The histology and mechanics of leg lengthening by callus distraction were studied in 27 growing rabbits. Tibial diaphyses were subjected to subperiosteal osteotomy, held in a neutral position for 10 days and then slowly distracted at 0.25 mm/12 hours, using a dynamic external fixator. Radiographs showed that the gap became filled with callus having three distinct zones. Elongation appeared to occur in a central radiolucent zone; this was bounded by two sclerotic zones. Histologically, the radiolucent zone consisted of longitudinally arranged cartilage and fibrous tissue while the sclerotic zones were formed by fine cancellous bone. New bone occasionally contained islands of cartilage, suggesting it had been formed by endochondral ossification. After completion of distraction, the two sclerotic zones fused, shrank and were eventually absorbed, leaving tubular bone with a new cortex. When the periosteum had been removed at the operation, callus formation was markedly disturbed and there was failure of bone lengthening. Scraping of endosteum, in contrast, did not have a pronounced effect. These results suggest that the preservation of periosteum is essential if bone lengthening by callus distraction is to succeed, and that preservation of the periosteum is more important than careful corticotomy

Aims

Limb-lengthening nails have largely replaced external fixation in limb-lengthening and reconstructive surgery. However, the adverse events and high prevalence of radiological changes recently noted with the STRYDE lengthening nail have raised concerns about the use of internal lengthening nails. The aim of this study was to compare the prevalence of radiological bone abnormalities between STRYDE, PRECICE, and FITBONE nails prior to nail removal.

Aims

The management of a significant bony defect following excision of a diaphyseal atrophic femoral nonunion remains a challenge. We present the outcomes using a combined technique of acute femoral shortening, stabilized with a long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis with a temporary monolateral fixator.

Internal lengthening devices in the femur lengthen along the anatomical axis, potentially creating lateral shift of the mechanical axis. We aimed to determine whether femoral lengthening along the anatomical axis has an inadvertent effect on lower limb alignment. Isolated femoral lengthening using the Intramedullary Skeletal Kinetic Distractor was performed in 27 femora in 24 patients (mean age 32 years (16 to 57)). Patients who underwent simultaneous realignment procedures or concurrent tibial lengthening, or who developed mal- or nonunion, were excluded. Pre-operative and six-month post-operative radiographs were used to measure lower limb alignment. The mean lengthening achieved was 4.4 cm (1.5 to 8.0). In 26 of 27 limbs, the mechanical axis shifted laterally by a mean of 1.0 mm/cm of lengthening (0 to 3.5). In one femur that was initially in varus, a 3 mm medial shift occurred during a lengthening of 2.2 cm.

In a normally aligned limb, intramedullary lengthening along the anatomical axis of the femur results in a lateral shift of the mechanical axis by approximately 1 mm for each 1 cm of lengthening.

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. 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

Introduction: In the management of patients with bone neoplasm, we are confronted with various status which is difficult to treat. External fixation is useful for such status, and result in succes. The purpose of this study is to report that patients of bone neoplasms were treated with external fixation. Materials and methods: Fifteen patients with bone neoplasm who had treated by external fixation are an objective of this study, between 1989 and 2000. Clinical and pathological diagnosis is osteosarcoma in 7, giant cell tumor in 4, Ewing’s sarcoma in 1, chondrosarcoma in1, osteochondroma in 1, enchondroma in 1. Patients were divided into 4 groups depends on difference of indication of external fixation. Result. Group 1. Immobilization of pathological fracture. Two patients with osteosarcoma of femur and one patient with GCT of humerus were treated by external fixation for their pathological fracture. Group 2. Bone lengthening or correction for bone defect or deformity. We performed external fixation with Ilizarov fixator for bone lengthening following bone defect after tumor excision in 4 patients. Mean length of bone defect was 83.5 (22–150) mm. Two in 4 cases were stopped bone lengthening owing to local recurrence and progression of disease. And in 2 patients, we performed correction with external fixation for bone deformity arised by enchondroma of humerus and osteochondroma of ulna. Group 3. Stabilization for vascularized bone graft. We performed vascularized fibular graft after wide resection and stabilized with external fixator in 2 patients with humeral sarcoma. Group 4. Salvage of infected prosthesis. There were 4 patients with infected prosthesis. Three of them were treated by bone lengthening technique after removal of prosthesis. Mean length of bone defect was 264 (220–330) mm and mean term of fitting external fixator was 583.7 (442–726) days. Discussion: Advantages of treatment with external fixation for bone defect, bone deformity and pathological fracture arise from bone neoplasm are mentioned as follows. It could immobilize pathological fracture that is difficult for plaster cast immobilization. It could compensate for bone defect following tumor resection. It is useful method for salvage of the infected prosthesis. Disadvantages of using of external fixation are mentioned as follows. In case of bone lengthening, it is need to perform a complete tumor control. Treatment term is longer. It is need pin site management. Treatment with external fixation is one of the useful method for pathological fracture, bone deformity, shortening, bone defect and infected prosthesis arise from bone neoplasm

