Correction of crooked nail deformity by modified osteoplastic reconstruction

To correct crooked nail deformity, which results from the partial loss of the distal phalanx, soft-tissue restoration alone is usually not enough to restore the length and shape of the nail structure. The authors treated 10 crooked nail fingertips by modified osteoplastic reconstruction, which included the elevation of the dorsally based volar skin flap and an iliac bone graft covered by an adequate skin flap. During the postoperative follow-up, the nail straightened, although not to the preinjury extent, along the restored distal phalanx with bony support. The authors' osteoplastic reconstruction, which involves the enhancement of the fingertips with composite tissues, presents a practical method for the correction of crooked nail deformity.     

Correction of pincer nail deformity with phenol

From 2006 to 2009 we treated nine cases (11 toes) with pincer nail deformity of the first toe, using phenol. There were 8 women and 1 man, age range 9-81 years (mean 51). They were followed up for 7-17 months (mean 12) and all reported improvement of the pincer nail deformity and disappearance of pain from the first toes. Only one woman complained of a recurrent pincer nail deformity eight months after the first treatment, and the procedure was repeated. The mechanism of improvement is contraction of the phenolised wound away from the lateral nail fold, which gradually stretches and flattens the nail bed. We conclude that this technique is a simple and effective treatment for pincer nail deformity.     

Limb lengthening with a fully implantable mechanical distraction intramedullary nail

AIM: The morbidity of fixator-assisted distraction osteogenesis should be reduced by intramedullary lengthening devices. The ISKD (intramedullary skeletal kinetic distractor) is a new, fully implantable mechanical lengthening nail. In a prospective cohort trial the possibilities and limitations of the device used on femur and tibia are examined. METHODS: 22 patients with a mean age of 25 (range: 16-46) years were treated with an ISKD for femoral (n = 16) and tibial (n = 6) lengthening. The average leg length discrepancy was 48 (range: 25-80) mm. The follow-up was 21 (range: 7-37) months. Clinical and radiological results and complications were evaluated. RESULTS: The results of femoral and tibial applications of the ISKD are different. At the tibia, in three patients a pseudarthrosis occurred and slow callus formation was observed twice. An equinus contracture became evident in 2 patients. At the femur, in one case the lengthening was not accomplished with the device. Five patients were manipulated under anaesthesia at least once to achieve the aim of distraction. Three of these patients received retrograde implantation of the ISKD. An infection or interlocking screw failure was not observed either at the femur or the tibia. CONCLUSION: The ISKD reduces fixator-associated problems but incorporates its own difficulties which are mainly based on the guidance of the device. Careful patient advice in monitoring the lengthening process is mandatory. At the femur 8 cm of lengthening can be achieved but the nail tends to "block". Proper reaming and osteotomy techniques are important. A lengthening of more than 1 mm/day is recommended to prevent early consolidation. At the tibia weak callus formation and soft tissue contractures occur, therefore not more than 4 cm lengthening should be planned, the distraction speed has to be reduced noticeable below 1 mm/day and the initial immobilisation should be for more than a week.     

Limb lengthening by epiphyseal distraction

Summary Limb lengthening has been obtained using the technique of epiphyseal separation-distraction, initially in animal experiments and subsequently in operations on twenty-six human patients. The increase of length obtained ranged from 5–11 cm in the tibia and femur.There was no need for osteotomy, internal osteosynthesis, or bone grafting. The quality of the new bone formation was good and there have been no secondary fractures at the site of lengthening.

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Résumé Les auteurs ont réalisé l'allongement des membres inférieurs par une technique de «séparation-distraction épiphysaire», d'abord chez l'animal, puis chez l'homme. Vingt-six interventions ont été pratiquées. Le gain de longueur obtenu est compris entre 5 et 11 cm, tant au tibia qu'au fémur.Ce procédé ne nécessite ni ostéotomie, ni ostéosynthèse, ni greffe osseuse. L'os néoformé est de bonne qualité et il n'y a eu aucune fracture secondaire au niveau de l'allongement.

