Background:. External fixators are not as well tolerated around the femur when compared to the tibia. Lengthening with an intramedullary device is therefore attractive. Method:. We reviewed all cases of femoral lengthening performed at our unit from 2007 to 2014. Cases of non-unions, concurrent deformities, congenital limb deficiencies and lengthening with an unstable hip were excluded. This left 33 cases for review. Healing index, implant tolerance and complications were compared. Results and Discussion:. In 20 cases the Precice lengthening nail was used and in 13 cases the LRS external fixator system. The desired length was achieved in all cases in the Precice group and in 12 of 13 cases in the LRS group. The Precice group had a more rapid return to full weight bearing. The mean healing index was 31.3 days/cm in the Precice and 47.1 days/cm in the LRS group. There was an increased incidence of complications with LRS lengthening, including pin site infections and regenerate deformity. Implant tolerance and the patients' perception of the cosmetic result were better with the Precice treatment. Conclusion:. We conclude excellent functional results with fewer complications and greater patient satisfaction in femoral lengthening with a Precice intramedullary nail

Limb reconstruction requires high levels of patient compliance and impacts heavily on social circumstances. The epidemiology and socioeconomic description of trauma patients has been well documented, however no study has assessed the epidemiology of limb reconstruction patients. The aim of this project is to describe patients attending Limb Reconstruction Services (LRS) in order to highlight and address the social implications of their care. All LRS cases under a single surgeon in a district general hospital were included from 2010 – 2016. Demographics, ASA grade, smoking status, mental health status and employment status were collated. Postcode was converted into an Index of Multiple Deprivation score using GeoConvert® software. Patient socioeconomic status was then ranked into national deprivation score quintiles (quintile 1 is most affluent, quintile 5 is most deprived). Deprivation scores were adjusted by census data and analysed with Student's T-test. The distance from the patient's residence to the hospital was generated through AA route planner®. Patient attendance at clinic and elective or emergency admissions was also assessed. Patient outcomes were not part of this research. There were 53 patients, of which 66% (n=35) were male, with a mean age of 45 years (range 21–89 years). Most patients were smokers (55%, n=29), 83% (n=42) were ASA 1 or 2 (there were no ASA 4 patients). The majority of indications were for acute trauma (49%), chronic complications of trauma (32%), congenital deformity (15%) and salvage fusion (4%). Mental health issues affected 23% (n=12) of cases and 57% of working-aged patients were unemployed. Mental health patients had a higher rate of trauma as an indication than the rest of the cohort (93% vs. 76%). Deprivation quintiles identified that LRS patients were more deprived (63% in quintiles 4 and 5 vs. 12% of 1 and 2), but this failed to reach statistical significance (p=0.9359). The mean distance from residence to hospital was 12 miles (range 0.35–105 miles, median 7 miles). The patients derived from a large region made up of 12 local authorities. There was a mean of 17 individual LRS clinic attendances per patient (range: 3–42). Cumulative distance travelled for each patient during LRS treatment was a mean of 495 miles (range 28 – 2008 miles). The total distance travelled for all 53 patients was over 26,000 miles. The results largely mirror the findings of trauma demographic and socioeconomic epidemiology, due to the majority of LRS indications being post-traumatic in this series. The high rates of unemployment and mental health problems may be a risk factor for requiring LRS management, or may be a product of the treatment. Clinicians may want to consider a social care strategy alongside their surgical strategy and fully utilise their broader MDT to address the social inequalities in these patients. This strategy should include a mental health assessment, smoking cessation therapy, sign-posted support for employment circumstances and a plan for travel to the hospital. The utilisation and cost of ambulance services was not possible with this methodology. Further work should prospectively assess the changes in housing circumstances, community healthcare needs and whether there was a return to employment and independent ambulation at the end of treatment

