Distraction osteogenesis for the treatment of post traumatic complications using a conventional external fixator. A novel technique

PURPOSE: To evaluate the clinical results of post traumatic complications treated by the author's own technique using an AO/ASIF conventional external fixator (without special distraction device). MATERIALS AND METHODS: There were 70 patients (77 limbs) with an average of 26.8 years (range, 4-54). There were 33 femurs, 43 tibias and one ulna. The following post traumatic complications were treated: 14 limb shortening, 20 nonunion, 28 malunion 14 infected open fractures with bone loss and 1 chronic osteomyelitis. Linear lengthening was performed in 29 limbs, acute de-rotation and subsequent lengthening in two limbs, gradual angular correction in six limbs, combined gradual angular correction and subsequent lengthening in 10 limbs, combined acute angular correction and subsequent lengthening in eight limbs and 22 limbs with bony defects were treated with the technique so-called "bone transportation". All of the limbs were treated with an AO/ASIF conventional external fixator, using the author's own technique with distraction rate of 1 mm in one step on alternate day (1 mm/48 h). RESULTS: A new bone formation in the distraction gap was achieved in 73 of the 77 limbs. Four cases without consolidation were successfully treated with an iliac bone graft combined with plating or reapplication of the external fixator. Average new bone formation was 5.6 cm (range, 1-17 cm). The average follow-up period was 10.8 months (range, 1-71 months) after removal of the fixator. The average healing time was 244.7 days (range, 60-836 days) and the healing index was 50 days/cm (range, 17-100 days). In the group with associated angular deformity the mean correction was 18.5 degrees (range, 10-40). CONCLUSIONS: The author's technique of distraction osteogenesis, using a conventional external fixator combined with a distraction rate of 1 mm/48 h (1 mm/step) adequately treated the post traumatic complications. No extra equipment was needed other than readily available AO/ASIF fixation systems. The described technique, using an AO/ASIF fixator as a lengthening apparatus was simple and cost-effective.     

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。     

Femoral lengthening with a motorized intramedullary nail

Purpose — We assessed whether an intramedullary lengthening device would reduce the problems normally associated with the external fixation technique. We also wanted to determine whether it is a reliable construct for limb lengthening and deformity correction in the femur.

Patients and methods — We conducted a matched-pair comparison of 30 femoral lengthenings, 15 with a motorized intramedullary nail (the nail group) and 15 lengthenings with an external ring fixator (the fixator group). The patients were matched based on age, sex, amount of lengthening, and the etiology of leg length discrepancy. Mean lengthening was 35 (25–55) mm in the nail group and 38 (15–75) mm in the fixator group. Outcome measures were: lengthening and alignment achieved, consolidation index, knee range of motion (ROM), and complications.

Results — The pairs in this matched-pair study were similar in terms of age, sex, diagnosis, and amount of lengthening. The planned amount of lengthening was achieved in all patients in both groups and axis correction was considered sufficient. The mean radiographic consolidation index in the nail group, at 1.5 (0.9–3.0) months/cm, was better than the mean value for the fixator group (1.9 (0.9–3.4) months/cm) (p = 0.01). Knee ROM was better in the nail group during the lengthening, 6 weeks after lengthening was completed, and 6 months after lengthening was completed (p < 0.001). A larger number of complications were observed in the fixator group than in the nail group.

Interpretation — A lengthening nail may be superior to external fixation in femoral lengthening, when the anatomical conditions and the complexity of the deformity allow the use of an intramedullary nail.     

Bifocal tibial corrective osteotomy with lengthening in achondroplasia: an analysis of results and complications

The results and complications of bifocal tibial osteotomies with gradual correction and lengthening by Ilizarov ring fixator performed in 47 tibiae in 24 achondroplastic patients were analyzed. Comparison was made between the parameters of angular and torsional deformities of the tibia preoperatively, at fixator removal, and at last follow-up. Of these parameters, statistically significant change was seen postoperatively in the values of medial proximal tibial angle, lateral distal tibial angle, mechanical axis deviation, and tibial torsion, which changed from 78.8 +/- 7.05 degrees, 103.2 +/- 11.8 degrees, 25.1 +/- 14.6 mm (medial), and 22.7 +/- 10 degrees (internal) preoperatively to 87.3 +/- 6.3 degrees, 90.9 +/- 5.4 degrees, 5.3 +/- 10 cm (medial), and 15.8 +/- 4.2 degrees (external), respectively, at the time of fixator removal; and this correction was maintained during the follow-up period. Mean total tibial lengthening was 6.84 +/- 1.3 cm. Average healing index was 26.06 days/cm. Complications observed were 15 pin tract infections, 1 residual varus, 1 overcorrection into valgus, 2 recurrence of varus, 22 equinus contractures, 2 premature consolidations, and 3 fibula malalignments. Recurrence of varus was observed in limbs with a residual abnormal medial mechanical axis deviation due to femoral deformity. A hundred percent incidence of equinus was observed in limbs with tibial lengthening of more than 40%, with distal tibial lengthening of more than 15%. To minimize the risk for occurrence of equinus, we recommend restriction of distal tibial lengthening in achondroplasia to less than 15%, although total tibial lengthening may exceed 40%. Fibula malalignment was not observed after double fibula osteotomy. This procedure is safe and efficacious if performed with strict adherence to prescribed technique.     

