Comparative clinical study on deformity correction accuracy of different external fixators

Purpose

In this study, the correction accuracy of Smart Correction spatial fixators and of Ilizarov-type external fixators are compared in terms of deformity complexity.

Methods

Seventy-seven (40 male, 37 female) bone segments of 57 patients treated with a Smart Correction device were compared with 94 (51 male, 43 female) segments of 68 patients treated with an Ilizarov fixator. Mean age of the Smart Correction group was 20.69?±?12.94 years, and or the Ilizarov group 22.45?±?12.18 years. Patients were categorised according to limb lengthening and the number of deformity planes.

Results

A longer correction period was found with Ilizarov (66.53?±?47.7 days) compared with Smart Correction (49.05?±?35.6 days) devices. The bone healing index of the Ilizarov group was significantly better compared with the spatial group. Residual deformity after treatment was significantly lower with the Smart Correction device; however, this relationship could not be shown between subgroups. Although there was no significant difference between subgroups, mean residual deformity was higher with the increasing number of planes of the deformity.

Conclusions

The Smart Correction fixator is an accurate device that allows ease of application and planning. It demonstrates higher accuracy for correcting deformities compared with an Ilizarov external fixator. With an increasing number of planes, the difference between the two devices becomes even more pronounced. The relationship between the complexity of the deformity and residual deformity may possibly be significantly greater in favour of the Smart Correction fixator in a study with a larger sample size.     

Forearm lengthening using Ilizarov external fixator

Background

We present our experience with forearm lengthening using Ilizarov external fixator in cases of length discrepancies between radius and ulna and forearm–wrist deformity that occurred duo to different causes.

Methods

Twelve patients were treated by Ilizarov external fixator between 2008 and 2010 with a mean age of 10 years. There were seven males and five females. The etiology was Madelung’s deformity in seven patients, multiple cartilaginous exostosis in three patients, post-traumatic growth arrest of distal radius epiphysis in one patient, and chronic osteomyelitis of radius in one patient. The length discrepancy ranged from 1 to 4 cm (mean 2.2 cm). Lengthening of radius was done in nine patients and lengthening of ulna in three patients. The mean of follow-up period was 2 years.

Results

At follow-up, all patients were satisfied with the functional and cosmetic results. There was an improvement in pain and range of motion .The mean length gained was 2.2 cm and the mean healing index was 43.7 days/cm.

Conclusions

Lengthening of short forearm is functionally, cosmetically, and psychologically beneficial. The Ilizarov method is a reliable, successful, and safe method, and it is the gold standard to treat forearm length discrepancy and deformity problems preserving a satisfactory function of upper limb during treatment.     

Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

Purpose

Proximal first metatarsal osteotomies are recommended for the surgical treatment of moderate to severe hallux valgus deformity. This study aimed to compare correction of intermetatarsal and hallux valgus angles and complications of proximal crescentic, Ludloff, proximal opening wedge, proximal closing wedge, proximal chevron and other proximal first metatarsal osteotomies.

Methods

A systematic search for the keywords “(bunion OR hallux) AND (proximal OR crescentic OR basilar OR opening OR closing OR shelf OR Ludloff) AND osteotomy” in the online databases MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was performed.

Results

There was a mean correction of hallux valgus angle of 20.1° [confidence interval (CI) 18.7–21.4] and of intermetatarsal angle of 8.1° (CI 7.7–8.9). The overall complication rate reached 18.7 %.

Conclusions

The results of this study reveal higher corrective power of proximal osteotomies compared to meta-analysis data on diaphyseal osteotomies.     

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.     

Pre-centralization soft tissue distraction for Bayne type IV congenital radial deficiency in children

There are several surgical options for the treatment of severe congenital radial deficiency. The aim of the current study was to evaluate the results of a staged protocol consisting of gradual soft tissue distraction with an Ilizarov external fixator followed by centralization of the ulna. Three patients (four extremities) with Bayne type IV radial club hand were treated at an average age of 18 months. At a follow-up of 26 months, an average correction of 72 degrees in the hand-forearm angle and an improvement of 19 mm in the hand-forearm position were obtained. There were no cases of neurovascular compromise, wound infection, carpal resection, or ulnar shortening. All families were pleased with the results. These findings suggest that a staged surgical approach is a technically feasible alternative in the treatment of severe congenital radial club hand deformity in young children.     

