Plating after lengthening (PAL): technical notes and preliminary clinical experiences

Introduction Shortening the period of time for the external fixator after limb lengthening decreases the complication rate and increases the patient satisfaction. Material and method We describe the plating after lengthening (PAL) as a new technique on five patients with limb length discrepancy (1 femoral, 4 tibial) who had lengthening procedure with Ilizarov technique. The mean amount of lengthening was 50 mm. The mean lengthening period was 100 days (5–135 days). When the lengthening period ended, the locking compression plate was applied percutaneously by using the technique of minimal invasive plate osteosynthesis, and the Ilizarov external fixator was removed. Results The fixator-free period was achieved at the beginning of the consolidation phase, except in two patients, which were delayed for plating because of pin-tract infection. No complication was encountered except in one patient who had limited flexion of knee joint. There was no need for blood transfusion. Discussion The PAL, which shortened the period of time for the external fixator, was an easy and safe method for the fixation of the bone after limb lengthening.     

Femoral lengthening in young patients: An evidence-based comparison between motorized lengthening nails and external fixation

BACKGROUNDFemoral lengthening is a procedure of great importance in the treatment of congenital and acquired limb deficiencies. Technological advances have led to the latest designs of fully implantable motorized intramedullary lengthening nails. The use of these nails has increased over the last few years.AIMTo review and critically appraise the literature comparing the outcome of femoral lengthening in children using intramedullary motorized lengthening nails to external fixation.METHODSElectronic databases (MEDLINE, CINAHL, EMBASE, Cochrane) were systematically searched in November 2019 for studies comparing the outcome of femoral lengthening in children using magnetic lengthening nails and external fixation. The outcomes included amount of gained length, healing index, complications and patient reported outcomes.RESULTSOf the 452 identified studies, only two (retrospective and non-randomized) met the inclusion criteria. A total of 91 femora were included. In both studies, the age of patients treated with nails ranged from 15 to 21 years compared to 9 to 15 years for patients in the external fixation group. Both devices achieved the target length. Prevalence of adverse events was less in the nail (60%-73%) than in the external fixation (81%-100%) group. None of the studies presented patient reported outcomes.CONCLUSIONThe clinical effectiveness of motorized nails is equivalent or superior to external fixation for femoral lengthening in young patients. The available literature is limited and does not provide evidence on patient quality of life or cost effectiveness of the interventions.     

Tuberculous Pyomyositis of Forearm Muscles

Tuberculous pyomyositis is a rare entity reported in literature. The presented case reports the occurrence of such a lesion in forearm muscles, without any bony involvement. The ambiguity in its diagnosis led to inadequate management by the primary care physician. Clinical suspicion, positive tuberculin test, culture of acid-fast bacilli, ‘effective drainage’, and timely anti-tubercular chemotherapy ultimately resulted in a good clinical recovery. This case has been presented to increase the awareness about the existence of such an entity in clinical practice, thereby influencing its workup and the possible modes of management. Investigations were performed at North Bengal Medical College and Hospital, Sushrutanagar, Darjeeling, India.     

Interlocking Nailing of Forearm Fractures

Aim of the study : The aim of this retrospective study is to evaluate the results after treating diaphyseal fractures of the radius and ulna with an interlocking intramedullary nail.

Materials and methods : Between 2001 and 2005, 78 patients with 118 fractures were treated using the ForeSight intramedullary nail (Smith & Nephew, Memphis, USA). The average patient age was 37.02 years. In the postoperative period, early and late complications were evaluated through radiological and functional methods. The average period of follow-up was 25 months (range: 12–58 months).

Results : The average length of time to demonstrated bone healing was 14.2 weeks. Four cases of prolonged healing were observed. Pseudo-arthrosis formation did not occur. Assessment of function according to Anderson gave the following results: full range of movement in 88.6% of patients; mild restriction of movement in 10.1%; severe restriction of movement in 1.3% of patients. The implanted material was extracted from 27 patients. Refractures did not occur. Postoperative complications included: 1 superficial infection, 3 cases of incomplete radio-ulnar synostosis; one case of compartment syndrome.

