. THE CASE REPORT: The first clinical symptoms of precocious puberty such as increased growth rate and breast enlargement were observed when the girl was 4 years old. The height (above the 97 centile) and weight (90-97 centile) were measured during the physical examination. The advancement of sexual features was determined as follows: thelarche III degrees , pubarche II degrees , axillarche II degrees . The LHRH test used in this differential diagnosis revealed the pubertal level of gonadotropins, when plasma levels of dehydroepiandrosterone, prolactin, thyroid-stimulating hormone and alpha-fetoprotein levels were correct. The advanced bone age was 8 years and 10 months, while the height age was 7 years. The final diagnosis was based on MRI scan. The patient is currently treated with an analog of gonadoliberine (Diphereline). In conclusion, we aspired to notice that the pharmacological treatment of hypothalamic hamartoma may be safe and effective. Suppression of puberty to the normal time of pubescence gives a child the chance to reduce health discomforts as well as further emotional and social problems.