     

Digital lengthening by gradual distraction

The authors report their experience of digital lengthening and analyze the indications and results of 12 cases performed over 13 years in the plastic and reconstructive surgery service of the Kassab institute. Distraction was performed using a mini-orthofix device. In majority of cases, the procedure was performed on young people, manual workers and victims of industrial accidents. The lengthened osseous segment was the 1st metacarpal in 7 cases, the proximal phalanx of the index in 3 cases, the 3rd metacarpal once and the proximal phalanx of the middle finger in one case. Gradual distraction at the rate of 0.25 to 0.5 mm/day was carried out in 10 cases using the procedure of "callotasis". In 2 cases the distraction was performed at a rate of 1 mm/day followed by bone graft. Callotasis allowed us to obtain an average lengthening of 17 mm (61.5%) in distraction of the phalanx, and 26 mm (63.3%) in distraction of the first metacarpal. This technique avoids the spontaneous shortening observed after the use of bone graft alone. Complications are relatively frequent but had little influence on the final result.     

Limb lengthening by physeal distraction

I evaluated 10 consecutive lengthenings through the upper tibial physis in 9 patients. A bilateral frame consisting of two small-sized Wagner devices and two pairs of 4-mm transfixing pins with 5-mm-diameter central threads were used. The median lengthening was 6.7 cm. Complications were frequent. The risk of a growth disturbance is very high, and physeal distraction should therefore only be applied towards the end of the growth period.     

Limb lengthening by physeal distraction

I evaluated 10 consecutive lengthenings through the upper tibial physis in 9 patients. A bilateral frame consisting of two small-sized Wagner devices and two pairs of 4-mm transfixing pins with 5-mm-diameter central threads were used. The median lengthening was 6.7 cm. Complications were frequent. The risk of a growth disturbance is very high, and physeal distraction should therefore only be applied towards the end of the growth period.     

Bone lengthening by physial distraction

Summary Experimental physial distraction was carried out in the distal part of the femur in 45 two-month old lambs in order to study the basic mechanisms of lengthening as ell as the viability of the growth cartilage after using this method. The animals were divided into three groups (A, B and C), and each group into three subgroups (1, 2 and 3) according to the rate of distraction used (2 mm/day, 1 mm/day, 0.5 mm/day) and the time of sacrifice.The results obtained show that the basic lengthening mechanisms consists, firstly, in the production of a fracture between the metaphysis and the epiphysis and, secondly, that the lower the distraction speed employed, the greater is the short-term and long-term viability of the growth cartilage. Optimum viability was observed at a distraction rate of 0.5 mm/day.On this basis we conclude that in clinical practice physial distraction could be indicated for children at an early stage of skeletal growth and repeated later provided that the rate of distraction is kept within reasonable limits.

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Résumé Une étude expérimentale portant sur la distraction épiphysaire au niveau de l'extrémité distale du fémur a été réalisée chez 45 moutons âgés de 2 mois, dans le but d'étudier les mécanismes d'allongement ainsi que la vitalité du cartilage de croissance. Les animaux ont été divisés en trois groupes (A, B, C) et 9 sous-groupes (1, 2, 3) selon la vitesse de l'allongement (2 mm/jour, 1 mm, 0,5 mm) et la date à laquelle ils ont été sacrifiés.Les résultats obtenus montrent que le mécanisme de base consiste dans la création d'une fracture épiphysodiaphysaire et, d'autre part, que plus la vitesse d'élongation est lente, plus le cartilage de croissance est viable à court et à long terme. Les meilleurs résultats furent obtenus à la vitesse de 0,5 mm/jour. On peut donc conclure qu'en pratique la distraction épiphysaire peut être indiquée chez les enfants dont l'âge osseux est bas, et qu'elle peut être répétée ultérieurement, à condition de maintenir la vitesse d'allongement dans des limites raisonnables.

     

Tibial lengthening by epiphyseal distraction

Tibial lengthening by slow distraction of the distal epiphysis using the dynamic axial fixator was performed in 3 patients near to skeletal maturity, in 2 patients with congenital origin and in one with achondroplasia. The obtained lengths were 4.4 cm (17% of the tibial length), 3.7 cm (12%) and 3.6 cm (19%). There were no serious complications. Bone formation at the site of distraction was thought to be periosteal in origin when assessed using X-rays and computerized tomography. There was no radiological evidence that bone at the distracted sites was formed by an apposition from the metaphyseal side which is expected in cases of stimulation of endochondral ossification in the growth plate. There was no further measurable growth at the distracted growth plates after lengthening. This method is useful for limb lengthening near the time of epiphyseal closure.     

