Limb lengthening and correction of deformity in the lower limbs of children with osteogenesis imperfecta

We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods. The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions. We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI.     

单边轨道式延长外固定支架牵张治疗肱骨短缩合并近端畸形

目的探讨应用单边轨道式延长外固定支架治疗肱骨短缩合并近端畸形的疗效。方法回顾性分析2015年3月至2018年4月上海交通大学附属第六人民医院骨科采用单边轨道式外固定支架治疗的10例肱骨短缩合并近端畸形患者资料。男8例,女2例;年龄15~27岁,平均19.6岁。肱骨短缩伴近端内翻8例,伴肱骨近端内翻并后凸畸形2例;肱骨短缩6~11 cm,平均8.5 cm。上臂外侧置入半钉,安装单边外固定支架,于近端截骨后即时矫正肱骨近端畸形,中段截骨后予以缓慢延长。根据Cattaneo等制定的标准评价肢体功能。结果所有患者术后均获随访,时间15~41个月(平均20个月)。延长长度5~12 cm(平均7.5 cm);肩关节外展幅度平均为160°(130°~180°),比术前(平均90°)改善。9例患者延长区成骨良好,1例因延长区成骨不良,进行了自体髂骨移植后愈合。未出现钉道深部感染、桡神经损伤等并发症。肢体功能根据Cattaneo等的标准:8例9侧肢体为优,2例为良。结论单边轨道式延长外固定支架是治疗肱骨短缩合并近端畸形的可靠选择,掌握外固定支架安装技术,防治并发症可以获得满意的疗效。     

Correction of tibial deformity in adults

 This report from five hospitals in Japan describes the results of correcting adult tibial deformities using external fixation. There were 49 patients with 59 lower limb deformities, with trauma being the most common cause of the deformity. Varus angulation was the most common deformity, and the most common magnitude was 11°–30°. Twenty-two patients had a leg-length discrepancy. The aim of the correction was to normalize both the mechanical axis and the inclination of the knee and ankle joints. In 63% of the patients corrections were performed gradually during bone lengthening or acutely after bone lengthening. Altogether, 71% of the patients were completely corrected, and no leg-length discrepancies remained after correction in 47%. Complications were encountered in 22 patients, about half of which were pin tract infections, 28% refractures, and the remainder delayed consolidation or fixator failure. There were no neurological or circulatory complications. The average fixation duration was 9 months. The average hospital charges were 3 740 000 yen in bilateral correction patients and 1 940 000 yen in unilateral correction patients. External fixation can correct not only the mechanical axis and joint inclination but also leg-length discrepancy simultaneously. Received: June 10, 2002 / Accepted: January 14, 2003 RID="*" ID="*" Offprint requests to: W. Sato     

Humeral lengthening and deformity correction

Nine patients with achondroplasia and one patient with Apert syndrome underwent the surgical lengthening of both humerus and simultaneous correction of both associated bone deformity. An unilateral external fixator was applied to the lateral aspect of the humerus with four half-pins and percutaneous predrilling osteotomy was performed at the apex of flexion deformity of the bone. During the waiting period before distraction, the flexion deformity of the distal humerus was corrected using an additional external fixator. Slow gradual distraction was subsequently carried out at a rate of 0. 25 mm every 6 hours. The average lengthening was 8 cm (range 7.5 to 9 cm), the overall treatment time 312 days (range 192 to 406 days), and the average healing index 39.0 days/cm. The average correction of the elbow flexion deformity was 20 degrees. We believe this treatment is useful to improve the function of the arms and the activity of daily living for the patients with bilateral short humeri.     

Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis

Background In neuromuscular diseases, limb lengthening and foot deformity correction are associated with a high risk of complications associated with distraction callus and joint contracture. We have found no published articles of tibial lengthening and concomitant foot deformity correction using the Ilizarov method or traditional methods. To compare result of gradual distraction with triple arthrodesis for foot deformity combined with tibial lengthening, we investigated healing index and complications of two methods.

Patients and methods We reviewed 14 patients with permanent deformity after poliomyelitis who underwent tibial lengthening and concomitant foot deformity correction using the Ilizarov external fixator. Tibial lengthening over an intramedullary nail was performed in 3 patients and lengthening without a nail was performed in 11 patients.

