Outcomes of lengthening short lower-extremity amputation stumps with planar fixators

Patients with short lower-extremity amputation stumps exhibit poor prosthetic fit and inefficient gait. Often they are fit at the next-higher prosthetic level, increasing energy consumption. This study aimed to characterize the risk/benefit ratio of stump lengthening with planar external fixators. All patients lengthened for functionally short amputation stumps were reviewed. Outcome measures included changes in prosthetic use, soft tissue problems, qualitative gait analysis, and surgical complications. Patients averaged 15.1 years of age at surgery, with 4.1 years of follow-up. The average lengthening index was 9.2 mm/mo. Femoral lengthenings obtained more length (8.7 vs. 6.9 cm). After treatment, prosthetic skin-related complications decreased and qualitative gait parameters improved. Most (85%) wore a standard prosthesis for their amputation level after surgery, whereas none could before. There were 1.4 complications per patient, all successfully surgically treated. Lengthening is time-consuming and associated with frequent complications but results in improved gait and energy consumption.     

Lengthening of congenital limb length discrepancy using callotasis: early experience of the Hospital for Sick Children.

Seventeen patients were reviewed after callotasis lengthening for congenital limb length discrepancy. The average age at lengthening was 10.8 years. Length discrepancy before lengthening ranged from 4.5 cm to 12 cm for the leg, and 24 mm to 30 mm for the forearm. At completion of the lengthening process, all but one patient had their discrepancy corrected successfully. The difficulties encountered were classified into problems, obstacles and complications. All patients suffered from superficial infection, but in only one case did this become a complication, resulting in a residual femoral discrepancy of 2 cm. Of the other three patients who suffered a complication, one fractured through the newly formed bone. The fracture was treated conservatively. In two further femoral lengthenings, the fixator had to be exchanged under general anaesthesia because it had reached its maximum excursion. Callotasis appears to be a safe and reliable method for correcting congenital limb length discrepancy in children.     

Complete fibular hemimelia: a long-term review of four cases

Fibular hemimelia is a partial or total aplasia of the fibula, and is usually associated with other anomalies of the tibia, femur and foot. It represents the most frequent congenital defect of the long bones and is the most common skeletal deformity in the lower limbs. A retrospective study was made of four patients (three males and one female) with total aplasia of the fibula. The average follow-up was 15 years. Three patients were treated by successive tibial lengthenings; in one case amputation was carried out using the Syme technique. Lengthening required numerous operations and led to many complications, whereas the amputated case involved a single surgical operation without complications. The results of our cases and those reported in the literature suggest early amputation as the treatment of choice of Type II fibular hemimelia.     

Limb lengthening and deformity correction with externally controlled motorized intramedullary nails: evaluation of 50 consecutive lengthenings

Background and purpose — Limb lengthening with an intramedullary motorized nail is a relatively new method. We investigated if lengthening nails are reliable constructs for limb lengthening and deformity correction in the femur and the tibia.

Patients and methods — 50 lengthenings (34 Precice and 16 Fitbone devices) in 47 patients (mean age 23 years [11–61]) with ≥12 months follow-up are included in this study. 30 lengthenings were done due to congenital and 20 because of posttraumatic deformity (21 antegrade femora, 23 retrograde femora, 6 tibiae). Initial deformities included a mean shortening of 42?mm (25–90). In 15 patients, simultaneous axial correction was done using the retrograde nailing technique.

Results — The planned amount of lengthening was achieved in all but 2 patients. 5 patients who underwent simultaneous axial correction showed minor residual deformity; unintentionally induced minor deformities were found in the frontal and sagittal plane. The consolidation index was 1.2 months/cm (0.6–2.5) in the femur and 2.5 months/cm (1.6–4.0) in the tibia. 2 femoral fractures occurred in retrograde femoral lengthenings after consolidation due to substantial trauma. There were 8 complications, all of which were correctable by surgery, with no permanent sequelae.

Interpretation — Controlled acute axial correction of angular deformities and limb lengthening can be achieved by a motorized intramedullary nail. A thorough preoperative planning and intraoperative control of alignment are required to avoid residual and unintentionally induced deformity. In the femur relatively fast consolidation could be observed, whereas healing was slower in the tibia.     

