Pedobarographic analysis of body weight distribution on the lower limbs and balance after ankle arthrodesis with Ilizarov fixation and internal fixation.

BACKGROUND: A number of various techniques were proposed to stabilized ankle arthrodesis, among them external and internal fixation. Appropriate balance and adequate distribution of lower limb loads determine normal biomechanics of the locomotor system. We hypothesized that various techniques used to stabilize ankle arthrodesis may exert different effects on (1) balance and (2) distribution of lower limb loads. METHODS: Retrospective analysis included 47 patients who underwent ankle arthrodesis with external stabilization with Ilizarov fixator (group 1, n = 21) or internal stabilization with screws (group 2, n = 26) between 2007 and 2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform. RESULTS: In group 1, average load of the operated and non-operated limb amounted to 48.8% and 51.2%, respectively, and in group subjected to internal stabilization to 48.4% and 51.6%, respectively. Neither the intragroup nor the intergroup differences in the distribution of lower limb loads were statistically significant. Mean length of the center of gravity (COG) path was 137.9 cm for group 1 and 134 cm for group 2, and mean COG area amounted to 7.41 cm2 and 6.16 cm2, respectively. The latter intergroup difference was statistically significant. CONCLUSIONS: Balance after ankle arthrodesis with Ilizarov fixation is worse than after the same procedure with internal stabilization. Despite correction of ankle deformity, musculoskeletal biomechanics still remains impaired. While ankle fusion with either Ilizarov or internal fixation provide appropriate distribution of lower limb loads, none of these procedures normalize patients' balance.

Results and biomechanical consideration of treatment of congenital lower limb shortening and deformity using the Ilizarov method.

One of the applications of the Ilizarov apparatus is the correction of congenital shortening and deformities. Ilizarov external fixator produces biomechanical structure with surrounding tissue, which is the reason why very important is correct stability of fixator. Large distraction in the case of high value of lengthening, and large deformity corection result in shear stresses that occur additionally in the regenerate, which can potentially lead to damage of the regenerating nutritive microcirculation of bone tissue and bone fragment displacements. Our objective was to assess the results of the Ilizarov method in the treatment of congenital shortening taking into account treatment strategy and the size of the axis of lengthening and correction. Our research problems include presenting the effects of biomechanics of musculoskeletal deformations on treatment results, presenting complications and their treatment. Between 1989 and 2009, 62 patients underwent surgery to correct congenital lower limb deficiencies at our Clinic; 33 patients were followed-up. In total, there were 70 surgeries (2.12/patient). Axial correction was performed in 26 patients (78.79%). Average age at the start of the treatment was 15.58 years. Mean follow-up was 8.58 years. Mean lengthening per surgery was 3.17 cm with the lengthening index of 50.7 day/cm. Results were very good for 23 patients, good for 7 patients, satisfactory for 3 patients. Complications appeared in 24 patients, problems occurred in 74.42% of the cases, obstacles in 4.65% of cases, and true complications in 20.93% of the cases. The best results were achieved in the treatment of patients with two-stage and two-segment lengthening with a total elongation of less than 7 cm, and without correction of the axis. Congenital shortening of the lower limb should be treated comprehensively because the shortening applies to all segments, and disturbs biomechanics of all lower limb. In the case of axial correction and large amount of elongation high soft tissue forces counteract the distraction forces. Hybrid construction may help to shorten treatment time, increase fixator stability and decrease rate of complications. We suggest use of hybrid Ilizarov fixator, especially when large elongation and axis corection are planned.

Distribution of radiological density in bone regenerate in relation to cyclic displacements of bone fragments.