不同骨延长器治疗肢体畸形并大段骨缺损

[目的]利用Ilizarov支架、Orthofix肢体重建系统（Orthofix LRS）及Hybrid固定系统（Hybrid Fixation System）与Orthofix LRS的组合，对不同的肢体畸形并大段骨缺损进行矫形及骨延长治疗，同时观察其疗效。[方法]自2000年8月-2004年3月分别用Ilizarov支架、Orthofix LRS及Hybrid支架与Orthofix LRS的组合进行骨痂牵开／骨段滑移治疗合并肢体畸形的大段骨缺损。畸形处采用线形／楔形截骨。畸形愈合并骨短缩者楔形截骨后进行骨痂牵开骨延长术，骨不连并畸形及短缩者接合点加压与截骨矫形骨段滑移延长同时进行。[结果]矫正股骨短缩畸形7cm1例，胫骨6例，内翻畸形2例，后成角畸形2例，混合畸形2例。平均延长5．3cm（4．5—7cm），平均延长时间3．5个月，平均延长后外固定时间7个月，无神经血管损伤，膝踝关节活动未受影响。[结论]Ilizarov支架、Orthofix LRS、Hybrid固定系统与Orthofix LRS的组合用于骨痂牵开／骨段滑移治疗合并肢体畸形的大段骨缺损均能达到矫形及骨延长的治疗目的。Orthofix LRS及Hybrid固定系统与Orthofix LRS的组合较Ilizarov支架操作简便，安全可靠，患者乐于接受。     

Metacarpal distraction lengthening

Metacarpal osteotomy and distraction lengthening is an excellent method of treating patients with multiple digit aplasia, metacarpal hypoplasia, and some types of digit amputation. The authors describe their technique and the results obtained in 24 patients operated on for 41 metacarpals.     

Correction of deformity and shortening due to post traumatic epiphyseal arrest by distraction osteogenesis

Growth arrest in the epiphyseal plate during childhood often causes both periarticular deformities and limb length discrepancy, leading to compartmental osteoarthrosis and gait disturbance or spinal disorders, respectively. Distraction osteogenesis using external fixators with hinge systems appears to be useful for the simultaneous correction of deformity and shortening. In this paper, we evaluated cases of lower limbs with periarticular deformities and limb length discrepancy after epiphyseal plate injury that has been treated by distraction osteogenesis using external fixators. This is the first report regarding the outcomes of distraction osteogenesis for a group of patients having deformity and limb length discrepancy due to traumatic arrest of the physis. Successful outcomes may promise the use of this method as the first choice for the treatment of growth disorders after the arrest of the epiphyseal plate in the lower limbs. However, treatment under 20 years of age may provide a better outcome with a lower incidence of complications.     

骨外固定牵引架联合跟腱延长矫治重度瘢痕性跟腱挛缩畸形

目的:探讨骨外固定牵引架联合跟腱延长术矫治重度瘢痕性跟腱挛缩畸形的临床治疗效果,为重度跟腱挛缩畸形提供新的治疗思路.方法:2004年3月～2008年10月,对9例重度瘢痕性跟腱挛缩患者进行矫治.手术分两期进行,第一期手术设计跟腱瘢痕瓣行跟腱延长术,同时上骨外固定牵引架,创面碘仿纱布覆盖,然后进行外固定支架牵引矫治跟腱挛缩畸形,待踝关节达到合适角度后,进行第二期手术,采用中厚皮片修复创面.结果:所有9例患者,跟腱挛缩畸形均得到良好的矫治,8例患者跟腱瘢痕瓣存活良好,1例患者出现不同程度的远端坏死,在第二期手术时一并修复,术后加强功能锻炼,术后随访3月～26月,直立行走活动自如.结论:采用骨外固定牵引架联合跟腱延长术矫正重度跟腱挛缩畸形的方法,避免了骨关节及血管神经损伤等并发症,较快地矫正踝关节至功能位,短时间恢复患者下地行走,可以作为重度跟腱挛缩畸形的理想治疗方法之一.     