Tibial lengthening over an intramedullary nail

Background Long-term application of an external fixator to treat leg-length discrepancy and short stature often causes complications, such as pin-tract infection or loss of range of motion at the knee or ankle (or both). Prolonged fixator use also interferes with the activities of daily living. To minimize such problems, we have combined intramedullary nailing with external fixation. Using this technique, the external fixator can be removed more quickly after completing the lengthening. Methods We combined intramedullary nailing with lengthening in 13 tibias (8 patients) and then compared these cases with 17 standard tibial lengthenings (16 patients) using an external fixator alone. In both groups we excluded patients who had a history of previous bone infection, open fracture, immature bone, soft tissue compromise, antineoplastic chemotherapy, or bone deformity of a severity that required gradual deformity correction. We also excluded cases with lengthening of less than 3 cm. Results The mean external fixation index differed significantly between the two groups, but the consolidation index did not. Mean operating time for lengthening combined with intramedullary nail placement was approximately 60 min longer than for standard lengthening without nail placement; intraoperative blood loss was not greater in the nailing group. Complications related to the external fixator were far fewer in the combined intramedullary nailing and lengthening group compared with the control group, and callus formation was satisfactory for both groups. Conclusions A combination of intramedullary nailing and external fixation produces callus formation as good as that obtained by the standard Ilizarov method of lengthening. Furthermore, this combined procedure decreases the external fixation time and is associated with fewer complications.     

Tibial lengthening using a reamed type intramedullary nail and an Ilizarov external fixator

The aim of this study was to evaluate the efficacy of tibial lengthening using a reamed type intramedullary nail and an Ilizarov external fixator for the treatment of leg length discrepancy or short stature. This retrospective study was performed on 18 tibiae (13 patients) in which attempts were made to reduce complications. We used an Ilizarov external fixator and a nail (10 mm diameter in 17 tibiae and 11 mm in one tibia) in combination. Average limb lengthening was 4.19 cm (range, 2.5-5.5). The mean duration of external fixation was 12.58 days per centimetre gain in length, and the mean consolidation index was 40.53 (range, 35.45-51.85). All distracted segments healed spontaneously without refracture or malalignment. Gradual limb lengthening using a reamed type intramedullary nail and circular external fixation in combination was found to be reliable and effective and reduced external fixation time with fewer complications.     

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.     

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.     

Bilateral valgus-extension osteotomy of hip using hybrid external fixator in spondyloepiphyseal dysplasia: early results of a salvage procedure

The treatment of spondyloepiphyseal dysplasia (SED) congenita patients with severe bilateral hip involvement is difficult because it involves deformities of multiple joints and of the spine. The purpose of this study was to evaluate the results of the procedure described below as a method of treatment for bilateral hip involvement in SED congenita patients. We performed proximal femoral valgus-extension osteotomy with distal femoral varus osteotomy using a hybrid external fixator in eight patients (seven male patients and one female patient) or 16 hips. The patients had a mean age of 16.37 years (range, 9-25 years) at the time of surgery. The mean valgus angle at the proximal osteotomy site was 53.4 degrees on the right side and 52.5 degrees on the left side, and the mean varus angle at the distal osteotomy site was 22 degrees . Mean fixator time was 19.8 weeks (range, 10-42 weeks). After an average follow-up of 25.9 months, the mean modified Harris hip score had improved from 67.9 points to 79.1 points, which was statistically significant (P=0.012). Preoperative knee range of motion was achieved at the last follow-up in all patients. Waddling gait was absent in three patients, reduced in four patients, and was the same in one at the last follow-up. Mean limb length gain was 3.5 cm (range, 0-5 cm), mean limb length discrepancy less than 0.5 cm, and the mechanical axis was realigned in all. In conclusion, our early results suggest that proximal valgus-extension osteotomy with distal femoral varusization can be a useful treatment option in young patients with bilateral hip involvement in SED congenita.     

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.     