We asked how bone fragment displacement could influence the distribution of radiological density in bone regenerate formed during the process of bone lengthening. The metatarsi of 21 sheep were lengthened by 20 mm by the Ilizarov method. The bone fragments were externally fixed with a specially designed ring external fixator equipped with linear actuator driver system. The test sheep were divided into three experimental groups: the G1 and G2 groups (N = 8) and the GR group (N = 5)--the reference group. In the case of sheep from the G1 and G2 groups, the lengthening was supplemented with mechanical stimulation of the regenerate in the form of cyclic bone fragment displacements (CBFDs) with the amplitudes of 1 mm (G1) and 2 mm (G1). Mechanical stimulation was applied over 30 days for 1 h per day with a frequency of 1 Hz. Eight weeks after the procedure the sheep were sacrificed in accordance with the required procedures. The analysis of the degree of bone regenerate mineralization involved the studies based on the CT scanning. The analysis of the results obtained is based on the paramenter called the degree of regenerate mineralization (RMD). The analysis of radiological density was carried out in the selected measurement areas. Such an area was located in three horizontal zones, taking into account the regenerate height, i.e. in its middle part (half regenerate length); the top part, 2 mm from the edge of the proximal fragment; and the bottom part, 2 mm from the edge of the distal fragment. The value of the RMD parameter varies significantly, depending on the bone regenerate area. The results obtained show that the CBFD = 2 mm accelerates the rate of mineralization of an eight-week-old regenerate. In the case of CBFD = 1 mm, the mineralization rate is lower by more than a dozen per cent.

Use of thermography to monitor the bone regenerate during limb lengthening--preliminary communication.

BACKGROUND: Bone regenerate is routinely assessed on X-ray images obtained every 7 to 14 days in the distraction period and every 14 to 28 days during the stabilisation period. Tissue reconstruction during new bone formation and increased metabolism in the tissues being lengthened are associated with an increase in the temperature of the limb. The aim of this study was to establish a correlation between the bone regenerate, assessed on the basis of X-ray evidence, and thermographic images of the limb registered in a non-invasive manner with a thermographic camera. A positive correlation would enable a reduction in the number of X-ray studies in the future. MATERIALS AND METHODS: Bone lengthening using the Ilizarov technique of distraction osteogenesis was performed in 18 patients (9 men and 9 women) aged 12-74. The lengthened segments included the crus in 13 patients, the thigh in 4 patients and lower arm in 1 patient. Assessments of the bone regenerate were made during periodic follow-up visits on the basis of X-ray images and compared to thermographic images, on the basis of which thermal indices were established. The indices comprised the difference in the temperatures between the lengthened limb at the lengthening site and the contralateral limb at the same level, as well as the difference in the temperature of the lengthened limb at the lengthening site and at selected nearby points. RESULTS: A statistical analysis of the results of the monitoring of distraction osteogenesis established a statistically significant correlation between the regenerate status and thermal indices. The strongest correlation between X-ray and thermographic images was obtained in the frontal view for the crural bones. Mean values of Spearman's correlation coefficient for the tibia and femur were rS = 0.925 (p < 0.01) and 0.724 (p < 0.05), respectively. CONCLUSIONS: As a non-invasive method of measuring temperature thermography is a valuable adjunct to the traditional diagnostic methods and can be used successfully to monitor and evaluate the formation and remodelling of the regenerate at all stages of the treatment. It is particularly useful for the assessment of the bone regenerate in the tibia. The robust correlation between the regenerate and thermal indices measured with Spearman's correlation index enables a reduction in the number of radiographic studies of up to 50% in most cases. Moreover, thermography enables early detection of soft tissue inflammation around Kirschner wires.

Evaluation of follow-up results of McBride operative treatment for hallux valgus deformity.

BACKGROUND: Hallux valgus still remains a problem in orthopaedic surgery, a fact attested to by over a hundred operating procedures for the correction of this deformity that have been elaborated until now. The aim of the study was to evaluate the results of the McBride procedure for surgical correction of the hallux valgus deformity using an anatomic & functional foot scoring system and roentgenometric assessment. MATERIAL AND METHODS: 121 feet in 65 women who underwent the McBride procedure for a hallux valgus deformity at the Orthopaedic Department of the Wroclaw University of Medicine in the years 1995-2001 were analysed. The follow-up period varied from 4 to 11 years, for an average of 6.5+4.2 years. Foot function was assessed with a scoring system developed by the author. The roentgenometric examination comprised the following parameters: hallux valgus angle, intermetatarsal angle 1-2, metatarsal I varus angle, and medial sesamoid displacement. RESULTS: After the operation the number of painless feet as well as walking ability increased. The number of bunions and the number of painful callosities beneath metatarsal heads also decreased in a statistically significant manner. The average hallux valgus angle on physical examination decreased by 17.2 o. The mean overall functional score increased from 31.2 to 74.1 points, i.e. it rose by two categories, from 'poor' to 'good'. The overall satisfaction rate (excellent and good results) was 76.9%. There were 4 cases (3.3%) of hypercorrection and 14% of the 121 patients experienced a recurrence of the valgus deformity. CONCLUSIONS: The McBride procedure is still useful in the treatment of hallux valgus for selected groups of patients, on condition that the qualification criteria are very strictly adhered to.