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

Aims

Given the possible radiation damage and inaccuracy of radiological investigations, particularly in children, ultrasound and superb microvascular imaging (SMI) may offer alternative methods of evaluating new bone formation when limb lengthening is undertaken in paediatric patients. The aim of this study was to assess the use of ultrasound combined with SMI in monitoring new bone formation during limb lengthening in children.

Purpose: The purpose of this study was to evaluate centromedullary pinning for bone lengthening. We studied an animal model to discover the details of bone regeneration and assess the advantages of the technique. We present our early clinical results. Material and methods: Progressive lengthenings of the tibia by centromedullary pinning were performed in eleven dogs. Distraction began on day 5 and lasted 28 days. Arteriograms were obtained after sacrifice.We also analysed 17 cases of limb lengthening in patients: one arm, two forearms, nine femurs, five tibias. Mean patient age was 14 years. Mean gain in bone length was 6.2 cm. Results: The experimental work demonstrated that intensive bone regeneration requires faster distraction. Early bone union was observed in four dogs. Bone healing was complete at about 15 days in all dogs. The centromedullary pins were left in place in three dogs after removing the external fixator. There was no secondary deformation. The arteriogram showed that the nourishing artery was not ruptured. In our patients, delay to healing was shorter. The radiograms demonstrated intensive bone regeneration. Endosteal regeneration was significant and was never inhibited. Significant periosteal reaction was observed. The planned gain in length was achieved in all patients. We did not have any complications. Discussion: Bone lengthening methods using a centromedullary nail provide absolute stability while avoiding external fixation but at the cost of complete destruction of the centromedullary vascular supply. Our animal experiments and clinical experience prove that elastic centromedullary pins do not inhibit endosteal regeneration but, on the contrary, partial destruction of the marrow with intact vascularisation stimulates bone regeneration. For bone lengthenings, centromedullary pinning is the only method of internal fixation allowing optimal conditions for bone regneration. Conclusion: The progressive distraction of the elastic centromedullary pin during the lengthening period stimulates the regenerative processes. The biological effect of the vascular “displacement” from the centre to the periphery of the bone fragments leads to significant periosteal reaction. Elastic centromedullary pinning adds stability to the bone fragments. Associating the two methods allows removal of the external fixator leaving the centromedullary pins in place. By strengthening the regenerated bone, the pins provide a certain degree of additional stability

Aims

As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach.