Results The mean external fixation time was 6 (3.6- 10) months without nail and 1.6 (1.5-1.7) months with nail, whereas the mean healing index was 1.8 (0.8-3.1) months/cm without nail and 2 (1.8-2.3) months/cm with nail. Concomitant foot treatments included triple arthrodesis in 7 patients, pantalar arthrodesis in 2 patients with fiail ankle, and gradual foot frame distraction without bony foot procedures in 5 patients. Delayed consolidation and recurrent equinus contracture of the ankle requiring additional lengthening of the Achilles tendon were the most common bone and joint complications during tibial lengthening.

Interpretation The gradual foot frame distraction method was associated with major complications, such as recurrent foot deformity, joint luxation, and arthritis. We therefore recommend triple arthrodesis as a concomitant procedure during tibial lengthening     

可调组合式下肢外固定支架的改良及临床应用

目的 介绍自制可调组合式下肢畸形外固定支架系列构型,探讨该装置的临床应用原则.方法 在Ilizamv环形外固定支架的基础上,根据国人下肢畸形矫正与重建的需要及便于医生穿针安装操作的要求,将组合式外固定支架的配件与 Ilizarov环形外固定支架结合,加入弹簧牵伸装置与螺纹半针固定技术,研制了管状骨微创截骨矫形的工具,并根据下肢残缺畸形的特点,术前预先设计组装好个体化矫形器械.自2004年1月至2010年12月,应用改良Ilizarov外固定矫形器治疗下肢畸形患者146例,男95例,女51倒;年龄3.6～61.0岁,平均33.4岁;髋部畸形18例,膝关节屈曲畸形49例,膝关节周围股骨外翻畸形10例,胫骨内翻畸形46例,胫骨骨缺损、骨不连伴复合畸形23例结果 患者术后获8 ～46个月(平均28.6个月)随访.139例下肢畸形获得矫正、下肢力线基本恢复,行走功能明显提高.1例患者术后截骨端出现位移,重新调整外固定支架后纠正;2例膝关节周围内外翻畸形尚残留10°～ 15°内翻;3例在骨延长过程中出现膝关节屈曲功能障碍.4例患者出现术后针道感染.髋部畸形按Harris评分标准:由术前(36.91±3.14)分提高为(86.25±2.26)分;49例膝关节屈膝畸形完全矫正;胫骨骨不连处及新生骨均愈合,功能基本恢复.结论 改良的下肢畸形外固定矫形支架具有Ilizarov环形外固定器的主要功能,可满足下肢多数畸形矫正、残缺修复与功能重建的需要,临床应用能达到预期治疗目标,适合在临床中进一步推广.     

Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis

BACKGROUND: In neuromuscular diseases, limb lengthening and foot deformity correction are associated with a high risk of complications associated with distraction callus and joint contracture. We have found no published articles of tibial lengthening and concomitant foot deformity correction using the Ilizarov method or traditional methods. To compare result of gradual distraction with triple arthrodesis for foot deformity combined with tibial lengthening, we investigated healing index and complications of two methods. PATIENTS AND METHODS: We reviewed 14 patients with permanent deformity after poliomyelitis who underwent tibial lengthening and concomitant foot deformity correction using the Ilizarov external fixator. Tibial lengthening over an intramedullary nail was performed in 3 patients and lengthening without a nail was performed in 11 patients. RESULTS: The mean external fixation time was 6 (3.6-10) months without nail and 1.6 (1.5-1.7) months with nail, whereas the mean healing index was 1.8 (0.8-3.1) months/cm without nail and 2 (1.8-2.3) months/cm with nail. Concomitant foot treatments included triple arthrodesis in 7 patients, pantalar arthrodesis in 2 patients with flail ankle, and gradual foot frame distraction without bony foot procedures in 5 patients. Delayed consolidation and recurrent equinus contracture of the ankle requiring additional lengthening of the Achilles tendon were the most common bone and joint complications during tibial lengthening. INTERPRETATION: The gradual foot frame distraction method was associated with major complications, such as recurrent foot deformity, joint luxation, and arthritis. We therefore recommend triple arthrodesis as a concomitant procedure during tibial lengthening     

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.     

