Introduction. To determine the advantages and risks of plating after lengthening (PAL) of tibia in children and adolescents. Materials and Methods. 35 consecutive tibial lengthenings were done for limb length discrepancy (LLD) in 26 patients. Gradual lengthening by an external fixator from a tibial (usually diaphyseal) osteotomy was followed by internal fixation with a lateral tibial submuscular plate. The mean age at the time of the lengthening was 10.3 years (4.8 – 16.8 years). The aetiology for LLD was congenital in 21, acquired in 3, and developmental in 2 patients. The mean follow-up was 4.3 years (8 months – 9.9 years). Results. The mean lengthening was 5cm (3–8.6cm) or 19.1% (10.8 – 35.2%) of the initial length of tibia. It took 78.8 days to reach the target length at a lengthening rate of 0.75mm/day. The mean time to plate substitution after cessation of lengthening was 24.7days/109 days after osteotomy. This led to an average external fixation index (EFI) of 23.1days/cm. Optimisation of this technique by judicious estimation of timing of plate substitution would reduce the EFI. Consolidation was recorded at 192 days after osteotomy. Bone healing index (BHI) was 39.8days/cm and was age dependent: <12 year olds = 37.5 days/cm; 12 years = 44.7 days/cm. Using the estimated consolidation time if treatment was solely by external fixator, calculated by tripling the time taken to reach target length after osteotomy, the BHI in this series would have been 52.9 days/cm (p < 0.001). Knee flexion recovery to > 90 degrees was noted at 153.5 days after plating. One greenstick fracture occurred 116 days after plate insertion, 1 tibial shaft fracture occurred 315 days post removal of plate - both following injury and were treated conservatively. Six episodes of sepsis, 5 superficial and 1 deep were treated with antibiotic suppression. The plates were removed from 28 tibiae, 437.4 days after insertion. Conclusions. Plating after lengthening not only reduces the fixator time but appears to achieve consolidation faster than if treatment was by external fixation alone. This facilitates early recovery of joint motion and limb function

Introduction: Plastic deformation of the regenerate bone is a complication noted soon after limb lengthening. However, less is known about the factors responsible for the development of plastic deformation. Materials and Methods: Retrospective analysis of 35 X-rays of achondroplast children who had limb lengthening were reviewed. The study compared Monofocal Vs Bifocal and Long lengthenings(> 10 cms) Vs modest lengthenings(≤ 10 cms) of tibial lengthening. Other parameters included in study were Bone healing Index, total length gained and sagittal and coronal axial deformities. There were 20 females and 15 males, 21 long lengthenings and 14 modest lengthenings in the study. The joint orientation and diaphyseal angles(antero-posterior and lateral X-ray views) was used for the measurement of plastic deformation of the regenerate bone. Results: The mean age at operation was 10 years (range; 6–16 years). There were 29 cases of monolateral fixator and 6 of Ilizarov ring fixator, Of which 26 had monofocal lengthening and 9 had bifocal lengthening (34 callotasis and 1 chondrodiastasis). The total average length gained was 10 cms (range; 23–152). The mean bone healing index and external fixation index/time were 41 days and 352 days respectively. Plastic deformation of the regenerate bone was seen in 26 cases in total. 24 out of 29 cases of monolateral fixator (82%) developed plastic deformation. 44%(4/9) of bifocal group and 84%(22/26) of monofocal group showed evidence of plastic deformation. The long lengthenings showed plastic deformation in 85% (18/21) of the cases, whereas only 57%(8/14) of the cases were positive in modest lengthening group. Most of the axial deviation was in the coronal plane in 92% (24/26) and the sagittal plane accounted to only 23%(6/26) requiring surgical correction. Conclusions: Long lengthenings and monofocal techniques showed more plastic deformation than bifocal and short lengthenings. However, Ilizarov ring fixator with bifocal corticotomy seemed to be promising with less association with the above entity in our recent experience

Purpose: To alert the Orthopaedic fraternity that smoking needs to be considered in the Paediatric population and highlight it’s adverse effect on bone healing index. Method: During assessment of Paediatric patients who had undergone limb reconstruction surgery, a sub-population was found to have a prolonged time to consolidation of the regenerate to norm. Screening for contributing factors, we were surprised to learn that this subgroup were active smokers. Revisiting their radiographs, it was felt that the quality of the regenerate appeared to differ from non-smokers. Results: We identified 12 patients who were active smokers. 2 also had parents who smoked. They all exhibited a prolonged time to regenerate consolidation. We calculated their bone healing indices to compare with non smokers and found significant differences. Conclusion: Smoking has adverse effects on bone healing in children as well as adults. We have drawn up an advise sheet to make patients and their parents aware of the adverse effects of active and passive smoking on bone healing