Progressive elongation of lower member by callotasis in the child: Results of 36 lengthenings

The authors reviewed a series of 36 progressive lengthenings of the lower member by callotasis (22 femur and 14 tibia) in 33 patients with an inequality of length of the lower member (ILLM). Median age was 13 years; etiology was dominated by infection, congenital defects, and trauma. The lengthening procedure was completed in 26 children; it was necessary to abandon seven lengthening attempts. Median lengthening achieved was 45 (range 30–100) mm. Complications were frequent, with 66 during the different stages (184%). Most were benign (40); seven were determined to be grave, requiring abandonment of the lengthening; while 17 were judged as serious and required an unforeseen supplementary general anesthesia. Upon review of these results, it appears that progressive lengthening is an attractive technique with considerable benefits. However, management is not simple and complications are frequent, requiring close collaboration between the nursing team, the child, and the child's parents. For patient and family, the psychological benefits of this procedure are considerable.     

Comparison between upper and lower limb lengthening in patients with achondroplasia: a retrospective study

Lengthening of the humerus is now an established technique. We compared the complications of humeral lengthening with those of femoral lengthening and investigated whether or not the callus formation in the humerus proceeds at a higher rate than that in the femur. A total of 24 humeral and 24 femoral lengthenings were performed on 12 patients with achondroplasia. We measured the pixel value ratio (PVR) of the lengthened area on radiographs and each radiograph was analysed for the shape, type and density of the callus. The quality of life (QOL) of the patients after humeral lengthening was compared with that prior to surgery. The complication rate per segment of humerus and femur was 0.87% and 1.37%, respectively. In the humerus the PVR was significantly higher than that of the femur. Lower limbs were associated with an increased incidence of concave, lateral and central callus shapes. Humeral lengthening had a lower complication rate than lower-limb lengthening, and QOL increased significantly after humeral lengthening. Callus formation in the humerus during the distraction period proceeded at a significantly higher rate than that in the femur. These findings indicate that humeral lengthening has an important role in the management of patients with achondroplasia.     

Complications in limb-lengthening procedures: a review of 49 cases.

The purpose of this study was to examine the nature and number of complications relative to magnitude of limb lengthening. Results and complications of 50 limb-lengthening procedures were analyzed. There were 49 patients. Mean age was 21 years (range, 7-48 years). Lengthening was performed in 24 femora, 18 tibiae, 4 humerii, 3 radii, and 1 ulna. Average length gained was 5 cm (range, 3-15 cm) at average follow-up of 48 months (range, 12-76 months). Desired length was accomplished in all but 1 patient. The 69 complications varied in severity, but only 5 of these significantly impaired end results. The most serious complications occurred in patients with >30% bone lengthening. Patients with <15% lengthening had a significantly decreased complication rate. The healing index was lower in children. We conclude that incidence and severity of complications after limb-lengthening procedures are significantly influenced by relative lengthening of bone.     

Limb lengthening in achondroplasia

Background:Stature lengthening in skeletal dysplasia is a contentious issue. Specific guidelines regarding the age and sequence of surgery, methods and extent of lengthening at each stage are not uniform around the world. Despite the need for multiple surgeries, with their attendant complications, parents demanding stature lengthening are not rare, due to the social bias and psychological effects experienced by these patients. This study describes the outcome and complications of extensive stature lengthening performed at our center.Results:Nine patients aged five to 25 years (mean age 10.2 years) underwent limb lengthening procedures for 18 tibiae, 10 femora and 8 humeri. Four patients underwent bilateral lengthening of all three segments. The mean length gain for the tibia, femur and humerus was 15.4 cm (100.7%), 9.9 cm (52.8%) and 9.6 cm (77.9%), respectively. Healing index was 25.7, 25.6 and 20.6 days/cm, respectively, for the tibia, femur and humerus. An average of 33.3% height gain was attained. Lengthening of both tibia and femur added to projected height achieved as the 3^rd percentile of standard height in three out of four patients. In all, 33 complications were encountered (0.9 complications per segment). Healing index was not affected by age or bone segment.Conclusion:Extensive limb lengthening (more than 50% over initial length) carries significant risk and should be undertaken only after due consideration.     

Simultaneous ipsilateral femoral and tibial lengthening with the Ilizarov method.

Eight pediatric patients who underwent nine simultaneous ipsilateral femoral and tibial lengthenings with the Ilizarov external fixator were reviewed. The patient's demographics, diagnoses, corticotomy levels, mechanical axes, healing indices, amounts of lengthening, and complications were recorded. The patients' average age was 8 years 10 months (5 years 4 months-15 years 10 months) with an average follow-up of 49 months (30-88 months). The percentage of femoral lengthening averaged 16.7% (8-23%) with an average healing index of 28 days/cm (20-38 days/cm). The percentage of tibial lengthening averaged 18% (9.6-23.6%) with an average healing index of 29 days/cm (1940 days/cm). Four complications in three patients occurred as a direct result of the lengthening process. Three of the complications involved soft-tissue contractures, which were each successfully treated with one additional surgical procedure, whereas the fourth complication involved poor bone regeneration and required bone grafting and additional immobilization.     