Neutral ring fixation for high-risk nonplantigrade Charcot midfoot deformity

BACKGROUND: Charcot foot arthropathy negatively impacts the health-related quality of life (HRQL) of affected individuals. The disease process often is responsible for the development of significant deformity and disability, often progressing to lower extremity amputation. Many patients are morbidly obese, immunocompromised, and have complex wounds with underlying bony infection or poor bone quality, making operative correction and internal fixation problematic. METHODS: Using a prospective clinical algorithm, 26 consecutive diabetic adults with multiple diabetic co-morbidities, including morbid obesity, had operative correction of nonplantigrade Charcot midfoot deformity at the midfoot level. Correction was maintained with a neutrally applied three-level ring external fixator. Average body mass index was 38.31 +/- 12.51. Nineteen patients used insulin. Fourteen had open wounds with underlying osteomyelitis. The altered relationship between the forefoot and hindfoot was measured as 14.04 +/- 31.09 degrees in the anteroposterior axis, and 16.70 +/- 17.47 degrees in the lateral axis before surgery. Surgery included Achilles tendon lengthening, excision of infected bone, correction of the multiplanar deformity, and culture-specific parenteral antibiotic therapy. RESULTS: At a minimum 1-year followup, 24 of 26 patients were ulcer and infection free and able to ambulate with commercially-available depth-inlay shoes and custom accommodative foot orthoses. One patient died of unrelated causes, and one had transtibial amputation for persistent infection. Four developed recurrent plantar ulcers, which resolved with excision of underlying bony prominences. There were two stress fractures through olive wire pin sites, one requiring intramedullary nailing. The radiographic anteroposterior axis was corrected to 3.12 +/- 9.42 degrees, and lateral to 10.42 +/- 11.86 degrees after surgery. CONCLUSIONS: Morbidly obese diabetic individuals with multiple co-morbidities complicating severe Charcot foot deformity can achieve correction of midfoot deformity after operative correction of the deformity and maintenance of that correction with a neutrally applied ring external fixator.     

应用Ilizarov支架一期矫正儿童创伤后下肢成角伴短缩畸形

目的 探讨应用Ilizarov支架以一期手术、渐进矫形的方法治疗儿童创伤后下肢成角伴短缩畸形的可行性以及根据畸形的病理变化正确组装支架的方法.方法 对2005年3月至2007年9月间收治的6例创伤后下肢成角伴短缩畸形患儿采用上述方法治疗.术前常规拍摄双下肢全长站立位X线片,测量患肢短缩和成角畸形的程度并确定成角旋转中心的位置.术中安装支架时,铰链安置在成角旋转中心水平.术后7 d开始通过调整支架螺杆渐进矫正成角和短缩畸形并且每2周拍摄X线片观察畸形矫正和新骨生长情况.全长X线片证实恢复了下肢机械轴线和长度后停止调整支架,每月拍摄X线片复查,待新生骨痂矿化满意后去除外固定支架.随访中记录肢体长度、畸形有无复发以及关节活动范围,并根据X线片观察下肢力线、关节水平线与机械轴线角度以及新牛骨塑形情况.结果 6例患儿中除1例于骨折畸形愈合部位截骨矫形,邻近骨段延长外,余5例均利用微创截骨部位完成矫形与延长.术后平均矫正成角畸形34.8°(20°～58°),平均延长5.3 cm(3.5～6.5 cm).所有患儿下肢机械力线恢 复,相关关节角度恢复至正常范围,双下肢等长.末次随访时X线片显示延长骨痂愈合良好.结论 应 用Ilizarov支架一期矫正儿童下肢成角伴短缩畸形安全、可靠,可精确恢复下肢长度与机械轴线.术前 须科学分析畸形的病理变化,正确设计支架铰链的水平与位置.     