Aims. Little is known about the effect of haemorrhagic shock and resuscitation on fracture healing. This study used a rabbit model with a femoral osteotomy and fixation to examine this relationship. Materials and Methods. A total of 18 male New Zealand white rabbits underwent femoral osteotomy with intramedullary fixation with ‘shock’ (n = 9) and control (n = 9) groups. Shock was induced in the study group by removal of 35% of the total blood volume 45 minutes before resuscitation with blood and crystalloid. Fracture healing was monitored for eight weeks using serum markers of healing and radiographs. Results. Four animals were excluded due to postoperative complications. The serum concentration of osteocalcin was significantly elevated in the shock group postoperatively (p < 0.0001). There were otherwise no differences with regard to serum markers of bone healing. The callus index was consistently increased in the shock group on anteroposterior (p = 0.0069) and lateral (p = 0.0165) radiographs from three weeks postoperatively. The control group showed an earlier decrease of callus index. Radiographic scores were significantly greater in the control group (p = 0.0025). Conclusion. In a rabbit femoral osteotomy model with intramedullary fixation, haemorrhagic shock and resuscitation produced larger callus but with evidence of delayed remodelling. Cite this article: Bone Joint J 2018;100-B:1234–40

To review the results of limb lengthening and deformity correction in fibular hemimelia, fifty-five patients with fibular hemimelia underwent limb reconstruction at Sheffield Children’s Hospital. According to Achter-man and Kalamchi classification, twenty-six were classified as Type IA, six as Type IB and twenty-three as Type II fibular hemimelia. All patients had at least some shortening of ipsilateral femur but forty-nine had sig-nificant femoral deficiency. Lengthening of tibia and in significant cases femur was done using De Bastiani or Vilarrubias or Ilizarov methods. Ankle valgus and heel valgus were corrected through osteotomies either in the supramalleolar region or heel. Equinus was corrected by lengthening of tendoachelis with posterior soft tissue release and in severe cases using Ilizarov technique. The average length gained was 4.2 cm (range 1 to 8) and the mean percentage of length increase was 15.82 (range 4.2 to 32.4). Mean bone healing index was 54.23 days/cm. Significant complications included knee subluxation, transient common paroneal nerve palsy, and recurrence of equinus and valgus deformity of foot. Overall alignment and ambulation improved in all patients. Knee stiffness due to cruciate deficient subluxations needed prolonged rehabilitation. Presence of 3-ray foot gives a better functional result and cosmetic acceptance by patients. The Ilizarov frame has the advantage to cross joints and lengthen at the metaphysis. Limb reconstruction in fibular hemimelia using limb lengthening and deformity correction techniques improve functional status of involved lower limb

Aims: To review the results of limb lengthening and deformity correction in fibular hemimelia. Methods: Fifty-five patients with fibular hemimelia underwent limb reconstruction at Sheffield Children’s Hospital. According to Achterman and Kalamchi classification, twenty-six were classified as Type IA, six as Type IB and twenty-three as Type II fibular hemimelia. All patients had at least some shortening of ipsilateral femur but forty-nine had significant femoral deficiency. Lengthening of tibia and in significant cases femur was done using either De Bastiani, Vilarrubias or Ilizarov methods. Ankle valgus and heel valgus were corrected through osteotomies either in the supramalleolar region or heel. Equinus was corrected by lengthening of tendoachelis with posterior soft tissue release and in severe cases using Ilizarov technique. Results: The average length gained was 4.2 cm (range 1 to 8) and the mean percentage of length increase was 15.82 (range 4.2 to 32.4). Mean bone healing index was 54.23 days/cm. Significant complications included knee subluxation, transient common paroneal nerve palsy, and recurrence of equinus and valgus deformity of foot. Overall alignment and ambulation improved in all patients. Knee stiffness due to cruciate deficient subluxations needed prolonged rehabilitation. Presence of 3-ray foot gives a better functional result and cosmetic acceptance by patients. The Ilizarov frame has the advantage to cross joints and lengthen at the metaphysis. Conclusion: Limb reconstruction in fibular hemimelia using limb lengthening and deformity correction techniques improve functional status of involved lower limb