Ensuring precision in lower limb deformity correction through a combination of temporary external fixation followed by internal fixation: Results of a retrospective study

Background:

It is important to plan preoperatively when contemplating internal fixation following deformity correction. Surgeons often find it difficult to retain the achieved correction till the end of internal fixation. To maintain precise correction we used hybrid technique which uses both external and internal fixation. The objective of the study was to evaluate the effectiveness of this hybrid technique in achieving and retaining desired correction.

Materials and Methods:

In this retrospective study, we evaluated the magnitude of deformity with radiological parameters. We compared correction which was planned and correction which was achieved. The technique was used during surgery for corrective osteotomies. Before carrying out the osteotomy, rail fixator with two swivel clamps was applied. After osteotomy swivel clamps were loosened. Desired correction was achieved. While fixator held the fragments in corrected position, definitive internal fixation was carried out. External fixator was removed after completion of internal fixation. Position of mechanical axis ratio, mechanical lateral distal femoral angle and mechanical medial proximal tibial angle were measured before and 12 weeks after surgery. Student t-test was used to analyze the difference between correction which was planned and correction which was achieved.

Results:

There was no statistical difference between the desired correction and the correction achieved.

Conclusions:

Temporary use of external fixator while correcting angular deformities of lower limb allows to achieve accurate correction.     

Outcome of index finger pollicisation

Background

Pollicisation of the index finger for absence or severe hypoplasia of the thumb has been reported as a good procedure to recreate a new ‘thumb’ with good cosmesis and acceptable function. The purpose of this study is to evaluate the outcome of our series from different viewpoints.

Methods

Seventeen patients with 24 involved hands were willing to come back for evaluation. The mean age at operation was 12 months. In 8 hands there was also a radial club hand. Buck Gramcko’s technique was used with slight modifications. The mean follow-up time was 53 months (ranging from 6 to 142). The outcome was determined in a variety of ways: the functional assessment, cosmesis (objectivated with measurement of thumb length, girth and nail size) and a subjective evaluation of function and aspect done with a patient/parent questionnaire and a visual analogue score.

Results

The mean functional score was: one excellent, eleven good, five fair and five poor results. The mean length was 96% the width was 93%, the nail width was 85%. There was no significant different outcome in the syndrome related thumbs versus the isolated cases, unilateral versus bilateral cases. A significant worse outcome was seen for function and subjective evaluation in the radial club hand associated thumbs and for the functional score for the more severe Blauth group.

Conclusion

The general outcome for non radial club hand associated thumb reconstructions was satisfying. There was good correlation between the different scoring systems.     

Correction of complex equino cavo varus foot deformity in skeletally mature patients by Ilizarov external fixation versus staged external–internal fixation

Background

Complex foot deformity is a multi-planar foot deformity with many etiologic factors. Different corrective procedures using Ilizarov external fixation have been described which include, soft tissue release, V-osteotomy, multiple osteotomies and triple fusion.

Methods

In this study we compare the results of two groups of skeletally mature patients with complex foot deformity who were treated by two different protocols. The first group (27 patients, 29 feet) was treated by triple fusion fixed by Ilizarov external fixator until union. The second group (29 patients, 30 feet), was treated by triple fusion with initial fixation by Ilizarov external fixation until correction of the deformity was achieved clinically, and then the Ilizarov fixation was replaced by internal fixation using percutaneous screws. Both groups were compared as regard the surgical outcome and the incidence of complications.

Results

There was statistically significant difference between the two groups regarding duration of external fixation and duration of casting with shorter duration in the group 2. Also there was statistically significant difference between both groups regarding pin tract infection with less incidence in group 2.

Conclusion

Early removal of Ilizarov external fixation after correction of the deformity and percutaneous internal fixation using 6.5 cannulated screws can shorten the duration of treatment and be more comfortable for the patient with a low risk of recurrence or infection     

Management of forearm deformities with ulnar shortening more than 15 mm caused by hereditary multiple osteochondromas

Background

Treatment for forearm deformities caused by hereditary multiple osteochondromas is still controversial. The purpose of the study was to describe the outcome of treatment with the combined use of ulnar lengthening and excision of osteochondromas.