Objectives. Pedicle-lengthening osteotomy is a novel surgery for lumbar spinal stenosis (LSS), which achieves substantial enlargement of the spinal canal by expansion of the bilateral pedicle osteotomy sites. Few studies have evaluated the impact of this new surgery on spinal canal volume (SCV) and neural foramen dimension (NFD) in three different types of LSS patients. Methods. CT scans were performed on 36 LSS patients (12 central canal stenosis (CCS), 12 lateral recess stenosis (LRS), and 12 foraminal stenosis (FS)) at L4-L5, and on 12 normal (control) subjects. Mimics 14.01 workstation was used to reconstruct 3D models of the L4-L5 vertebrae and discs. SCV and NFD were measured after 1 mm, 2 mm, 3 mm, 4 mm, or 5 mm pedicle-lengthening osteotomies at L4 and/or L5. One-way analysis of variance was used to examine between-group differences. Results. In the intact state, SVC and NFD were significantly larger in the control group compared with the LSS groups (P<0.05). After lengthening at L4, the percentage increase in SCV (per millimetre) was LRS>CCS>FS>Control. After lengthening at L5 and L4-L5, the percentage increase in SCV (per millimetre) was LRS>FS>CCS>Control. After lengthening at L4 and L4-L5, the percentage increase in NFD (per millimetre) was FS>CCS>LRS>Control. After lengthening at L5, the percentage increase in NFD (per millimetre) was CCS>LRS>control>FS. Conclusions. LRS patients are the most suitable candidates for treatment with pedicle-lengthening osteotomy. Lengthening L4 pedicles produced larger percentage increases in NFD than lengthening L5 pedicles (p < 0.05). Lengthening L4 pedicles may be the most effective option for relieving foraminal compression in LSS patients. Cite this article: P. Li, L. Qian, W. D. Wu, C. F. Wu, J. Ouyang. Impact of pedicle-lengthening osteotomy on spinal canal volume and neural foramen size in three types of lumbar spinal stenosis. Bone Joint Res 2016;5:239–246. DOI: 10.1302/2046-3758.56.2000469

Purpose: The aim of this part retrospective and part prospective study was to establish the incidence of pinsite infections and assess evolution of changes in practice. Methods: Data was collected retrospectively and prospectively for pin site infections from the inception of limb reconstruction service viz. 1985 to January 2002. There were 812 patients, 1042 limb segments, and 9935 pins. The various external fixators used were limb reconstruction system (LRS) 549; Ilizarov 397; Sheffield ring fixator (SRF); Dynamic axial fixator (DAF) 35; LRS/Sequoia 8; LRS/Garche 7; and Pennig 5. Results: The pin site infections were graded from 0 to 6 ( Saleh & Scott). There were no infections in 206 segments. The infection grade is shown below:. We changed our pin tract care practice from 1996. We had a significant decrease in pin tract infections since then (p< 0.0001). We also found that using Ilizarov wires had significantly less infections than with half pins used with monolateral fixators (p< 0.0001; linear trend, p= 0.0338). There were 48 patients that required hospital admissions for IV antibiotics. and of these 10 patients required debridement. There were no residual long lasting infections or chronic osteomyelitis. Conclusion: Attention to detail in insertion of wires and half pins is crucial to avoid pin site infections. This audit supports the fact that external fixation is a safe method from the point of view of infection contrary to general belief

Purposes of the study. To assess safety, lengths gained, frame time and perform cost analysis of the technique of submuscular plating to the femur and tibia following distraction osteogenesis. Introduction. Since 2005 we have performed submuscular plating to the femur and tibia after distraction osteogenesis in order to shorten time in external fixator. Aim. To assess safety, lengths gained, frame time and perform cost analysis. Methods. Retrospective analysis using notes and digital radiographs, with cost codes for 2011 prices. Patients. 23 patients (14 male), mean age 11 (range 4 to 17). 14 diagnosed as congenital longitudinal deficiency. Total 37 bones lengthened (14 femur and tibia, 7 tibia only, 2 femur only). Ilizarov fixator most commonly used for tibia, LRS fixator for femur. Results. Mean length gained 68 mm per patient, 43 mm per bone. Mean frame time 121 days. Fixator index 0.59 months/cm per patient, 0.90 months/cm per bone. Mean cost £20100 per patient, £12500 per bone, £2800 per cm length. Cost attributable to plating £5100 per patient, £3300 per bone. Complications: 5/24 had pinsite infections, 2/24 required tendon releases, 1/24 had deformity, 1/24 sustained a fracture proximal to femoral plate. No deep infections. Conclusions. Plating after lengthening is a safe procedure with no deep infections. The frame time is low (0.6 months/cm per patient) but increases overall costs by an extra £5000