Complications of distraction lengthening in the hand

This study examined the features of 16 complications from 51 distraction lengthenings in the hands of 43 patients. From 1996 to 2006, 24 metacarpals and 27 phalanges were lengthened at a rate of 0.5 and 0.25 mm/day, respectively, using a callus distraction technique. The indications were congenital (33 cases in 27 patients) and traumatic (18 cases in 16 patients) deformities. The average percentage lengthening in the phalanges and metacarpals was 62% (16 mm) and 63% (34 mm), respectively. The distraction rates in the phalanges and metacarpals were 69 and 52 days/cm, respectively. The overall complication rate was 31%. Major complications requiring secondary procedures were non-union (one case), fracture (one case), premature union (one case), angulations (two cases) and dislodgment of pins (two cases). The minor complications encountered were delayed callus formation (four cases), joint stiffness (four cases) and soft tissue thinning (one case). Traumatic deformities had more complications than the congenital ones (nine of 18 cases and seven of 33 cases, respectively). The phalanges had a higher rate of complication than the metacarpals (11 of 27 cases and four of 24 cases, respectively). Most patients with complications except for two children with dislodgment were as satisfied with the final results as those without complications. Although callus distraction in the hand requires a long treatment period and has a relatively high rate of complication, it appears to be effective in achieving adequate bone length. A high level of patient compliance and prompt management of complications by an experienced surgeon are essential for achieving good results.     

Treatment of complex limb deformities in children with the Ilizarov technique

Twenty-nine children underwent 36 Ilizarov procedures for a variety of limb deformities. We present the results in 11 patients, six with leg length discrepancies and five with achondroplasia, who underwent lengthening procedures using the Ilizarov method. Lengthening was accomplished in 15 of the 16 procedures (93%). Average increase in femur length was 10 cm (32%), in tibial length 7.5 cm (30%), in humerus length 11 cm (40%). Eleven complications occurred. The most common were pin tract infections (4), joint contractures (2), transient nerve injury (4), premature consolidation (5), and three fractures of the regenerated bone. The complication rate was as high as in other methods, but with the Ilizarov apparatus longer segments of bone were lengthened and more complex deformities were treated. The number of complications were lessened as experience was gained.     

Ilizarov technique. Results and difficulties.

Of 100 cases treated by the Ilizarov method, 91 patients were reviewed from February 1985 to March 1990. There were 32 tibial fractures (29 open) and 21 nonunions (nine infected). There were 47 cases of limb lengthening (28 tibia and 19 femur). The results were as follows: good, 83%; fair, 13%; and poor, 4%. Slight and intermittent pain in some wire of the device was frequent (69%). Average bone healing time in tibial fractures was 4.95 months and 5.83 months in tibial nonunions. In bone-lengthening operations, the average lengthening index in the tibia was 1.02 months/cm (lengthenings ranged from 3 cm to 10 cm, with a mean of 5.71 cm), whereas in the femur, the average lengthening index was 1.14 months/cm (lengthenings ranged from 3 cm to 7 cm, with a mean of 5.34 cm). Manually-tensed wires produced frequent problems (24.5%), whereas wire tensed by the dynamometric tensioner produced problems in only 7.8% of the cases. Despite good results, the Ilizarov technique requires adequate training to reduce an overall complication rate (approximately 30%).     

Results of femoral lengthening over an intramedullary nail and external fixator

INTRODUCTION: Current techniques of operative limb lengthening usually are based on distraction osteogenesis. One of the techniques is limb lengthening over an intramedullary nail. AIM OF PAPER: The goal of this study is to evaluate the results of femoral lengthening over an intramedullary nail. MATERIAL: Between 1999 and 200619 femoral "over nail" lengthenings were performed. There were 7 males and 12 females. Mean patients' age at surgery was 15.8 years, and mean initial femoral shortening was 5.1 cm. Operative technique consisted of one-stage implantation of intramedullary nail and external fixator. Ilizarov apparatus was used in 9 patients, monolateral fixator in 10 cases--ORTHOFIX in 9 patients, Wagner fixator--in 1 patient. Intramedullary nail was locked proximally with screws or Schanz pins from external fixator. After distraction phase, external fixator was removed and distal locking screws were applied. METHODS: Evaluation criteria: obtained lengthening, time of external fixator, treatment time, healing index, external fixation index, range of motion in hip and knee joints and complications according to Paley. RESULTS: The mean lengthening was 4.6 cm, and mean distraction time was 66.6 days. Mean time of external fixation was 115.5 days, and external fixation index was 26.2 days for centimeter. Healing index was 36.9 days for centimeter. In cases with monolateral fixator, healing index did not differ with the whole group. During treatment 18 complications occurred, for a rate of 0.9 complication per segment. CONCLUSIONS: Lengthening over an intramedullary nail reduces the time of external fixator. Over nail femoral lengthening can prevent axis deviation following regenerate bending. Complication rate is similar to lengthenings with the classic Ilizarov technique. There are no differences in the treatment time in relation to the type of external fixator.     