Methods

Fourteen patients with hereditary multiple osteochondromas had forearm deformities which belongs to type I Masada deformity. The mean relative ulnar shortening was 19.9 mm (range, 16–23). All patients ranging from 4 to 15 years old had operative treatment. Clinical evaluation involving the assessment of pain, activities of daily living, and range of motion of the wrist and forearm was performed. The radiographic evaluation was relative ulnar shortening (RUS), radial articular angle (RAA), carpal slip (CS), and radial bowing. Besides, we also evaluated the amount of ulnar lengthening, external fixation time, and external fixation index.

Results

The mean EFT was 101 days (range, 84–133), and the mean external fixation index was 44.4 days/cm (range, 33.6–51.2). During the mean 43.1 months follow-up, four patients had mild pain and two patients had mild restriction of daily activities. The rotation of forearm and motion of wrist had increased except in Case 3. The RAA, CS, and radial bowing had been improved except in Case 6 and 7. In all patients, relative ulnar shortening had been corrected. According to the functional evaluation criteria recommended by Krimmer, there were ten excellent and four good.

Conclusions

The combined use of ulna lengthening and excision of osteochondromas is a proper and effective treatment method to the type I Masada deformity with the relative ulnar shortening more than 15 mm.     

Bilateral double osteotomy in severe torsional malalignment syndrome: 16 years follow-up

Background

Torsional malalignment syndrome (TMS) is a well defined condition consisting of a combination of femoral antetorsion and tibial lateral torsion. The axis of knee motion is medially rotated. This may lead to patellofemoral malalignment with an increased Q angle and chondromalacia, patellar subluxation and dislocation. Conservative management is recommended in all but the most rare and severest cases. In these cases deformity correction requires osteotomies at two levels per limb.

Materials and methods

From 1987 to 2002 in our institution three patients underwent double femoral and tibial osteotomy for TMS bilateral correction (12 osteotomies). All patients were reviewed at mean follow-up of 16 years.

Results

At final follow-up no patients reported persistence of knee or hip pain. At clinical examination both lower limbs showed a normal axis and a normal patella anterior position. Pre-operative femoral version measurement showed an average hip internal rotation of 81.5° (range 80°–85°) and average hip external rotation of 27.2° (10°–40°). Thigh–foot angle measurement showed an average value of 38.6° (32°–45°). At final follow-up femoral version measurement showed an average hip internal rotation of 49° (range 45°–55°) and average hip internal rotation of 44.3° (20°–48°) (Figs. 1, 2, 3, 4, 5, 6). Thigh–foot angles measurement showed an average value of 21.6° (18°–24°) outward.

Conclusion

We recommend a clinical, radiographical and CT scan evaluation of all torsional deformity. In cases of significant deformity, internally rotating the tibia alone is not sufficient. Ipsilateral outward femoral and inward tibial osteotomies are our current recommendation for TMS, both performed at the same surgical setting.     

Bilateral tibial lengthening over the nail: our experience of 143 cases

Introduction

Using lengthening over an intramedullary nail as a technique for cosmetic purposes improves the individuals’ quality of life and provides more satisfactory results due to less external fixator period.

Methods

This study reports a case series of 143 individuals who underwent bilateral tibial lengthening over an intramedullary nail for cosmetic purposes together with the review of parameters related to the surgery and complications. Level of satisfaction was measured with the standard visual analog scale at least 1 year after removal of external fixator.

Results

In this study, mean (SD) age of patients was 26.6 (7.26) years. 85 (59.4 %) participants were male and 58 (40.6 %) were female. Mean end lengthening of all individuals was 6.65 cm. The mean external fixator period was 93.7 days. Complication rate was 0.74 per segment but it decreased to 0.45 when pin-tract infection was excluded. Complications were categorized based on Paley et al.’s classification as 129 problems, 85 obstacles and no sequelae. Interestingly, 44 (30.8 %) individuals had no problem and obstacle.

