Background: The occurrence of congenitally short metatarsals is associated with an abnormal gait and an aesthetically displeasing appearance. Similarly, short metacarpals result in severe cosmetic disfigurement, particularly in young female patients. Methods: We examined and performed bone lengthening surgery in 13 female and 2 male patients. Of these, procedures were conducted on 12 metatarsals of 8 patients, 4 metacarpals and 1 metatarsal of a single patient, 1 metacarpal and 1 metatarsal of a single patient and 7 metacarpals of 5 patients. The mean age of the patients who underwent metacarpal procedures was 14.5 (10–21) years while the mean age of those who underwent metatarsal procedures was 17.5 (10–25) years. The callotasis method was employed for these procedures and we used either a unilateral external fixator and/or a circular external fixator. Results: The mean healing index and increase in metacarpal length was 1.6 (1.1–2.3) months/cm and 17.6 (13–26) mm, respectively. The mean follow-up period for patients who underwent metacarpal lengthening was 57.5 (12–96) months. The mean healing index and increase in metatarsal length was 1.6 (1.0–2.0) months/cm and 24.3 (20–30) mm respectively. The mean follow-up period for patients who underwent metatarsal lengthening was 48.3 (12–72) months. The preoperative AOFAS (American Orthopaedic Foot and Ankle Society) scores were good in 5 and excellent in 9 cases. The functional scores of metatarso-phalangial (MTP) joint of lengthened metatarsals for the lesser toe were excellent in 12 and good in 2 cases based on the AOFAS scoring system. All patients who underwent metacarpal lengthening reported that they were satisfied and could conduct their daily activities with good functional and aesthetic results. Complications included 4 angulations, 1 subluxation and 1 non-union and were seen in 6 of the metatarsal lengthening cases that exceeded 40% (or > 20 mm) of the total length of the original bone. Interpretation: There are recommendations in the literature that allow for the avoidance of severe complications and for the shortening of the consolidation period. We conclude that the periosteum must be protected with percutaneus osteotomy and lengthening should be performed at a rate of 0.25 mm twice a day, should not exceeding 40% of the original bone length (or > 20 mm). If the anticipated lengthening exceeds these predefined values then we suggest that the procedure should be performed using a circular external fixator with temporary fixation of the MCP or the MTP joint and the inclusion of the proximal phalanx in the frame

Patient's non acceptance of a bulky external fixator, the incidence of fractures of the regenerate, muscle transfixion giving rise to contractures especially in the Tendo Achilles, increased index of consolidation and the frequency of infections has made Limb lengthening with external fixators alone unpopular. In a retrospective study, we evaluated the technique of limb lengthening over a sub muscular plate combined with Ilizarov external fixator as an alternative to external fixator alone and whether the combined procedure is successful in reducing the external fixator period. 15 patients (14 with length discrepancy in the lower limb and 1 with low stature) and a total of 16 limbs (15 tibiae and 1 femur) were lengthened over a sub muscular plate fixed on the proximal segment followed by corticotomy and application of external fixator. Lengthening was achieved at 1 mm/day followed by distal segment fixation with three or four screws on reaching the target length. The pre operative target length was successfully achieved in all patients at a mean of 4.4 cm (2.2 to 6.5 cm). The mean duration of external fixation was 59.2 days (33 to 107 days) with the mean external fixation index at 16.7 days/cm (10.95 to 23.78). Infection complicated the procedure in two patients and one patient had mild Tendo Achilles contracture. Lengthening over a plate drastically reduces the time external fixator needs to worn and is preferred by patients to limb lengthening over an external fixator alone. patient Lengthening over a plate provides an alternative method for limb lengthening, can be applied to children with open physes and to deformed bones. [Lengthening over a Plate]