Humeral lengthening and deformity correction with the multiaxial correction system

Limb lengthening for humeral length discrepancy is typically accomplished using a traditional monolateral external fixator frame or an Ilizarov-type device, which have distinct shortcomings for the correction of concomitant deformity and application to the upper extremity, respectively. A new monolateral frame, the multiaxial correction (MAC) system, provides advantage over other monolateral frames and Ilizarov-type devices for humeral lengthening and may achieve similar outcomes. The purpose of this study was to report on the use of the MAC system for limb lengthening in pediatric patients, each with humeral length discrepancy and deformity. Surgical technique for applying the frame to the humerus is described briefly. A retrospective review of all pediatric patients with humeral length discrepancy treated with the MAC system by one orthopedic surgeon at a major teaching hospital was performed. Clinical data, operative records, and radiographs were reviewed for each patient. A total of three humeri in three children were lengthened over a 3-year period. There were two girls and a boy, with a mean age of 10.3 ± 1.9 years. Etiologies for their discrepancies were osteomyelitis and posttraumatic physeal arrest. Mean initial humeral length discrepancy was 9.4 ± 2.3 cm. All patients had proximal varus deformities, which were partially corrected during treatment. Mean lengthening was 6.5 ± 0.8 cm, and mean healing index was 27.1 ± 4.1 days/cm. Mean follow-up was 23.0 ± 9.9 months. There were no major complications. In conclusion, the MAC system is well suited to the correction of humeral length discrepancies and associated humeral deformities in children. Level of evidence: level IV case series.     

Treatment of post-traumatic limb shortening]

The physiological phenomenon of changes in callus formation during distraction was first described by Codivilla at the beginning of this century. Having investigated and proved the influence of tension stress on callus formation, Ilizarov used this as a method to treat limb shortening and deformities. Because of his remarkable results we introduced this method in our hospital in 1990, using the original Ilizarov ring fixator. From November 1990 to December 1991, we used this technique in 10 cases of combined post-traumatic bone shortening with deformity (the tibia was affected in six patients, the femur in three and the forearm in one). The mean shortening was 3.1 cm, the mean varus or valgus deformity 9.5 degrees, the mean anteflexion or recurvation 8.3 degrees, and the mean rotation deformity 8.5 degrees. Distraction/correction lasted between 8 and 55 days (mean: 37 days). Fixation was necessary for between 60 and 339 days. If corticotomy was performed in the diaphyseal bone, fixation lasted almost twice as long (11.33 days/mm lengthening) as in the metaphyseal area (6.55 days/mm lengthening). There were 14 complications, most of which were considered minor. The latter included pin infections (4), wire breaking (1) and restricted range of motion of the knee or ankle (5). Among the major complications were two nerve irritations, which recovered spontaneously, and two pin-induced local bone infections, which required surgical intervention. Achievement of the goals of treatment-complete correction of shortening and deformity-was not affected by these complications.     

Correction of distal femoral deformity

This retrospective study reviews 12 distal femoral osteotomies in nine patients performed for angular and rotational deformities, using the Orthofix external fixator. All osteotomies progressed to solid union with reliable correction of the deformity. Few complications were encountered. Simultaneous lengthening was performed on one patient successfully. This method proved to be a safe and precise means of correcting distal femoral deformity with the option of simultaneous correction of length discrepancy.     

Correction of complex lower limb deformities by the Ilizarov technique: An audit of complications

This is an audit of complications resulting from correction of complex lower limb deformities by the Ilizarov technique. 33 patients (40 bone segments) were reviewed and divided into 4 groups according to the type of surgery carried out: limb lengthening and/or correction of deformity, bone or joint stabilisation, treatment of nonunion or bone defect, angular and/ or rotation correction. Most minor complications were fixator specific. Pin tract infections were almost universal but responded well to oral antibiotics and rarely resulted in osteomyelitis. Major complications were procedure specific and more common in those patients who underwent leg lengthening, treatment for nonunion and bone transport. There was also a high incidence of nerve injury as a result of acute angular deformity correction. Despite the high complication rate the Ilizarov technique remains an effective tool for complex lower limb reconstruction surgery.     

Taylor spatial frame-software-controlled fixator for deformity correction-the early Indian experience

Background:

Complex deformity correction and fracture treatment with the Ilizarov method needs extensive preoperative analysis and laborious postoperative fixator alterations, which are error-prone. We report our initial experience in treating the first 22 patients having fractures and complex deformities and shortening with software-controlled Taylor spatial frame (TSF) external fixator, for its ease of use and accuracy in achieving fracture reduction and complex deformity correction.

Settings and Design:

The struts of the TSF fixator have multiplane hinges at both ends and the six struts allow correction in all six axes. Hence the same struts act to correct either angulation or translation or rotation. With a single construct assembled during surgery all the desired axis corrections can be performed without a change of the montage as is needed with the Ilizarov fixator.