Aims. Since 2005 we have performed submuscular plating to the femur and tibia after distraction osteogenesis in selected cases in order to shorten the time in external fixator. The aim was to assess safety, lengths gained, frame time and perform cost analysis. Methods. Retrospective analysis using notes and digital radiographs, with cost codes for 2011 prices. 23 patients (14 male), mean age 11 (range 4 to 17) were analysed. 14 were diagnosed as congenital longitudinal deficiency. Total 37 bones lengthened (14 femur and tibia, 7 tibia only, 2 femur only). Ilizarov fixator most commonly used for tibia, LRS fixator for femur. Results. Mean length gained 68mm per patient, 43mm per bone. Mean frame time 121 days, with mean 75 days of lengthening, and mean 46 days between the cessation of lengthening and the plating procedure. Fixator index 0.59 months/cm per patient, 0.90 months/cm per bone. Mean cost £20100 per patient, £12500 per bone, £2800 per cm length. Cost attributable to plating £5100 per patient, £3300 per bone. Complications: 5/24 had pinsite infections, 2/24 required tendon releases, 1/24 had deformity, 1/24 sustained a fracture proximal to femoral plate. No deep infections. In terms of patient satisfaction, families of patients who had also undergone a prior lengthening with frame only, 80% preferred plate after lengthening. Conclusions. Plating after lengthening is a safe procedure with no deep infections. The frame time is low (0.6 months/cm per patient) but increases overall costs by an extra £5000 per patient. There is room to improve the fixator index further if the time between cessation of lengthening and the plating procedure (currently 46 days) is shortened

The purpose of this study is to classify the pitfalls, obstacles and complications that occur during distraction histogenesis and also to evaluate the risk factors likely to lead to these problems. In this study we have retrospectively and prospectively studied the difficulties occurring during distraction histogenesis since 2003. We studied 74 patients (mean age 19,2 years, age range 11–60 yrs) whose 97 limbs segments were lengthened. 21 patients underwent angular correction, 42 patients limb lengthening, 17 patients both angular correction and limb lengthening and 14 non-union correction. In 46 cases, we used the Ilizarov fixator, in 38 the Taylor Spatial Frame and in 10 cases the monolateral external fix-ator Orthofix LRS. Difficulties that occured during limb lengthening were subclassified into pitfalls, obstacles, and complications. For all cases we have recorded the time of appearance of all these difficulties and have associated them with the severity of the initial deformity. The total number of difficulties in distraction histogenesis was 20%. The number of presenting problems was estimated 5.4% and involved knee subluxation, pin breakage and malalignments. Obstacles presented in 9.5% and included cases with poor bone regeneration, peroneal nerve palsy, premature consolidation and heel cord lengthening. Finally complications were noted in 5.4% of the cases. These consisted of infection, fracture, non-union and loss of range of knee motion. The problems, obstacles and complications that occur during distraction histogenesis can all impact on the optimal therapeutic target. Extensive surgical experience, and optimal pre-operative planning in conjunction with the type of the original deformity may all contribute in minimising these difficulties