Introduction. Since 2001 we use the flexible intramedullary nailing (FIN) in bone lengthening in children. This study estimates results of EF+FIN association considering the duration of external fixation and complications. Materials and Methods. Since 2001 we performed 294 bone lengthenings (338 segments of UL and LL) in 250 children 3 to 16 years old (11.01±0.23 in average). The length discrepancy was congenital in 163 cases, the sequelae of trauma or osteomyelitis were observed in 87 patients. In group I (195 cases) the Ilizarov fixator alone was applied, in group II the Ilizarov fixator (91 cases) or TSF® (8cases) were combined with FIN. The healing index was compared between the groups of the same etiology with similar type of distraction osteosynthesis. The date of consolidation corresponded to the day of removal of the external fixator, while intramedullary nails remained in place thus protecting the bone. Healing index was calculated by relating the duration of wearing of the external fixator (in days) and the amount of lengthening (in cm). Results. Reduction of the healing index is noted in each compared category. Thus, in congenital shortening in monofocal distraction osteosynthesis of the femur the healing index decreased from 29.8 (group I) to 20.4 days per cm, in bifocal tibial lengthening from 22.7 (group I) to 16.3d/cm (group II), in humeral lengthening – from 30.2 to 21.3 d/cm. In fact, it appears that the association of the external fixator of the Ilizarov type or TSF® with FIN allows to reduce the healing index significantly: in 12 of 16 compared categories the reduction of the index was from 20% to 40% or from 4.0 to 19.1 days per cm. In group I four cases of deep infection of soft tissues, 2 osteomyelitis, 21 fractures or deformities after frame removal were manifested. In group II – onlyone case of deformation after frame removal, absence of severe infectious complications, 8 cases of migration of the intramedullary wires. Discussion. FIN creates an elastic and resistant system during the lengthening. We even suggest that it stimulates the formation considering an apparent decrease of the healing index. On the other hand, the elasticity of nails prevents secondary fractures or deformations after frame removal. Conclusion. Combination of the circular EF and FIN in limb lengthening in children significantly decreases the duration of external fixation and the amount of severe infections and fractures

We investigated the effect of bone lengthening by callotasis on longitudinal growth of the tibia in rabbits. Ninety-nine five-week-old immature rabbits were divided into five groups according to the percentage of lengthening: group I, 10%; group II, 20%; group III, 30%; group IV, 40%; and group V, sham operation without lengthening. Corticotomy was performed at the proximal metaphysis of the left tibia and the right tibia was used as a control. The lengthening rate was 0.25 mm twice daily. Radiological, histomorphometric, and immunohistochemical studies were done on animals killed at the time of corticotomy, at the completion of lengthening, and thereafter every two weeks until 12 weeks. Tibial lengthening did not cause retardation of growth when the bone was lengthened by up to 20%. When the bone was lengthened by 30% or more, growth retardation was evident, and persisted until skeletal maturity

The mammalian growth plate is a complex structure which is essential for the elongation of long bones. However, an understanding of how the growth plate functions at the cellular level is lacking. This review, summarises the factors involved in growth-plate regulation, its failure and the consequence of injury. We also describe some of the cellular mechanisms which underpin the increase in volume of the growth-plate chondrocyte which is the major determinant of the rate and extent of bone lengthening. We show how living in situ chondrocytes can be imaged using 2-photon laser scanning microscopy to provide a quantitative analysis of their volume. This approach should give better understanding of the cellular control of bone growth in both healthy and failed growth plates

Aims

Distraction osteogenesis (DO) is a useful orthopaedic procedure employed to lengthen and reshape bones by stimulating bone formation through controlled slow stretching force. Despite its promising applications, difficulties are still encountered. Our previous study demonstrated that pulsed electromagnetic field (PEMF) treatment significantly enhances bone mineralization and neovascularization, suggesting its potential application. The current study compared a new, high slew rate (HSR) PEMF signal, with different treatment durations, with the standard Food and Drug Administration (FDA)-approved signal, to determine if HSR PEMF is a better alternative for bone formation augmentation.

Management of bone defects is a common surgical challenge encountered following any high energy trauma. Femur fractures with bone loss account for 22% of all the fractures with bone loss/defect, and 5% to 10% of distal femur fractures are open injuries. It was estimated in 2008, that, more than 4.5 million open fractures occur annually in India. In this retrospective study, patients who received bone allograft from our tissue bank between May 2012 and September 2015 were analysed. Of the 553 allografts issued, at that point in time, 26 were used in patients who underwent reconstruction for distal Femur fractures primarily. Fractures with defect or bone loss from 12 cc (1cm) to 144 cc (12cm) were treated with either Internal or External fixation and bone allograft. Morcellised cancellous, or a cortical strut, were used to fill or reconstruct the defect or void. The radiological outcome in terms of fracture union was assessed and Knee society score was used to assess the functional outcome. Complications such as non- union, infection, stiffness and need of revision or additional procedures were also assessed. Osseous consolidation was achieved in all the 26 patients with a Median time of 24 weeks (16 to 60). The Median Functional Knee Society Score was 80, indicating satisfactory functional outcome. Infection was noted in one patient, but it was not attributed to the allograft. Additional minor procedures like bone marrow infiltration, corticotomy for bone lengthening were required in 10 patients. Our studycomprises the largest group of patients treated primarily with Allograft to reconstruct or fill the void of bone loss encountered with distal Femur fracture. Reconstruction of massive bone defects, in patients of distal Femur fractures, with bone allograft, shows encouraging results. The surgeon can achieve the goal of restoring form and function of these difficult injuries in a single stage and the technique will provide the freedom to reconstruct the bony defect up to 150 cc (12 cm length) and recreate the anatomy to near normal. This allows for early mobilisation of patients and restoration of their daily routine at the earliest