Materials and Methods:

Twenty-seven limb segments were operated with the TSF fixator. There were 23 tibiae, two femora, one knee joint and one ankle joint. Seven patients had comminuted fractures. Ten patients who had 13 deformed segments achieved full correction. Eight patients had lengthening in 10 tibiae. (Five of these also had simultaneous correction of deformities). One patient each had correction of knee and ankle deformities. Accurate reduction of fractures and correction of deformities and length could be achieved in all of our patients with minimum postoperative fixator alterations as compared to the Ilizarov system. The X-ray visualization of the osteotomy or lengthening site due to the six crossing struts and added bulk of the fixator rings which made positioning in bed and walking slightly more difficult as compared to the Ilizarov fixator.

Conclusions:

The TSF external fixator allows accurate fracture reduction and deformity correction without tedious analysis and postoperative frame alterations. The high cost of the fixator is a deterrent. The need for an internet connection and special X-rays to operate the fixator add to its complexity.     

Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases

OBJECTIVE: To evaluate the results of bifocal compression-distraction method for the acute treatment of open tibia fractures with bone and soft-tissue loss. DESIGN: Patients were selected for bifocal compression-distraction (shortening and lengthening) who had open tibia fractures with bone and soft-tissue loss and a Mangled Extremity Severe Score of 6 and below indicating good leg viability. PATIENTS: Bifocal compression-distraction osteogenesis using the Ilizarov type circular external fixator was applied to 24 patients with 14 grade IIIA and 10 grade IIIB open tibia fractures with bone and soft-tissue loss. Mean age of the patients was 30.6 years (range 18-53). The mean bone defect was 5 cm (range 3-8.5). The mean soft tissue defect was 2.5 x 3.5 (1 x 2-10 x 5) cm. INTERVENTIONS: Acute shortening at the fracture site was done for patients with bone defects up to 3 cm to achieve apposition of bone ends. Gradual shortening at a rate of 2 mm/d was done for patients who had bone defects more than 3 cm. Leg length discrepancy was overcome by lengthening at the same time through a corticotomy at a proximal or distal level depending on fracture localization, until there was equalization of leg lengths. RESULTS: Mean follow-up period was 30 months (range 18-60). Mean bone healing time was 7.5 months (range 4-11). The mean time in external fixation was 7.1 months (range 3-10), and the average external fixator index was 1.4 months/cm. Results were evaluated using the Paley bone and functional assessment scores. The bone assessment results were excellent in 21 and good in 3 patients. Functional assessment scores were excellent in 19, good in 4, and fair in 1 patient. Pin site infections were present in 10.7% of the pin sites. There were 52 complications in 24 patients, for a complication rate per patient of 2.08. Of the complications, 48.1% were problems (minor complications), 38.5% obstacles (major complications requiring a surgical solution), and 13.4% sequelae (true complications). Minor complications included soft tissue inflammation and infection, translation/angulation, and delayed maturation during distraction and transient knee contracture and loss of motion. All grade 1 and 2 soft tissue inflammations and infections healed with nonoperative therapy. Major complications included pin tract infection and reinfection, equinus deformity, frame failure, and premature consolidation, all of which required additional surgery to correct the problem. Sequelae included leg length discrepancy, loss of knee/ankle range of motion, knee flexion contracture, malalignment, and chronic osteomyelitis. CONCLUSION: Bifocal compression-distraction osteogenesis is a safe, reliable, and largely successful method for the acute treatment of open tibia fractures with bone and soft-tissue loss. Further nonoperative or operative treatment can correct most complications.     

Correcting and lengthening of metatarsal deformity with circular fixator by distraction osteotomy: a case of longitudinal epiphyseal bracket

The condition known as longitudinal epiphyseal bracket or delta phalanx is a rare congenital anomaly that affects the tubular bones of hand or foot. Metatarsal epiphyseal bracket restrains longitudinal growth, causing progressive deformity and resulting in a short, broad metatarsal and a medially deviated metatarsophalangeal joint and hallux magnus. Although there are some case series describing metatarsal lengthening with the unilateral fixator in the literature, we could not find any case that combines both metatarsal lengthening and deformity correction with the circular external fixator. Gradual lengthening and deformity correction without bone grafting and soft-tissue modification were carried out in a case with bilateral longitudinal epiphyseal bracket of the first metatarsals of the foot. A literature review and treatment method for epiphyseal bracket in a 9-year-old boy is presented. Excellent clinical, and functional results were obtained with circular and semicircular fixators.     