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

Limb lengthening with external fixators has many complications, like pin track infection, joint stiffness, severe pain and stress fracture after removal of external fixator. Prolonged period in external fixator interferes with rehabilitation and activities of daily living. We describe our results with ISKD (intramedullary skeletal kinetic distractor) system, an internal limb lengthening device, activated with rotations of 3 degrees. In this retrospective cohort we performed lengthening with the use of ISKD in 12 patients from March 2006 to date. Ten patients were included in this study as two patients had not completed the stage of consolidation. There were 7 male and 3 female patients. Their average age was 44 years (range 23–63). The mean follow up period was 16 months (range 12–24 months). Two patients had tibial lengthening and eight patients had femoral lengthening. The average lengthening desired was 42.5 mm (range 2.5 mm–75 mm). The average lengthening achieved was 38 mm. Mean hospital stay was 7 days (range 5–11 days). The distraction index was 1.2 mm/day. The average time to full weight bearing was 6 months (range 4 to 10 months). Mean healing time was 10.25 months. The mean healing index was 90.7 days/cm. If we remove two patients who took long time to heal, the mean healing index drops to 61 days/cm. Two patients needed bone grafting at the distraction site. None of the patients had infection, non-union of the distraction site or breakage of the nail. None of the patients had joint stiffness. All patients were completely satisfied with the treatment and had excellent functional results. We conclude that the low rate of complications, higher patient acceptability and avoidance of external fixation make ISKD a very attractive option for limb lengthening

Introduction. Growing rods are used in the treatment of early-onset scoliosis. The aim of this technique is to achieve deformity correction while maintaining spinal growth. Gradual stiffening or spontaneous fusion of the spine can interfere with the ability to lengthen. Furthermore, diminished acquired length with serial distraction is common and needs to be evaluated and quantified. The purpose of this prospective study was to measure the forces and amount of distraction over time in patients with early-onset scoliosis treated with growing rods. Methods. Distraction forces were measured prospectively during 60 consecutive lengthening procedures in 26 patients. All patients had single submuscular rod constructs with side-to-side connectors. For every measurement, output from a transducer on a dedicated pair of distraction calipers was recorded at zero load status, and the force was then recorded at every 1 mm lengthening; length was obtained at each event and was recorded in millimeters. Results. The force required to distract the spine doubled at the fifth lengthening procedure (mean 368 N [SD 54]), and the distraction force was significantly higher at the fifth lengthening than at previous lengthening (p<0·01). Mean length achieved at each distraction decreased over time, such that by the fifth lengthening, 8mm or less was consistently achieved. Conclusions. Distraction forces increase significantly after repeated lengthening of growing rod constructs, and the length obtained at each procedure decreases

Introduction. Indications for the use of external fixation include damage control orthopaedics, definitive fracture treatment, deformity correction and leg lengthening. Despite many advances in the development of external fixation techniques, pin-tract infection and loosening are still significant complications. They are the most commonly occurring complications during limb lengthening using external fixation, with some studies reporting an incidence of up to 80%. Objectives. The main aim of this systematic review was to investigate HA-coated versus uncoated external fixator pins used in patients undergoing leg lengthening and determine benefits in terms of pin loosening, infection and loss of reduction/malunion. Methods. A systematic literature search of MEDLINE (PubMed), EMBASE and Cochrane library databases was undertaken. Comparative trials investigating HA-coated versus uncoated external fixation pins used in patients undergoing leg lengthening procedures were identified. These were critically appraised as per the CASP (Guyatt et al) and CONSORT guidelines (Schulz et al., 2010). Primary outcome measures included pin loosening and infection. Secondary outcome measures included loss of reduction/malunion. Results. All studies identified had different criteria for defining pin loosening and infection. However, they all demonstrated a statistically significant reduction in loosening with HA-coated pins. Review of the studies included demonstrated insufficient evidence to determine any significant clinical benefit with regards to infection and malunion. Critical appraisal demonstrated average methodological quality of the studies. Conclusion. HA-coating of external fixator pins improves bone fixation and reduces loosening in patients undergoing leg lengthening procedures, but the influence on infection and malunion is not clear