Conclusions

Lengthening over an intramedullary nail provides bone formation in equal quality to that obtained by the conventional Ilizarov method, along with lower rate of complications. The large number of individuals involved in our study is a remarkable benefit which could be used as an appropriate sample to compare results for outcomes and complications.     

“Sliding angulation osteotomy”: preliminary report of a novel technique of treatment for chronic radial head dislocation following missed Monteggia injuries

Purpose

Neglected anterior radial head dislocation in type I Monteggia lesions leads to restriction of movement, deformity and instability of the affected elbow. If left untreated this leads to a painful arthritic elbow due to secondary degenerative changes. This is a difficult problem to manage and many intra-articular, extra-articular and combined procedures have been described with variable results. We report a new technique of sliding angulation osteotomy for this condition, which allows both lengthening and angulation of the ulna.

Methods

A novel technique of sliding angulation osteotomy of the proximal ulna was done to achieve reduction of the radial head. Four patients with persistent anterior radial head dislocation were treated at our institution with this technique.

Results

All of them had good clinical and radiological outcomes at final follow-up.

Conclusions

Sliding angulation osteotomy is a technically simple procedure, which achieves lengthening and angulation of the ulna simultaneously in the sagittal plane and reduces the radial head.     

Gradual bone transfer for the correction of the pubic diastasis using the Ilizarov technique in closure of bladder and cloacal exstrophy

Background

In the patient of the cloacal exstrophy, cloaca with local abdominal wall is disrupted and exposed inner surface of the bladder needs early closure. Pelvic osteotomies are required for severe cases whose bladder cannot be closed by the suture of soft tissue only. We developed a technique involving the gradual positioning of bone fragments using a light, Ilizarov external fixator. The usefulness of the technique was assessed.

An operative approach to address severe genu valgum deformity in the Ellis-van Creveld syndrome

Background

The genu valgum deformity seen in the Ellis-van Creveld syndrome is one of the most severe angular deformities seen in any orthopaedic condition. It is likely a combination of a primary genetic-based dysplasia of the lateral portion of the tibial plateau combined with severe soft-tissue contractures that tether the tibia into valgus deformations. Progressive weight-bearing induces changes, accumulating with growth, acting on the initially distorted and valgus-angulated proximal tibia, worsening the deformity with skeletal maturation. The purpose of this study is to present a relatively large case series of a very rare condition that describes a surgical technique to correct the severe valgus deformity in the Ellis-van Creveld syndrome by combining extensive soft-tissue release with bony realignment.

Methods

A retrospective review examined 23 limbs in 13 patients with Ellis-van Creveld syndrome that were surgically corrected by two different surgeons from 1982 to 2011. Seven additional patients were identified, but excluded due to insufficient chart or radiographic data. A successful correction was defined as 10° or less of genu valgum at the time of surgical correction. Although not an outcomes study, maintenance of 20° or less of genu valgum was considered desirable. Average age at surgery was 14.7 years (range 7–25 years). Clinical follow-up is still ongoing, but averages 5.0 years (range 2 months to 18 years). Charts and radiographs were reviewed for complications, radiographic alignment, and surgical technique. The surgical procedure was customized to each patient’s deformity, consisting of the following steps:

1. Complete proximal to distal surgical decompression of the peroneal nerve
2. Radical release and mobilization of the severe quadriceps contracture and iliotibial band contracture
3. Distal lateral hamstring lengthening/tenotomy and lateral collateral ligament release
4. Proximal and distal realignment of the subluxed/dislocated patella, medial and lateral retinacular release, vastus medialis advancement, patellar chondroplasty, medial patellofemoral ligament plication, and distal patellar realignment by Roux-Goldthwait technique or patellar tendon transfer with tibial tubercle relocation
5. Proximal tibial varus osteotomy with partial fibulectomy and anterior compartment release
6. Occasionally, distal femoral osteotomy

Results

In all cases, the combination of radical soft-tissue release, patellar realignment and bony osteotomy resulted in 10° or less of genu valgum at the time of surgical correction. Complications of surgery included three patients (five limbs) with knee stiffness that was successfully manipulated, one peroneal nerve palsy, one wound slough and hematoma requiring a skin graft, and one pseudoarthrosis requiring removal of hardware and repeat fixation. At last follow-up, radiographic correction of no more than 20° of genu valgum was maintained in all but four patients (four limbs). Two patients (three limbs) had or currently require revision surgery due to recurrence of the deformity.