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     

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     

Deformity correction followed by lengthening with the Ilizarov method

Deformity combined with shortening of 18 lower limb segments of 17 patients was treated with the Ilizarov method. Limb lengthening was done at the same treatment (monofocal treatment) or a separate osteotomy (bifocal treatment) was done after acute or gradual correction of the deformity using the Ilizarov hinge system. The external fixation time, amount of deformity correction, length gained, and incidence of complications were examined. Results were compared between monofocal versus bifocal treatment groups and between femoral versus tibial procedures. The average deformity corrected was 22.3 degrees, and the average lengthening was 44.4 mm. The external fixation index was 49.3 days/cm on average, ranging from 24.4 to 90 days/cm, and the mean duration of external fixation was 198 days, ranging from 77 to 352 days. Major complications requiring surgical treatment, such as premature consolidation and fracture, were seen in four patients. There were no statistically significant differences between the results for monofocal and bifocal treatment or treatment indices for femoral and tibial operations. The Ilizarov method was very effective for treatment of limb deformity combined with shortening. Monofocal treatment might be better if the total amounts of lengthening required are short to reduce surgical invasion. Longer treatment indices for tibial operations could not be verified from the current study.     

Sagittal plane deformity during femoral lengthening

The purpose of this study was to determine the incidence and degree of sagittal plane deformity that occurs during limb lengthening of the femur. Twenty-one patients (25 limbs) were identified who underwent femoral lengthening. The limbs were lengthened a mean of 6.1 cm, and mean follow-up was 1.5 years. The immediate postoperative deformity in the sagittal plane was 8.3°; this deformity did not progress during lengthening (P<.05). Mean displacement in the sagittal plane was 3.1 mm.Angular deformities, although typically small, can occur in the sagittal plane and may be accompanied by displacement. These deformities are usually present immediately postoperatively and typically do not worsen significantly with 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.     

再次应用外固定架治疗肢体延长和畸形矫正术中的并发症

目的：运用外固定架治疗肢体不等长或畸形，矫正具有潜在的并发症。现报道一组因治疗过程中或结束后该延长肢体出现并发症而需再次运用外固定架的病例。方法：1991年2月-1999年7月，共有261例（297肢体）用Or-thofix或Ilizarov外固定进行肢体延长或畸形矫正。其中儿童228肢体，成人69肢体。结果：儿童再次运用外固定架治疗的有22例次（9.65％），成人有4例次（5.8％0.总的再次运用外固定架率达8.75％。再次运用外固定架的原因为延长区再生骨的骨折和成角畸形。有4例患者最后接受截肢术。结论：对因先天性疾患致肢体严重残疾的患儿，再次运用外固定架治疗仍具有临床价值。     

Functional outcome after lengthening with and without deformity correction in polio patients

Poliomyelitis is one of the causes of limb length discrepancy. The aim of lengthening and deformity correction in such patients is to improve the functional mobility of the patient. This study aims to find out whether or not improvement of limb length inequality with or without deformity correction affects or improves ambulation. This prospective study included 32 skeletally mature patients managed using the Ilizarov technique and external fixation for limb lengthening with or without deformity correction. Functional Mobility Scale scoring was used for assessment of ambulation before lengthening and at the final follow-up. The average duration of follow-up was 2 years and 9 months. Lengthening alone did not change the Functional Mobility Scale score. While lengthening associated with deformity correction improved the mobility scale at 5 m only (in the house), it had no effect on the 50 and 500 m score.     

下肢长骨严重粉碎性骨折的治疗

目的：探讨下肢长骨严重粉碎性骨折的治疗方法。方法：41例患者，其中27例应用支架外固定治疗，14例应用联合内固定治疗。结果：骨折均愈合，愈合时间5－14个月，平均8．6个月。钉眼感染5例，骨折延迟愈合5例，再骨折1例，成角畸形3例。结论：支架外固定与联合内固定均为下肢长骨严重粉碎性骨折有效的治疗方法。支架外固定可使骨折满意复位，提供稳定的固定，可以维持肢体长度，特别适合合并有软组织病损的患者。     

Lengthening the ulna in patients with hereditary multiple exostoses

Deformity of the forearm is common in patients with hereditary multiple exostoses, producing cosmetic and functional impairment in which shortening of the ulna is a significant factor. The results of ulnar lengthening in 10 forearms of eight patients are reported. Lengthening was performed by osteotomy of the shaft followed immediately by a bone graft and internal fixation, or by gradual distraction with an external fixator. In all patients the appearance was improved and the range of radial deviation at the wrist was increased. In most patients forearm movement and radial head stability were improved. Partial recurrence of the deformity was seen during the follow-up of skeletally immature patients, but in general ulnar lengthening was found to be a useful operation.