Aims: To review the presentation, progression, treatment, and outcome of congenital posteromedial bow of tibia. Methods: Seventeen patients were studied using radiographs and medical records retrospectively. The time period was from 1989 to 2002. Data was collected with special reference to deformity correction and lengthening. Complications were analysed. Results: Eight of the patients were male and nine female; eleven of them had deformity correction and lengthening, whereas two are awaiting surgery, two underwent contralateral epiphysiodeses and one, periosteal stripping. Twelve were treated with the Ilizarov device, seven with LRS. The range of discrepancy pre – operatively was from 3 to 8.8 cm. Mean length gained was 3.7 cm with residual discrepancy within 0.6 cm. Complications noted were minor grades of infection and 3 patients required further corrective surgery. The bone-healing index was 62 days per cm. There was some decrease in ankle movement noted, this was unchanged or improved post-operatively. Conclusion: Successful simultaneous deformity correction and lengthening for this condition is possible. The Ilizarov frame provided more benefits in reducing complications. This is the largest series of lengthening and correction of this deformity published and the residual deformity and initial length discrepancy is greater than previously stated

Introduction and Aims: I was presented with a Land-mine victim with closed fracture of right talus, compound injury to left lower limb, and defect in heelpad. Distal third of tibia and most of hindfoot were missing. Left foot neurovascularly intact and he was able to move his toes. Aim: reconstruct left distal tibia to enable full weight-bearing. Method: Lower leg debrided. LRS applied, using proximal ring with Sheffield clamp and two rings around foot. Corticotomy of proximal tibia. Bone transport, 10 days later. Heel debridement, to clear necrotic bone. Two months later transported bone was 2cm from ankle. Sepsis controlled. Distal tibia beveled, bone transport continued. Docking procedure performed. Ex-fix adjusted, attaining compression of hindfoot and midfoot. Distal tibia and foot transported 4cm, to correct disproportion. Osteoset used for bone growth. During the following two years, length discrepancy resolved, sepsis manageable. X-rays showed two cortices between proximal tibia and transported tibia. Fixator removed two months later. Received orthotic boot. Results: In September 2003 the patient came for follow-up. There was no evidence of sepsis in the leg. He was full weight-bearing using an orthotic shoe and rocker bottom sole. There was no pain. He had left the army and was now working as a builder in his country of origin and putting in a whole day’s work. The length of the transported segment is approximately 14cm. It is now fully consolidated and four cortices are visible on x-ray. The fusion of the distal tibia into the foot is solid and no pain is experienced from that. Conclusion: Big defects in the distal tibia can be managed with a straight rail reconstruction system, using unifocal bone transport with proximal corticotomy

Aim: To review the outcome following growth plate arrest in distal femur and proximal tibia of different aetiology in adults. Materials and methods: We have reviewed, retrospectively, eight adult patients with lower leg deformity in the distal femur and proximal tibia, as a sequelae of growth plate arrest of different aetiology. These patients underwent tibial and femoral, correction and lengthening. The total number was 8 patients, there were 6 male and 2 female, with an average age of 22.8 years (17–34.8) The average follow up was 32.9 months (7.9–51.4). Results: Four patients had growth plate arrest following trauma (two patients were involved in road traffic accidents, one had Salter-Harris type V fracture of the proximal tibia and one had sport injury), two patients had iatrogenic growth plate arrest after internal fixation of tibial spine in one patient and after internal fixation of a popliteal muscle rupture in the other, one patient had Osgood Schlater disease, one patient had childhood osteomyelitis and one unknown pathology. The average shortening was 34.8 mm (8–60), the average maximum deformity in any one plane was 19.8 degree (6–40). All the patient underwent corrective surgery and lengthening, five patients had Sheffield Ring Fixator, two had Limb Reconstruction System and one had percutaneous osteotomy on Albizzia nail. The patients who underwent SRF and LRS stayed in the frame for an average 258 days (150–435). The residual leg length discrepancy was 5.5 mm (0–12). There was three grade one complications, three grade two complications, and one patient had grade IV complication following compartment syndrome. Four patients had grade two pin site infection and three patients had grade one. Conclusion: Growth plate arrest of the distal femur and proximal tibia can cause severe deformity and shortening of the lower limb in adult, and this deformity is amenable to correction in the end of growth using different techniques. We used Sheffield ring fixator in complex cases, to address both deformities and lengthening, while other techniques were used in less complex cases