Aim: presentation of a new lengthening device which is reliable and overcomes the problems seen with the classical Ilizarov frame, based on the principle of fluid mechanics. Methods: we followed ten cases until bone healing. After corticotomy, the telescoping nail is brought into the femur or tibia like a normal IM nail. Diameter for the femoral nail 13 mm, 12mm for the tibia nail. In the proximal sector of the nail, the sterile arachid oil presses the plunger of the hydraulic actuator (pressure cell) out of the piston. It pushes against the distal nail which is locked in the distal femur with two screws. In all but one case, lengthening was done because of post-traumatic shorthening. In one femur with a defect of 10 cm a bone transport was performed using this system to fill the gap. The pressure in the nail was increased with an external syringe-pump, attached two times daily via a quick coupling (swage lock) mechanism to the inlet port of the nail (60 Bar for the femur and 40 Bar for the tibia). Lengthening at a rate of 1.8 mm day was possible with remarkable comfort for the patient. The silver coated inlet port (tube of 2mm) gave no skin reaction in nine cases. In one femur there was slight drainage of fluid which stopped spontaneously after two weeks. While lengthening, patients were allowed to walk with partial weight bearing. After lengthening, the oil was released and the inlet port cut off underneath the skin. Results: all cases could be brought up to length in the desired time frame. Additional surgery was necessary in two cases to enhance bone healing (one autologous bone graft, one bone marrow injection). No implant failure or other undesired side effects were noticed with this method. Conclusion: preliminary good results were achieved with this new apparatus, which seems to give reproducible results with less burden to the patient. Lengthening can be achieved much faster than with the classical distraction method of Ilizarov

Purpose: To calculate a clinically relevant and intra-operatively accessible measure of olecranon length that could be reliably applied by the operating surgeon to optimise comminuted olecranon fracture fixation. Materials: One hundred normal adult anteroposterior and lateral radiographs of the elbow were studied with respect to the proximal olecranon width (OW), greater sigmoid notch width (SW) on lateral views, trans-epicondylar distance (TED), and trochlear width distance (TWD) on AP views. The mean ratios of TWD/SW and TED/SW and an index OW X SW/TED along with their standard deviation and normal ranges were calculated. Results: The average olecranon width was 24mm (range 21mm–28mm), sigmoid width was 25.8 mm (range 21mm–32 mm), trans-epicondylar distance was 58.53mm (range 49mm–74 mm), and the trochlear width distance was 27.1mm (range 22mm–32 mm). The average ratio of TWD: SW was 1.05 with a standard deviation of 0.09 and that of TED: SW was 2.27 with a standard deviation of 0.19. The average index worked out to be 10.58 with a standard deviation of 0.2. Conclusions: Comminuted fractures of olecranon are a surgical challenge since it is often impossible to gauge the correct length of the olecranon process. There have been no objective data described to prevent shortening or lengthening of the greater sigmoid notch after reconstruction. Our data can be easily applied to the clinical situation, by taking intra-operative radiographs, and calculating the index as demonstrated above. This index will guide the surgeon to obtain a more reliable length of the olecranon, and devolve surgical guesswork from the final outcome

Introduction. The practice of limb lengthening using intramedullary nails has surged in popularity in recent years. Our study explores the relationship between femur lengthening and overall height gain in adults undergoing cosmetic limb lengthening with telescoping magnetic intramedullary lengthening nails (MILNs). Materials & Methods. Demographic information, pre- and postoperative radiographic data, and secondary outcomes, such as mechanical angles and sagittal alignment, were analyzed for 42 adult femurs MILNs (PRECICE 2, NuVasive, Inc.). Height was assessed with a digital stadiometer. Limb lengthening was defined as the amount of nail distraction seen on a calibrated weight bearing X-ray at consolidation. mLDFA, mMPTA, MAD, AMA, and femoral sagittal bow were evaluated as secondary outcomes. Results. Mean starting height was 163.5 cm (SD 10.4, range 137–179) Post -lengthening mean height increased to 171.1 cm (SD 10.1, range 146.7–185.3). Average height gain was 7.5 cm (SD 1.3 cm, range 5.1–9.5). Average femoral lengthening was 7.3 cm (SD 1.14, range 4.1–10.1). There were no statistically significant difference between height gain and femur lengthening. Secondary outcomes showed reductions in femoral sagittal bow and AMA. Conclusions. We conclude that measuring femur lengthening is a reliable and accurate method of measuring gained height in deformity-free patients undergoing limb lengthening. We further reason that straightening of both femoral and spinal sagittal bow counteracts potential lengthening loss over the anatomical axis, versus mechanical axis lengthening