Gradual reduction of distal radial malunion using distraction osteogenesis

PURPOSE: To evaluate gradual distraction lengthening or distraction osteogenesis as a technique for treating malunions of the distal radius. METHODS: Twenty patients with clinical and radiographic evidence of distal radius malunion were treated with osteotomy of the distal radius using distraction osteogenesis. At the follow-up evaluation each patient was evaluated for healing rates, complications, resolution of pain, and radiographic alignment. Surgical treatment consisted of an application of a nonbridging external fixator that could be distracted to correct the deformity. A loosely set screw that connected the distal pins to the fixator served as a hinge and allowed the distal radius to rotate into a corrected position. Gradual distraction via distraction osteogenesis was initiated 1 week after surgery. RESULTS: Seventeen osteotomies healed uneventfully in an average of 9 weeks. Complications included 9 pin track infections. Two nonunions required bone grafting. One patient inadvertently compressed rather than distracted the fixator, leading to premature healing of the osteotomy. One patient ruptured the extensor pollicis longus. All complications resolved with additional intervention. Overall the patients showed radiographic and symptomatic improvement. CONCLUSIONS: An external fixator and distraction lengthening through distraction osteogenesis is a viable alternative to plate fixation and bone grafting. In 18 of 20 of our patients, the technique eliminated the need for bone grafting and the need for a second surgical procedure to remove a dorsal plate.     

Acute correction of lower limb deformity and simultaneous lengthening with a monolateral fixator

We have reviewed, retrospectively, all children with a lower limb deformity who underwent an acute correction and lengthening with a monolateral fixator between 1987 and 1996. The patients were all under the age of 19 years and had a minimum follow-up of eight months after removal of the fixator. A total of 41 children had 57 corrections and lengthening. Their mean age was 11.3 years (3.2 to 18.7) and there were 23 girls and 18 boys. The mean maximum correction in any one plane was 23 degrees (7 to 45). In 41 bony segments (either femur or tibia) a uniplanar correction was made while various combinations were carried out in 16. The site of the osteotomy was predominantly diaphyseal, at a mean of 47% (17% to 73%) of the total bone length and the mean length gained was 6.4 cm (1.0 to 17.0). Univariate analysis identified a moderately strong relationship between the bone healing index (BHI), length gained, maximum correction and grade-II to grade-III complications. For logistic regression analysis the patients were binary coded into two groups; those with a good outcome (BHI < or = 45 days/cm) and those with a poor outcome (BHI > 45 days/cm). Various factors which may influence the outcome were then analysed by calculating odds ratios with 95% confidence intervals. This analysis suggested a dose response between increasing angular correction and poor BHI which only reached statistical significance for corrections of larger magnitude. Longer lengthenings were associated with a better BHI while age and the actual bone lengthened had little effect. Those patients with a maximum angulatory correction of less than 30 degrees in any one plane had an acceptable consolidation time with few major complications. The technique is suitable for femoral deformity and shortening, but should be used with care in the tibia since the risk of a compartment syndrome or neurapraxia is much greater.     

Distraction histogenesis for hypertrophic nonunion of the tibia with deformity and shortening

The results of distraction histogenesis using Ilizarov techniques for 18 consecutive patients were evaluated. There were 13 male and 5 female patients. Their ages ranged from 11 to 74 years (average 36.8 years). All patients presented with established hypertrophic nonunion of the tibia, associated deformity ≥15° and leg shortening. There were no cases of active infection at the time of our treatment. The procedure included fibular osteotomy, application of a pre-constructed Ilizarov frame. Controlled distraction was done until complete deformity correction and equalization of leg length. Weight bearing was allowed during treatment. All patients (100%) had their nonunions consolidated with deformity correction and restoration of the normal mechanical axis of the limb. The leg length discrepancy was corrected in all cases. The follow up ranged from 29 to 50 months (average 37.2 month) after fixator removal. Distraction histogenesis, using Ilizarov techniques, is a reliable method for consolidation of hypertrophic nonunion, deformity correction and equalization of leg length all in one procedure through minimal surgical interference.