Treatment of non-union of the forearm using distraction-compression osteogenesis.

BACKGROUND: The goal of the study is presentation broad abilities like gives Ilizarov method in the treatment of posttraumatic nonunion the of forearm with concomitant shortening and axis deformity, in minimally invasive technique, with contemporary axis correction and lengthening . MATERIAL AND METHODS: . Authors present 6 patient operated on with the use of Ilizarov method, in years 2001-2005 , suffer from vital nonunion of the forearm - 6 cases radius; 1 case ulna and radius. In all cases with nonunion concomitant shortening of the radius from 2 to 3 cm and valgosity of radius with deformity in sagittal plane in 4 patients (2antecurvation, 2 retrocurvation). All patients had restricted rotation ROM of forearm and restriction of wrist motion . Author's modification of Ilizarov apparatus (with mini-Schanz's half-pins, which permitted rotation of forearm) was used in most of patients. In 3 cases monofocal slow correction with lengthening within nonunion was performed. In 2 cases bifocal, one-step slow correction of deformity and compression within nonunion with lengthening was performed. In 1 remaining case compression of ulna nonunion and compression with deformity correction of radius nonunion were performed. Distraction and correction start in 7 postoperative day in rate from 0,25 to 1 mm/day and correspondingly from1 to 2o/day. RESULTS: Time of correction and distraction was average 63,3 days (40 - 90 days) . Total time of stabilization was average 25,4 weeks (20 - 35 weeks). Bone union was obtained in all patients. In all cases considerable recovery of limb function was achieved. All patients had superficial pin-tract infection . One patient had staphylococcal pin-tract infection of soft tissues, which retreat after 3-weeks guided antibiotic therapy. CONCLUSION: The Ilizarov method permit for contemporary axis correction and/or distraction or compression. There is the method of choice in the treatment of nonunion of forearm with concomitant shortening and axis deformity.

The results of treatment of bone defects and non-union within the femoral shaft with shortening of femur using Ilizarov method.

BACKGROUND: The non-union within the femur with shortening of the limb as a consequence of trauma is an indication to choose external stabilisation as a method of treatment for that reason, that healing of the bone and surrounded soft tissues is disordered. MATERIALS AND METHODS: Authors discuss the results of treatment of 16 patients with post-traumatic bone defect and pseudarthroses with femur shortening. The injury was located in femur shaft in 8 cases, distal epiphysis in 5 cases and proximal epiphysis in 3 cases. 11 patients were treated in one stage, 4 patients were treated in two stages and 1 was held in three stages. First operation was made for achievement of union in place of bone loss or pseudarthrosis- the second and third- for elongation and correction of the axis of the femur. The follow-up consisted of 10 patients. In most cases subjective and objective improvement was achieved. RESULTS: The bone union was reached in 15 patients and in 1 case pseudarthrosis was observed. Patients who were considered to have next procedures due to remaining femur shortening or other limb deformity didn't see necessity of following treatment. CONCLUSION: The results of the current study indicated that Ilizarov's method can be successfully used in most patients with post-traumatic bone defect and pseudarthrosis with femur shortening. The method allows to reach the bone union, correct the deformity and lengthen the limb as well, what need mostly multi-stage treatment.

[Biomechanical properties of external Ilizarov fixator with hybrid implants system]. / Wlasciwosci biomechaniczne stabilizatora Ilizarowa z hybrydowym ukladem wszczepów.