Introduction. The FitBone lengthening nail (Orthofix UK) is an intramedullary device licensed for the lengthening of long bones in adults in the UK. It contains a motor powered by electricity transmitted via an induction coil placed underneath the skin. It was developed in Germany two decades ago but uptake in the UK has only started more recently. The aim of this study was to review the first cohort of FitBone lengthening nails in a unit with significant experience of other lengthening nails (including PRECICE and Stryde). Materials & Methods. Demographic, clinical and radiological data was prospectively collected on all FitBone cases starting in February 2022. Accuracy of lengthening rate, patient satisfaction and implant issues were all considered. Complications and learning points were recorded and discussed by the multidisciplinary team involved in the patients care. Results. Eleven lengthening nails were inserted between February and November 2022 (6 right femurs, 5 left femurs). The average patient age was 31 (16–57) with 4 females and 7 males. The average lengthening achieved was 44mm (13– 70) over an average of 59 days (35 to 104). Significant technical issues were encountered in this cohort of patients including slow opening up at osteotomy site (3 requiring speeding up of programme), early consolidation (one requiring re-do osteotomy) and backing out of locking screws (3 out of 11 nails). There were also patient use concerns with difficulty using the motor and the inability to reverse the lengthening without an additional component to the motor. Conclusions. We present the first UK cohort of patients with femoral lengthening using the FitBone implant and device. We highlight the technical and patient issues encountered during this learning curve and propose solutions to avoid these pitfalls

Introduction. Sheffield Children's Hospital specialises in limb lengthening for children. Soft tissue contracture and loss of range of motion at the knee and ankle are common complications. This review aims to look at therapeutic techniques used by the therapy team to manage these issues. Materials & Methods. A retrospective case review of therapy notes was performed of femoral and tibial lengthening's over the last 3 years. Included were children having long bone lengthening with an iIntramedullary nail, circular frame or mono-lateral rail. Patients excluded were any external fixators crossing the knee/ankle joints. Results. 20 tibial and 25 femoral lengthening's met the inclusion criteria. Pathologies included, complex fractures, limb deficiency, post septic necrosis and other congenital conditions leading to growth disturbance. All patients had issues with loss of motion at some point during the lengthening process. The knee and foot/ankle were equally affected. Numerous risk factors were identified across the cohort. Treatment provided included splinting, serial casting, bolt on shoes, exercise therapy, electrical muscle stimulation and passive stretching. Conclusions. Loss of motion in lower limb joints was common. Patients at higher risk were those with abnormal anatomy, larger target lengthening's, poor compliance or lack of access to local services. Therapy played a significant role in managing joint motion during treatment. However, limitations were noted. No one treatment option gave preferential outcomes, selection of treatment needed to be patient specific. Future research should look at guidelines to aid timely input and avoid secondary complications

Introduction. The effect of lower extremity lengthening on physeal growth is still controversial. We aim to compare data of the patients who had bilateral simultaneous femur and tibia lengthening with the patients who underwent the lengthening surgery separately for the femur and tibia at the end of completed skeletal maturation in terms of the effect of physeal growth. Materials and Methods. Twenty-six patients were included who operated in our clinic between 1995 and 2015 for limb lengthening. Fourteen patients with bilateral lengthening of the femur and tibia at the same time were named as simultaneous lengthening (SL). Twelve patients with bilateral lengthening of the femur and then bilateral tibia lengthening seperately were named consecutively lengthening (CL). All patients were followed until completion of growth. The physeal arrest was measured using predicted length (investigated with the multiplier method), the total amount of lengthening and final length. Results. Mean lower limb lengthening was 145 mm (48,5%) and 151 mm (46,6%) for simultaneous and consecutive groups respectively. For lower extremity length, the SL reached 527,6 mm while expected was 447,3 mm. Considering 151 mm lengthening, the mean growth disturbance for the SL was 70,7 mm. The CL group revealed a mean of 47,5 mm disturbance. For total height comparison, disturbance was 80,5mm and 65,4mm respectively. Conclusions. Although simultaneous four segment lengthening have more physiological physeal disturbance effects compared to consecutive operations, there was no statistical difference between the two groups