Comparison of the complication rates between first and second (repeated) lengthening in the same limb segment

The purpose of this study is to compare the incidence and types of complications in children who are undergoing first and second (repeated) lengthenings of the same bone. This is a retrospective review of 11 children (12 limbs) who underwent limb lengthenings of the same bone twice. There were 7 femoral and 5 tibial repeated lengthenings. Diagnoses included congenital femoral deficiency or proximal femoral focal deficiency in 6 patients, fibular hemimelia in 2, achondroplasia in 2, and tibial hypoplasia in 1. Mean age was 8.5 years for the first lengthening and 11.5 years for the second lengthening. There were 2.2 complications per lengthening for the first procedure and 1.5 for the second lengthening. There were 5 major and 22 minor complications for the first lengthening and 1 major and 17 minor complications for the second lengthening, none of these data were found to be statistically different. The healing index was 1.3 +/- 0.43 months per cm first lengthening and 2.2 +/- 1.7 cm for the second lengthening. This study did not demonstrate a significantly higher rate of complications with repeated lengthening of the same limb, although the time in the fixator for the second lengthening was longer and the degree of lengthening less.     

Results of leg lengthening using Wagner's technique

Nineteen leg lengthenings by Wagner's technique were reviewed. Average patient age was 13 years (range, 8-18 years). The gain averaged 3.9 cm (range, 1.1-10 cm). Complications were prolonged treatment period (9 cases), metal-work failure (6), loss of gain (5), malunion (6), fracture (5), deep infection (2), and joint problem (6). The osteogenesis in the elongation gaps affected the results. No callus formation by 40 days after osteotomy and no bridging callus by the end of elongation period were warning signs of poor osteogenesis. All tibial lengthenings and femoral lengthenings of more than 5 cm or 13% of the original length were at risk of poor osteogenesis. Proper stabilization and bone grafting were the most effective measures for poor osteogenesis. Currently, Wagner's technique is not the treatment of choice because new techniques with fewer complications are available. However, Wagner's technique is useful in the cases to which the new procedures are not applicable.     

The effects of limb lengthening on growth

The purpose of this study was to determine the effects of limb lengthening on the rate of growth of the lengthened limb. The rate of growth of the lengthened and control (contralateral) limb segment were determined radiographically pre- and postoperatively in 19 skeletally immature patients (20 limbs). There were 13 femoral and seven tibial lengthenings. The mean age at the time of lengthening was 9.4 years (range 4.2-12.3). The limbs were lengthened by a mean of 6.7 cm (24%). Mean follow-up was 3.6 years. No significant difference was found between the change in the rate of growth of the lengthened and control limb (P=0.59). This was true for both the femur and the tibia, when analyzed separately. This study indicates that the change in the rate of growth between the lengthened and control limbs did not vary significantly in our patient group.     

Pedicled flaps for lower extremity reconstruction in the elderly: a retrospective study of 16 cases

We reviewed a consecutive series of 16 patients above 60 years of age (mean age 71 years) who underwent reconstruction with pedicled flaps in the lower extremity. The soft tissue defects ranged from 9 to 50 cm and were caused in 11 patients (70%) by surgical complications from previous surgeries. Of these, 5 patients underwent a total joint replacement of the knee (4 cases) and of the ankle (1 case). Surgery consisted of 19 muscular flaps, and 3 fasciocutaneous flaps. Six patients were treated with a combination of 2 flaps. The overall surgical complication rate after reconstruction was 44%. There was no perioperative mortality and there were no medical complications. One patient required an above-the-knee amputation because of uncontrollable postoperative bleeding. A thrombectomy was performed in another patient to treat a postoperative popliteal artery occlusion with critical ischemia of the leg. Other complications included recurrent total joint replacement infections (2 cases), marginal flap necrosis (4 cases), and skin necrosis at the donor site (1 case). The mean hospitalization stay was 46 days. All patients but 1 completely healed, although secondary surgery was performed in 7 patients. The occurrence of complications was not correlated with the preoperative morbidity or an age above 75 years. The local complication rate was higher than reported for free flap in the same age category, but the lack of perioperative mortality and medical complications make it a low-risk option for reconstruction of small- to middle-sized defects in the elderly.     