Conclusions : Upon comparing the techniques of using plates with those of nailing in the treatment of forearm fractures, we have achieved comparable results with nailing. We therefore regard it as advantageous, in particular for treating open, serial and grossly comminuted fractures of the forearm bones.     

甲床扩大术的临床分析

目的报道临床应用甲床扩大术的方法及疗效。方法2001年6月至2004年1月，对因外伤引起手指远端缺损而致甲床过小的45例患者，采用切除甲皱襞和矩形推进皮瓣两种方法行甲床扩大术治疗。术后随访5个月-2年，以最后1次的功能进行评估。结果术后45例的甲床皆有不同程度的扩大，无明显并发症发生。结论甲床扩大术手术简单，效果满意，是治疗外伤性甲床部分缺损的有效方法。     

Ilizarov technique in management of nonunited fracture of both bones of the forearm

Nonunited fracture of the forearm, although not a common problem, is associated with marked disability. Nonunion can due to infection secondary to open fracture or can be a complication of surgical open reduction and internal fixation. Nonunion can also result from improper management or technique that is not suitable for the type of injury. This study reviews 11 patients with nonunited fractures of the shafts of the radius and ulna. Average duration of nonunion was 18 months. Nine patients presented with active infection or a history of infection in the form of open discharging wound with or without exposed bone, while two had no history of infection. Patients were managed by surgical debridment, removal of dead bone and hard wear, if any, and application of Ilizarov external fixation frame followed by acute shortening by compressing the fracture site. Three weeks later, gradual lengthening started to regain the normal length. Eradication of infection and sound union was achieved in all cases, with good hand, wrist, and elbow function on final follow-up. Limitation in pronation and supination ranges of movement were found in all cases. This could be due to multiple surgeries, long duration of management, the external fixation wires that crossed the distal and proximal radio-ulnar joints, or loss of the normal radial and ulnar bowing during lengthening. Ilizarov technique and external fixation represent an option in the management of resistant nonunion of diaphysial fractures in the forearm. Received: 5 July 2002, Accepted: 16 July 2002     

Does the use of an intramedullary nail alter the duration of external fixation and rate of consolidation in tibial lengthening procedures? A systematic review

We performed this systematic review to evaluate tibial lengthening procedures with the use of an intramedullary nail. We investigated the hypothesis that lengthening over a nail can reduce the time spent in an external fixator and increase the rate of consolidation thereby reducing the risk of complications and improving patient satisfaction. We conducted a comprehensive literature search using the MEDLINE, EMBASE and PubMed databases using the key words ‘tibia’ or ‘tibial lengthening’ and ‘nail’. This search was performed in December 2011 and repeated by both authors. Specific outcome measures were the duration of external fixation, rate of consolidation and complication rates. A total of 6 comparative studies published between 2005 and 2011 consisting of 494 procedures met our inclusion and exclusion criteria and were eligible for critical appraisal. The methodological quality of the studies was variable, and they were not homogenous enough for meta-analysis. Patients who have tibial lengthening over an intramedullary nail spend significantly less time in an external fixator. However, there is no reliable evidence to suggest that the rates of consolidation or complication are any different to those lengthened without an intramedullary nail.     

Growth factors in human serum during operative tibial lengthening with the ilizarov method

Despite the widespread clinical use of distraction osteogenesis for limb lengthening, the cellular and molecular mechanisms by which this surgical treatment promotes new bone formation in humans are not well understood. The aim of the research was to study the levels of growth factors (GFs) in the serum of patients that were undergoing tibial lengthening with the Ilizarov method of distraction osteogenesis. Those were patients with unilateral congenital discrepancy of the tibia (n = 12), unilateral posttraumatic tibial shortening (n = 7), and healthy patients that underwent cosmetic bilateral tibial lengthening (n = 10). The study established that unlike the congenital group, the posttraumatic group and healthy subjects showed a significantly evident increase in the levels of angiogenic GFs in their serum on day 10 of distraction. In the congenital group, the changes were not significant at this time point. The levels of TGF‐α, TGF‐β1, and TGF‐β2 tended to decrease on day 10 of distraction and on day 30 of the post‐distraction period in the cosmetic and posttraumatic groups while they grew in the congenital group. Most dynamic changes in the GFs levels during tibial lengthening were noted in the subjects undergoing cosmetic lengthening, and the least ones were in the congenital group. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31:1966–1970, 2013     

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.     