Introduction. Motorised intramedullary lengthening nails are considered more expensive than external fixators for limb lengthening. This research aims to compare the cost of femoral lengthening in children using the PRECICE magnetic lengthening nail with external fixation. Materials and Methods. Patients: Retrospective analysis of 50 children who underwent femoral lengthening. One group included patients who were treated with PRECICE lengthening nails, the other group included patients who had lengthening with external fixation. Each group included 25 patients aged between 11–17 years. The patients in both groups were matched for age. Cost analysis was performed following micro-costing and analysis of the used resources during the different phases of the treatments. Results. : Each group's mean patient age was 14.7 years. Lengthening nails were associated with longer operative times compared to external fixators, both for implantation and removal surgery (P-value 0.007 and <0.0001 respectively). Length of stay following the implantation surgery, frequency of radiographs, frequency of outpatient department appointments were all more favourable with lengthening nails. The overall cost of lengthening nails was £1393 more than external fixators, although this difference was not statistically significant (P-value 0.088). Conclusions. The cost of femoral lengthening with lengthening nails was not significantly higher than the external fixators’ cost. Further research to review the effectiveness of the devices and the quality of life during the lengthening process is crucial for robust health economic evaluation

Introduction. Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated. Materials & Methods. Retrospective radiological and clinical analysis of 25 patients (14 females, 11 males) who underwent intramedullary femoral lengthening with an antegrade PRECICE® lengthening nail as well as tHED of the distal femur and / or proximal tibia between 2014 and 2019. tHED was conducted by implantation of flexible staples (FlexTack™) either prior (n = 11), simultaneously (n = 10), or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). Results. The median initial LLD was 39.0 mm (35.0–45.0). 21 patients (84%) presented valgus and 4 (16%) showed varus malalignment. Leg length equalization was achieved in 13 patients at skeletal maturity (62%). The median LLD of patients with a residual LLD > 10 mm was 15.5 mm (12.8–21.8). Limb realignment was obtained in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Conclusions. The combination of antegrade femoral lengthening and tHED can efficiently correct LLD and coronal limb malalignment in skeletally immature patients. Nevertheless, achieving limb length equalization and realignment may render difficult in cases of severe LLD and angular deformity. Furthermore, the reported techniques ought to be thoroughly planned and executed and require regular clinical and radiological examinations until skeletal maturity to avoid - or timely detect and manage - adverse events such as overcorrection and rebound of deformity

Introduction. A 6cm femoral gain requires 5-Y during normal growth, but only 6–8-W surgically (x30–40 faster). In lengthening surgery, losses of muscle force (MF) and circumferences (MC) are major. Recovery is long, preventing sports till bone fusion. Can we maintain MC and strength throughout the entire lengthening and how?. We monitored for over 30 years patients for muscle force (isokinetic), circumferences, activities (including sports) and food intake, and acted on the 5 principles of the Osteostasis. Materials & Methods. Over 750 femoral lengthening with Full WB Nails (FWBN) got Isokinetic testing (≧1991), circumferences measurements (≧2012; 20-15-10-5-0cm above patella, max-calf, mini/max-ankle), food intake (≧2012), using MyFitnessPal App (≧2016), gradually enforced. Preoperative training along with a daily post-operative training are supervised by our trainers. Recommendations for food intake and activities were provided. Patients noted on a specific App all parameters. Compliance was noted. Results. Instead of a traditional 7–9cm circumference loss for 8–10cm gains using Ex-fix or nails, with FWBN and our protocols, no MC loss could be noted in compliant pre-trained patients, intensive early post-op resistance training, high calory intake (M:>4200, F:>3000; 20–25% Proteins) and supplements (no fat pad increase). Bone fusion could be obtained at the end of lengthening or within short weeks (Healing Index down to 8D/cm). Non-compliant patients (or using morphine), lost weight and MC. Conclusions. Increasing by 8–10cm muscle length, even bilaterally, and maintaining MC during lengthening, is possible, with very fast bone fusion. It requires building up several hundred of grams of muscles. The ‘building up equation’ associating resistance bike from the early post-operative phase with sports, strong food intake with increased protein intake, and added supplements with no morphine medication, proved to boost circumferences and bone fusion. It induced fast recovery, walking and sports capacities