Extensible endoprostheses for bone tumors of the proximal femur in children

Between 1983 and 1996, nine children were treated with extensible endoprosthetic replacements of the proximal femur after resection of primary bone tumors. Four patients died of their disease. The remaining five patients were observed for an average follow-up period of 7.6 years. In these five patients, the authors performed an average of 10.2 operations per patient, including five lengthenings and a mean total extension of 69.7 mm per patient. Acetabular loosening and hip dislocations were the most frequent complications. Only two patients have not had a revision or a major complication. Despite this, four children are alive with a functioning lower limb and a mean Musculoskeletal Tumor Society functional score of 77.6%. Extensible endoprosthesis of the proximal femur is a viable alternative to hip disarticulation and in selected children offers an opportunity for near-normal development of the lower limb by allowing equalization of limb length and the ability to walk without the use of mobility aids.     

Distraction osteogenesis of the femur using conventional monolateral external fixator

INTRODUCTION: The author has developed a new simple technique of distraction osteogenesis using conventional monolateral external fixator for femoral lengthening. The primary purpose of the present study was to evaluate the results of treatment with this new technique of femoral lengthening and also to evaluate the effect of preoperative and intraoperative variables on the outcome of distraction osteogenesis in general. MATERIALS AND METHODS: Fifty-one femora in 50 patients were lengthened. Limb-length discrepancy was the primary indication in all patients. The mean age of the patients at the time of the surgery was 21.9 years (range 5-48 years). The average follow-up period was 24.6 months after removal of the fixator (range 6-120 months). All lengthenings were performed using conventional AO/ASIF external fixator. Twenty-two femora had associated axial or rotational deformities. Gradual distraction was performed to increase length and to correct angular deformity in coronal plane. Acute closed wedge angular correction in sagittal plane or derotation was performed in 12 femora in this study. RESULTS: The length of the 51 femora was increased by an average 4.4 cm (range 1-13 cm), or 12% (range 2.5-40.9%). The average healing index was 50.5 days/cm (range 22.5-110.6 days/cm). Average gradual angular correction in coronal plane in 14 femora was 20.4 degrees (range 10-45 degrees ). Average acute correction in sagittal plane in five femora was 17 degrees (range 10-20 degrees ). Average acute derotation in six femora was 24.2 degrees (range 10-60 degrees ). There were a total of 61 complications, including 26 problems, 18 obstacles, and 17 sequelae. The overall rate of complications was 1.2 per femur. Fifteen femora had delayed consolidation (healing index >54 days/cm). Three of 51 lengthening procedures did not lead to consolidation (nonunion). A significant negative parabolic relationship was noted between the healing index and the amount of length gained (R = -0.47 and P = 0.004). There was a significantly positive exponential relationship between age and healing index (R = 0.51 and P < 0.001). Acute deformity correction, level of osteotomy (submetaphysis versus diaphysis) had no significant effect on healing index. The greater amount of length gained was associated with complications. CONCLUSIONS: The newly presented technique of distraction osteogenesis is a useful and cost-effective method for femoral lengthening. Increased lengthenings produced a better healing index but might associate with complications. Younger age was associated with better bone healing but age had no effect on complication rate. Level of osteotomy, acute deformity correction had no effect on healing index and rate of complications.     

Technique and complications of callus distraction in the treatment of bone tumors

Introduction: This study investigated the effects of chemotherapy, defect length, and patient age on the outcome and complications of callus distraction as a limb salvage technique in 17 patients. Materials and methods: The mean patient age was 18.4 years (range 7–47). Of 17 patients, 8 received chemotherapy and the remaining 9 patients did not. The mean defect length after excision of the lesion was 13 cm (range 8–20). The mean follow-up period for the patients whose treatments were completed was 55 months (range 20–90), the mean distraction index was 12.55 days/cm (range 11–15.7), and the mean external fixation index was 34.73 days/cm (range 30–41). Results: In two patients, local recurrence occurred before distraction was completed. Two patients died, and one of them was a patient in whom local recurrence had occurred. Complications included non-union in one patient, osteomyelitis in one patient, and premature callus, osseous bridge, and varus of the femur in one patient. The extremity functional score was 80% (range 26–100). Chemotherapy and defect length had no significant effect on the distraction or external fixation indices. In contrast, the increase in the external fixation index in those over 20 years old was significant (P=0.043). Conclusion: We found that chemotherapy and defect length have no significant effect on the outcome and complications with this technique, which was more successful in patients younger than 20 years.