Possible ways of improving the stability of the fragments of the femur under elongation by introducing hybrid implant systems (the Kirschner wires and the Schanz screws) into the Ilizarov fixator structure were explored. Experimental studies were conducted on physical models with the fixator mounted on a pipe section modelling the femur shaft. Ten modifications of the Ilizarov fixator were developed and tested. The designs differed in the kind and configuration of implants. The effect of the developed Ilizarov fixator designs was examined by comparing the coefficients of axial, transversal and torsional rigidity of the structures. The research results clearly show that the Ilizarov fixator's rigidity (particularly transverse rigidity) coefficients can be considerably increased by replacing the Kirschner wires with the Schanz screws or using hybrid systems of these implants. As a result, the stability of the femur fragments improves and so does the quality of the regenerated bone, which makes it possible to reduce the treatment time to a minimum.

The impact of selected biological factors on bone regeneration in distraction osteogenesis.

Background. Comparatively few reports have analyzed the biological factors influencing the course of distraction osteogenesis, such as the etiology and magnitude of shortening or the patient's age at surgery. The aim of our study was to assess the impact of selected biological factors on the course of bone regeneration in distraction osteogenesis of the lower leg. Material and method. We examined 126 patients, on whom 138 lower leg lengthening operations were performed. Congenital shortening was the most numerous cause (54.9%), followed by postinfectious (16.6%), posttraumatic (14.3%), neurogenic (7.9%), and achondroplastic (6.3%). The course of distraction osteogenesis was analyzed on the basis of duration of treatment, expressed by the lengthening index. Results. The highest lengthening index values were found in neurogenic patients, somewhat lower in congenital. The lowest lengthening index values were observed in postinfectious and posttraumatic shortenings, and in the group of bi-level lengthenings in achondroplastic patients. The lengthening index decreased along with increasing elongation. Lower lengthening index values were found in patients younger than 20 years, regardless of the method and number of osteotomy levels. Conclusions. There is clinical evidence for the impact of etiology, age, and magnitude of shortening on the course of distraction osteogenesis. The shortest treatment duration was found in shortening of acquired etiology and achondroplasia, and in patients older than 20 years. The values of the lengthening index were the lowest in lengthenings over 6 cm, whereas the greatest values were observed in lengthenings less than 4 cm.

[Usefulness of distraction osteogenesis in the treatment of knee arthrosis]. / Zastosowanie metody dystrakcyjnej osteogenezy w leczeniu operacyjnym artrozy stawu kolanowego.

AIMS: The purpose of this study is the assessment of efficiency of distraction osteogenesis (DO) as a method of operative treatment of knee arthrosis with co-existent varus deformity. MATERIAL AND METHODS: Authors undertook an attempt of evaluation of results of tibial corticotomy in 21 patients (25 operated knee joints) treated in Orthopaedic Clinic of Wroclaw Medical University in years 1995-2001, with the use of circular, external Ilizarov's fixator. All the operated patients underwent corticotomy of proximal tibial metaphysis followed by slow axis correction and bone regenerate formation started at 7th postoperative day. In orthopaedic examination functional evaluation of knee joint with modified point scale according to Ranawat (HSS-score) there were taken into account. In rentgenometric examination the limbs axis in the frontal plane and joint space morphology according to Ahlback were evaluated. RESULTS: The results in our group of patients were very encouraging. Accordingly to Ranawat scale, in majority of patients assessed before the treatment as poor and fair moved to group assessed as fair and good and even excellent. We observed decelerated regenerate formation and remodeling probably caused by advanced age of patients in 6 cases. In 3 cases persistent lose of entire correction was observed. CONCLUSIONS: In author's opinion DO as a method of operative treatment of unicompartmental knee arthrosis could be advocated as alternative method to traditional tibial osteotomy considering its biological effect stimulating regeneration of all tissues including cartilage even in advanced unicompartmental arthrosis.

A point system for evaluating patients with limb shortening and deformity.

This article presents a scoring scale for patients with shortening and axis deformity of the upper and lower limb, as well as short stature, enabling the evaluation and comparison of treatment outcome after limb lengthening.