Introduction. Management of deformity involving limb length discrepancy (LLD) using intramedullary devices offers significant benefits to both patients and clinicians over traditional external fixation. Following the withdrawal of the PRECICE nail, the Fitbone became the primary implant available for intramedullary lengthening and deformity correction within our service. This consecutive series illustrates the advantages and complications associated with the use of this device, and describes a novel technique modification for antegrade intramedullary lengthening nails. Materials & Methods. A retrospective cohort review was performed of patient outcomes after treatment with the Fitbone nail at two tertiary referral limb reconstruction services (one adult, one paediatric) between January 2021 to December 2023. Aetiology, indications, initial and final LLD, use of concomitant rail assisted deformity correction (ORDER), removal time and healing index were assessed. Complications of treatment were evaluated and described in detail, alongside technique modifications to reduce the rate of these complications. Results. 21 nails (18 femoral, 2 tibial, 1 humeral) were inserted in 6 adult and 13 paediatric patients. Post-traumatic and congenital/developmental LLD were the most common indications for surgery in the adult and paediatric cohorts respectively. ORDER was employed in 11 cases (9 femurs and 2 tibias). Treatment goals were achieved in all but one case. Complications included superficial infection, locking bolt migration, periprosthetic fracture and component failure. Seven patients required unplanned returns to theatre. Conclusions. The Fitbone nail is an established option for intramedullary limb lengthening, however its use in the UK has been relatively limited compared to the PRECICE until 2021. Our data helps to define its place for limb lengthening and complex deformity correction in both adult and paediatric patients, including in humeral lengthening and retrograde femoral insertion across an open physis. We have identified important potential risks and novel techniques to simplify surgery and avoid complications

Introduction. At Sheffield Children's Hospital, treatment of leg length discrepancy is a common procedure. Historically, this has been done with external fixators. With the development in intramedullary technology, internal nails have become the preferred modality for long bone lengthening in the adolescent population. However, it is important to review whether this technology practically reduces the known challenges seen and if it brings any new issues. Therefore, the aim of this review is to retrospectively evaluate the therapeutic challenges of 16 fit-bone intramedullary femoral lengthening's at Sheffield Children's Hospital between 2021–2022. Materials & Methods. The international classification of function (ICF) framework was used to differentiate outcomes. The patient's therapy notes were retrospectively reviewed for themes around structural, activity and participation limitation. The findings were grouped for analysis and the main themes presented. Results. There were 8 males, mean age 17.4 years (range 17–18) and 8 females, mean age 15.9 years (range 14–18). 5 right and 11 left femurs were lengthened. Underlying pathology varied amongst the 16 patients. All patients went into a hinged knee brace post operatively. Structural limitations included: pain, fixed flexion deformity of the knee, loss of knee flexion, quadriceps muscle lag, muscle spasms and gluteal weakness. The primary activity limitation was reduced weight bearing with altered gait pattern. Participation limitations included reduced school attendance and involvement in activities with peers. Access to Physiotherapy from local services varied dramatically. Five of the cohort have completed treatment. Conclusions. Anecdotally, intramedullary femoral lengthening nails have perceived benefits for families compared to external fixators in the adolescent population. However, there remain musculoskeletal and psychosocial outcomes requiring therapeutic management throughout the lengthening process and beyond. Therefore, quantifying these outcomes is essential for measuring the impact on each patient for comparison. To interpret these themes, we need to evaluate the outcomes objectively, this was not done consistently in this review. Future research should look at outcome measures that are sensitive to all aspects of the ICF. With an aim of improving the therapeutic treatment provided and the overall outcome for the children treated