Ankle arthrodesis combined with tibial lengthening using the Ilizarov apparatus

 We report our experience using the Ilizarov method to perform combined ankle arthrodesis and tibial lengthening in six patients (mean age 47 years; range 25–66 years). The average distraction length was 4.1 cm (range 1.1–6.8 cm), and the mean period of follow-up was 36 months (range 26–44 months). Three patients had active infection of the ankle. Four patients had undergone previous surgery, two of which were primary ankle arthrodeses. We performed compression-distraction in three patients and bone transport in three. In the compression-distraction group, the mean length gained was 1.9 cm, the mean external fixation index (EFI) was 144 days/cm, and the mean external fixation time was 246 days. In the bone transport group, the mean length gained was 6.2 cm, the mean EFI was 35.4 days/cm, and the mean external fixation time was 233 days. All cases achieved a good clinical result with a solid ankle arthrodesis and no infection, deformity, or need for additional support. The Ilizarov method may be practically applied for ankle arthrodesis, especially in complicated cases. The EFI and external fixation time tended to increase for patients with a length gain of 3 cm or less. Received: January 16, 2002 / Accepted: August 1, 2002 Offprint requests to: H. Tsuchiya     

Limb lengthening in achondroplasia by Ilizarov's method

Summary In achondroplasts limb lengthening can restore the normal proportion of the body. The Ilizarov method of limb lengthening has been used in 37 patients, 23 of whom have had an adequate follow-up after operation. In this technique the cortex of the bone is partially cut, leaving the medulla intact; the two bone segments are then subjected to distraction by means of a special apparatus. The bone tissue between the two segments starts regenerating and this allows a considerable increase in length. The results and complications are reported. It is considered that this method is based on sound principles and is free of major risks.

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Résumé Chez les achondroplases l'allongement des membres rétablit les proportions corporelles. La méthode d'Ilizarov a été utilisée avec succès dans une série de 37 cas, dont 23 ont été revus avec un recul de deux à quatre ans. Après corticotomie, respectant le canal médullaire, en exercant une distraction progressive des deux fragments on obtient dans la zone de section une régénération osseuse qui permet des allongements considérables. Les auteurs rapportent leurs résultats et leurs complications, ils pensent que cette méthode est valable et dépourvue de risques importants.

     

新式跟腱延长术治疗儿童马蹄足

目的 介绍一种新式跟腱延长术治疗儿童马蹄足的手术方法和要点,并观察术后疗效.方法 对2002年1月至2007年12月收治的19例(23足)儿童马蹄足患者采用跟腱矢状位3份切断交错滑移的方法进行跟腱延长,术后小腿石膏固定踝关节于背伸90°位2周,2周后开始全负重功能锻炼.于术前、术后短期及术后中期随访测量患足背伸角度,并行Corry修正步态医师等级量表评分(PRS).结果 本组17例(20足)获得随访,时间为1～5年(平均3.5年).结果 显示患者均能在2周后全部负重功能锻炼、患足踝关节角度从术前平均116.1°±15.0°下降到术后短期随访时的68.5°±9.6°及中期随访时的71.3°±8.5°,术前与术后比较差异有统计学意义(P<0.05).PRS中的膝反曲、足着地方式、总体改变指标术前与术后比较差异均有统计学意义(P<0.05),蹲伏差异无统计学意义(P>0.05).本组患者未出现跟腱断裂、跟行足等并发症.结论 新式跟腱延长术能增进跟腱的强度、满足延长长度、达到早期功能锻炼的目的并促进功能快速恢复,是一种有效的跟腱延长术式.     

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.