Long-term outcome lengthening and axis correction with the Ilizarov method in post-inflammatory shortening and deformity of the humerus.

Background. Post-inflammatory shortening and deformation of the humerus results from damage to the epiphyseal cartilage of this bone, and in particular to the proximal growth plate, most commonly caused by neonatal staphylococcemia. This is frequently accompanied by shortening of the femur, deformation of the hip and knee joints, the temporo-mandibular joint, and occasionally other joints as well. In the present article the authors present their own experiences with the application of osteogenesis in the post-inflammatory shortening and axis deformation of the humerus.
Material and methods. The clinical material consisted of 23 patients treated during the period 1995-2000 at the institutions represented by the authors in Wroclaw and Lodz. The average shortening was 8,5 cm (31,3%), and the average follow-up period was 2 years.
Results. The average lengthening achieved was 7,5 cm (40,5%), and the average lengthening index was 22,7 days/cm. complete axis correction was achieved in all patients with deformities of the humerus. More exact monitoring of the distraction process is necessary in the arm than in the lower limbs. Only 2 problems and 2 obstacles (according to Paley's classification of complications) were encountered in the course of treatment.
Conclusions. The results obtained indicate that the Ilizarov method is a safe and effective technique for the treatment of shortening and axis deformity of the humerus.

Strategy and tactics in limb lengthening.

This article discusses the basic rules and operating principles in limb lengthening for patients treated for anisomelia and in persons with short statue. Among the most essential issues regarding overall strategy are the degree shortening in the limb to be lengthened, the amount of lengthening, the age at which lengthening should be undertaken, the staging of treatment, the upper age limit for treatment, the rules for correcting limb deformities, and the issue of whether or not to shorten the healthy limb or inhibit its growth. On the level of surgical tactics, the author discusses procedure in cases with considerable shortening, shortening of the entire limb shortening of one segment, and in persons with short statue or particular diseases.

Long-term results of forearm lengthening and deformity correction by the Ilizarov method.

Background. Shortening and deformity of the forearm is most frequently caused by congenital disorders or posttraumatic injury. Given its complex anatomy and biomechanics, the forearm is clearly the most difficult segment for lengthening and deformity correction.
Material and methods. We analyzed 16 patients with shortening and deformity of the forearm, treated surgically, using the Ilizarov method in our Department from 1989 to 2001. in 9 cases 1-stage surgery was sufficient, while the remaining 7 patients underwent 2-5 stages of treatment. At total of 31 surgical operations were performed. The extent of forearm shortening ranged from 1,5 to 14,5 cm (5-70%). We development a new fixator based on Schanz half-pins.
Results. The length of forearm lengthening per operative stage averaged 2,35 cm. the proportion of lengthening ranged from 6% to 48% with an average of 18,3%. The mean lengthening index was 48,15 days/cm. the per-patient rate of complications was 88% compared 45% per stage of treatment, mostly limited rotational mobility and abnormal consolidation of regenerated bone.
Conclusions. Despite the high complication rate, the Ilizarov method is the method of choice for patients with forearm shortenings and deformities. Treatment is particularly indicated in patients with shortening caused by disproportionate length of the ulnar and forearm bones. Treatment should be managed so as cause the least possible damage to arm function, even at the cost of limited lengthening. Our new stabilizer based on Schanz half-pins makes it possible to preserve forearm rotation.

Lengthenin and axis correction of the thigh in various deformities of the hip joint.

Background. This article discusses the possibilities for using the Ilizarov, method to correct hip deformities accompanied by shortening of the thigh. This method enables multi-level, multi-plane, one-time or protracted correction of hip deformities with simultaneous limb lengthening. The authors present examples of such corrections of various type and etiologies.
Material and methods. Treatment outcomes were analyzed for 32 patients treated by the Ilizarov method for hip deformity and limb shortening as a sequela of purulent coxitis in infancy.
Results. The best outcomes were observed in patients with unstable or dislocated hip joints.
Conclusion. The results noted here should be taken under consideration in planning early surgery in children with Type IV deformity according to Choi et al.