Abstract. Congenital posteromedial bowing of tibia (CPMBT) progresses with decreasing deformity and increasing shortening. Lengthening in CPMBT has not been studied extensively. Our series compares duration and complications of lengthening in younger vs older children. Methods. 28 tibial lengthenings (23 patients) by a single surgeon, divided into two equal groups of 14 segments: group-A ≤ 5 years, Group-B > 5 years. Lengthening was done in all with external fixators. We measured preoperative (bo) and postoperative (po) deformities, initial limb length discrepancy (LLD), LLD at maturity (LLDm), % LLD, amount of lengthening (AmtL) and %L, external fixator duration (EFD) and external fixator index (EFI). We graded complications by Lascombes' criteria, results by ASAMI Bone score. Results. Mean age was 8.8 ± 7.1 years. Follow-up was 7.9 years. Group-A had significantly greater preoperative deformities. LLD was similar in both. Expected LLD at maturity (LLDM) using the multiplier method was greater than previously reported (group-A: 4.4 – 9.5 cm; group-B: 2.5 – 9.7 cm).%L was 24% in group-A and 15.7% in group-B (p=0.002). EFD and EFI were lesser in group-A than group-B. Lascombes' triple contract was fulfilled in 11/14 lengthenings in group-A vs. 3/14 in group-B. ASAMI bone score was good and excellent in both groups. Conclusions. In our large series of CPMBT lenghtenings, we found younger children presenting with large deformities and LLDm could be safely lengthened with lesser EFD and complications than older children

Introduction. There is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation. Materials & Methods. All patients in who a retained Precice nail at the time of the field safety notice were identified. Patients and families were contacted to explain the issued safety notice from the company and explain that we would be scheduling them for nail removal. This was part of our standard care but we prioritised this group on our waiting list. Consent was obtained for nail removal but also for histological assessment of canal scrapings, blood ion level analysis and independent assessment of the retrieved nail by our academic collaborators at University College Dublin. Ion levels were then repeated at an interval post removal with consent. Results. We identified 7 Precice nails in 5 patients still implanted. All patients had consolidated after lengthening and were ready for nail removal. Elevated Titanium blood ion levels were identified at the time of retrieval. Histological abnormalities consistent with metalosis were identified. In all cases the nail was grossly intact and examination of the motor showed no evidence of wear or failure. Follow up ion levels obtained post retrieval showed persistent elevation. Conclusions. Our retrieval audit shows persistent elevation of Titanium ion levels and abnormal histology despite apparent nail integrity. These findings require further evaluation in a larger retrieval series to determine if there is a high incidence of this phenomenon and if ion levels have a clinical effect

Introduction. “Bioexpandable” prostheses after resection of malignant bone tumors in children to lengthen the bone using the method of callus distraction may offer new perspectives and better long-term results. Materials and Methods. The bioexpandable prosthesis is equipped with an encapsulated electromotor which enables the device to perform distraction in an osteotomy gap with about 1mm/day. The new bone is improving the ratio from bone to prosthesis and therewith the potential stability of the final stem. The device is indicated, when limb length discrepancy is getting more than 3 cm or at maturity and can be used in a minimal invasive way for femur lengthening. Results. 11 patients were treated with the bioexpandable prosthesis. The mean age of the patients was 13,5 years and the mean amount of lengthening was 74mm. In 2 cases lengthening was performed in 2 steps and in 1 case in 3 steps. All lengthening procedures could be finished without complications. There was no infection and no technical problem. The bone regenerate in one tibia case was poor so that bone grafting from the iliac crest was necessary. Conclusions. The “bioexpandable” prosthesis is a new concept for limb lengthening after tumor resection in children. The latest patented version of the prosthesis under development allows all lengthening manoeuvres and the placement of the final stem via small incisions not only for the femur but also for the tibia