Mandibular lengthening by gradual distraction in humans

The purpose of this study was to evaluate human mandibular lengthening by gradual distraction. The operation was performed under nasoendotracheal anesthesia. After exposing the angle of the mandible through an intraoral incision, two half-pins were inserted on each side of the corticotomy line. Following this, a corticotomy was performed using a sagittal saw, and the mandible was gently fractured. The external bone lengthening device was applied leaving a bone gap of 3 mm. Serial distraction of 1 mm per day was started on the 10th postoperative day. The device was left in place for retention purposes for 9–11 weeks. Three patients (average age 10 years and 3 months) underwent this procedure. The distraction achieved was 19 mm. Postoperatively, improvement of facial asymmetry and increased volume and length of the mandible were noted without any perioperative complications. The follow-up period averaged 13 months. These results suggested that this procedure is beneficial for the treatment of craniofacial microsomia.     

Metacarpal lengthening by distraction histiogenesis in adults

Background:

Metacarpal lengthening in the hand is a new application for distraction neo-histiogenesis. Metacarpal lengthening with distraction helps in improvement in pinch function. Thumb lengthening is technically easy in comparison to other metacarpals. We present the operative treatment and post-operative outcome in nine patients with amputations and congenital anomalies.

Materials and Methods:

Nine patients underwent distraction osteogenesis for the treatment of amputations of the hand and other congenital anomalies. The dominant right hand was operated in eight cases and the left hand in one case. There were six males and three females. Improvement of function was always the aim of surgery. Age range was between 18 and 23 years. Thumb lengthening was performed in five patients and that of the index finger in four patients. Distraction started on the fifth post-operative day at the rate of 0.25 mm/day. Sensory function and bone consolidation was assessed before fixator removal.

Results:

The mean duration of distraction was 51 days (range, 42–60 days) and the distractor was removed at a mean of 150 days (range, 140 and 160 days) and the bones were lengthened by a mean of 24 mm (range, 20–28 mm) There was improvement of function in all cases.

Conclusion:

The metacarpal lengthening by distraction histiogenesis in congenital and traumatic amputations is safe and simple method to improve pinch function of hand.     

Metatarsal lengthening by callus distraction for brachymetatarsia

Twelve metatarsal lengthening procedures by callus distraction were performed in seven patients with brachymetatarsia. The mean age at the time of the surgery was 12.0 years (range, 11.1-14.5 years). The mean duration of follow-up was 5.2 years (range, 1.2-13.5 years). The bones were lengthened at a rate of 0.7 mm/day by a mean of 20 mm (range, 15-30 mm), which was 45% of their original length (range, 37-61%). The mean healing index was 73 days/cm (range, 41-98 days/cm). Corrective shortening osteotomy was performed in one case in which the metatarsophalangeal joint was dislocated due to excessive lengthening. In 10 of the remaining 11 cases, joint stiffness, narrowing of the joint space and some degree of plantar subluxation of the metatarsophalangeal joint were observed during distraction, but these were gradually resolved without either elongation of the tendon or metatarsophalangeal joint fixation with Kirschner wire.     

Metacarpal and phalangeal lengthening by callus distraction

Twelve metacarpals and two phalanges in 14 patients (nine males and five females) were lengthened between August 1992 and March 1999 by the callus distraction technique using a small external fixator (Orthofix). The indications were traumatic amputation (10 cases), aplasia (three cases) and hypoplasia owing to premature epiphyseal closure of the metacarpal (one case). All patients were reviewed with a median follow-up time of 39 (range, 9-88) months. The median age of the patients was 15 (range, 4-39) years. The median lengthening was 21 (range, 13-34) mm which was a median of 82% (range, 38-162) of the original bone length. The median times for callus distraction and consolidation were 4.5 and 7.5 weeks respectively. All except one patient tolerated the procedure well and were satisfied with the results. Functional improvement was seen in 13 out of 14 patients, but non-union was observed in one patient.