Purpose: The goal of this study was to evaluate the use of dual energy x-ray absorptiometry (DEXA) to subjectively assess distraction osteogenesis callous regenerate strength to aid in the determination of when to remove the external fixator device in patients undergoing distraction osteogenesis for limb length discrepancies. Methods: All patients that underwent distraction osteogenesis with either an Ilizarov or Orthofix frame from 1984 to 2005 at the Montréal Shriners Hospital Canada that had monthly DEXA scans prior to removal of their external fixators were included. The fixators were removed once two consecutive DEXA scans showed that the bone mineral density (BMD) had plateaued with a less than 10% successive increase in BMD. A retrospective chart and radiographical review was performed to assess the healing index and post fixator removal complications. Results: 30 patients underwent 32 corrections. There were 29 lengthenings and 3 lengthenings with angular corrections. The average lengthening was 5.4 cm (3.6–9.1). The healing index average was 49 days/cm (20–77). All patients were progressed from partial to full weightbearing within 6 weeks of fixator removal. There were 2 post removal fractures. One patient fractured through the regenerate and another fractured through a proximal pin site. Conclusions: Current methods of assessing distraction osteogenesis callous prior to removal of fixator are objective methods based on plain radiographs that have been shown to have poor interobserver reliability. Fractures occurring after fixator removal range between 10–15%. Using DEXA to determine when the regenerate bone mineral density and thus bone strength has plateaued yielded a post fixator removal regenerate fracture rate of 3% in our review. This new method of subjectively assessing the regenerate as compared to other objective radiological methods is a reliable alternative that safely predicts when to remove the fixator with a low post removal fracture rate while maintaining an acceptable bone healing index

Aim: To review the results of tibial lengthening and deformities correction in children using the Sheffield Ring Fixator. Materials and methods: We have reviewed, retrospectively, 25 patients (average 12.2 years old) who underwent predominantly lengthening of the tibia using the Sheffield Ring fixator. The average follow up was 25.7 months. For logistic regression analysis the patients were binary coded into two groups: those with a good outcome (BHI< 45 days/cm) and those with a poor outcome (BHI> 45 days/cm). Various factors which may influence the out come were then analysed. Results: The most common indication for tibial lengthening in our series was for fibular hemimelia in 6 patients and achondroplasia in 4 and growth arrest secondary to trauma in 3. The mean lengthening of 48.1 mm (25–76). The mean accuracy of lengthening achieved was 85%. 11 patients had foot plate extension, and 5 had cross knee extension for unstable knee. 10 patients had bifocal osteotomy, and 8 patients had spontaneous SLR for femoral lengthening or correction. The mean bone healing index was 49 days/cm (20–95). The mean maximum correction in any one plane was 150 (3–40), the site of the osteotomy was mainly metaphyseal at an average of 25% of the tibial length. There were 5 grade II complications, 9 grades I complications and one type III complication. Thirteen patients had grade I pin site infection, three had grade II and 12 had no pin site problems. A moderately strong relationship was identified between the BHI and a number of variables such as complications, maximum correction and pin site infection grade. The analysis of the factors which may influence the BHI suggested a correlation between increasing angular correction and poor out come BHI. Conclusion: In tibial lengthening in children there is a correlation between increasing angular correction and poor out come BHI

Purpose of the study: There is a link between complications and duration of instrumentation. Since 2001, we have associated circular external fixation (EF) and stable elastic centromedullary nailing (SECMN) to shorten the duration of the external fixation in bone lengthening in children. This study was designed to assess the results of the EF+SECMN for this indication. Material and methods: From 2001 to 2009, progressive bone lengthening was performed in 250 children aged 3 to 16 years. There were 295 progressive lengthening procedures involving 339 segments. Indications were congenital (n=163) and acquired (n=87) length discrepancy. In group I (195 lengthenings, 222 segments), the Ilizarov EF was used alone. In group II, the Ilizarov (n=92, 108 segments) or the TSF (n=8, 9 segments) EF was associated with SECMN. After insertion of the EF, the centromedullary nails were introduced after the osteotomies. The healing date was the date the EF was removed; the nails were left in place to protect the bone. The healing index was calculated from duration of the EF (in days) divided by lengthening (in cm). Results: Use of SECMN shortens the duration of EF irrespective of the aetiology, the segment, the lengthening method (mono- or polysegmental, mono- or poly-focal), with a statistically significant difference between the two groups (gain of 6 to 12 d/cm). In group I, deformities or fractures of the regenerated bone after removal of the EF occurred in 21 cases (10.77%), deep infections in 4 (2.05%), osetomyelitis in 2 (1.03%). In group II, the only complications were late healing (1%) and 10° angulation at the lengthening site (1%). The centromedullary nails migrated in eight patients, with no impact on the lengthening results. Discussion: With SECMN, the lengthening procedure is achieved with an elastic but resistant system. It is hypothesised that this system stimulates osteogenesis since the healing index is improved. SECMN does not prevent progressive correction of shaft or diaphyseal deviations. By shortening the duration of external fixation, this method had a great impact on reducing serious complications such as fractures and deep infections. Conclusion: SECMN can considerably reduce the duration of external fixation during bone lengthening procedures in children and reduce (or eliminate) most of the serious complications