Conclusion

The operative approach presented in this study has resulted in correction of the severe genu valgum deformity in Ellis-van Creveld syndrome to 10° or less of genu valgum at the time of surgery. Although not an outcomes study, a correction of no more than 20° genu valgum has been maintained in many of the cases included in the study. Further clinical follow-up is still warranted.

Level of evidence

IV.     

Die Korrektur posttraumatischer Deformitäten am Unterschenkel mit dem „Taylor Spatial Frame“

Objective

Correction of posttraumatic lower leg deformities using percutaneous osteotomy, external fixation with a ring fixator, and computer-assisted gradual correction with the Taylor Spatial Frame (TSF).

Indications

Posttraumatic lower leg deformities not suitable for acute correction and internal fixation or deformities that are suitable but have a significantly increased risk for complications: deformities with poor soft tissue coverage, rigid deformities that require gradual correction, complex mulitplanar deformities, deformities with shortening, and periarticular juvenile deformities.

Contraindications

Posttraumatic lower leg deformities which are suitable for acute correction and internal fixation are also suitable for deformity correction using the TSF. In these cases, however, we recommend acute correction and internal fixation in order to improve the patient comfort. Lack of patient compliance for self-contained correction and pin care.

Surgical technique

Percutaneous fixation of the TSF rings to the main fragments using transosseous K-wires and half pins (hybrid fixation). Percutaneous osteotomy of the tibia either by drilling across both cortices and completion of the osteotomy using an osteotome (DeBastiani method) or by using the Gigli saw with preservation of the periostal envelope. Connection of both rings with six oblique telescopic struts via universal joints (hexapod platform). Computer-assisted planning of the correction.

Postoperative management

Gradual postoperative correction of the deformity by changing the strut lengths according to the correction plan. Strut changes, if required. Osseous consolidation of the osteotomy site with the TSF or revision to internal fixation.

Results

The correction of posttraumatic lower leg deformities using the TSF was performed in 6 cases. The mean deformity was 15° (12–22°) in the frontal plane and 6° (4–8°) in the sagittal plane. The correction time was 19 days (14–22 days). The deviation between planned and achieved correction was 0–3° in the frontal plane and 0–2° in the sagittal plane. The osseous consolidation of the osteotomy site was carried out in the TSF in 5 cases with a mean external fixation time of 112 days (94–134 days). In one case, the TSF was removed after the correction and the osteotomy site was fixed using an intramedullary nail. Pin site infections were observed in 3 cases. There were no further complications. The treatment goal was achieved in all cases. The examination at final follow-up was performed after 1 year. All patients were able to walk without walking aids and with no pain at that time. They were able to perform all of their activities of the daily life and their leisure activities without limitations.     

Comparative study of callus progression in limb lengthening with or without intramedullary nail with reference to the pixel value ratio and the Ru Li��s classification

Introduction

Callus progression is a great concern during limb lengthening. In this study, we investigated the difference in callus progression between tibial lengthenings with and without intramedullary nail.

Method

Seventy tibiae in 38 patients with an average age of 24?years were lengthened with Ilizarov external fixator and nail; 56 tibiae in 40 patients with an average age of 28.6?years were lengthened with the same Ilizarov external fixator but without nail. The callus progression was compared with reference to pixel value ratio (PVR) and Ru Li??s classification. Statistical analysis was performed to compare the variation trend of PVR and incidence of various callus pathways (particular patterns of callus progression as outlined in Ru Li??s classification) and shapes of each aspect of callus between the two groups.

Results

The trend of PVR was not statistically different in posterior, lateral and medial aspects of the callus between the two groups, but averagely lower in the anterior aspect in the group without nail than that with nail. The group without nail presented less incidence of homogeneous pathway, greater incidence of heterogeneous pathway; also greater incidence of fusiform callus, less incidence of cylindrical callus.

Conclusion

It was concluded that with nail, the callus underwent a more favorable progression and even longer lengthening could be allowed.     

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.