Aims

The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited regarding outcomes and potential problems. We report on our early experience and raise awareness for the potential of adverse effects from this device.

Purpose. The purpose of this study was to assess the accuracy of three-dimensional camera technology when monitoring deformity correction by an Ilizarov frame and to compare it to manual measurements. Methods and Results. A model consisting of an Ilizarov frame built around an artificial tibia and fibula was used with retro-reflective markers placed on the frame and bones to allow for the positions of each to be detected by the camera system. Measurements made by the camera system were compared to measurements taken manually. In the assessment of frame lengthening, the camera system average error was 2% (SD 2%) compared to 7% (SD 6%) for manual measurement. In the assessment of bone lengthening, the camera system average error was 4% (SD 4%) compared to 34% (SD 8%) for manual measurement. The technology also demonstrated good accuracy in the measurement of angular deformity changes. Conclusion. The results of this study demonstrate that the measurement of deformity correction with three-dimensional infra-red camera technology is superior to manual measurements in a model of deformity correction. This method could replace or greatly reduce x-ray exposure in monitoring deformity correction post-operatively

Aims

This study aims to enhance understanding of clinical and radiological consequences and involved mechanisms that led to corrosion of the Precice Stryde (Stryde) intramedullary lengthening nail in the post market surveillance era of the device. Between 2018 and 2021 more than 2,000 Stryde nails have been implanted worldwide. However, the outcome of treatment with the Stryde system is insufficiently reported.

We report our experience of a humanitarian mission to treat the earthquake victims of October 2005 in Pakistan. The team with their equipment, in two periods of four and ten days respectively, treated 26 fractures in 25 patients with the Ilizarov frame and principles. There were 21 III B open fractures and three Tscherne III closed fractures. Seventeen fractures were infected with discharging pus and non-viable bone. Injuries were treated aggressively using different Ilizarov techniques of reconstruction surgery. All but two open fractures required a plastic surgical procedure for wound cover. Three months post-operatively eight out of thirteen fractures which had been treated in the first four days of the visit were healed and corticotomy for bone lengthening, performed during the second 10 days period visit. All wounds have remained clean with no evidence of superficial or deep infection. Limb lengthening procedures are planned for the rest of the patients

Aims and methods. We present a review of our use of the Ilizarov apparatus in a non-acute NGO hospital in Cambodia specialising in limb reconstruction. Frames are applied without on table image intensification. A retrospective case-note analysis of Ilizarov apparatus use for all indications was conducted. 53 frames were applied between November 2005 and October 2011. Indications for application were chronic open fracture, osteomyelitis, fracture malunion, infective and non-infective non-union, bone lengthening, primary bone tumour resection, ankle fusion, congenital deformity or pseudarthrosis, chronic hip dislocation, or a combination of the above. Results. Median delay in presentation was 104 weeks for all indications (range 4–864). Median treatment length was 21 weeks (3–76). The most frequent complication was pin-site infection. This occurred in 18 patients (34%). Return to theatre occurred in 21 patients (40%). Indications were frame adjustment, pin addition or removal, addition of bone graft or re-osteotomy. Failure of union occurred in three patients. These rates are comparable with those published in both Asian and Western literature. Conclusions. Our data demonstrate the versatility of the Ilizarov apparatus and its importance in limb reconstruction in a developing world setting. Our centre relies on it as a cost-effective tool for traditional and novel indications. In our centre the apparatus is applied without x-ray control and is maintained without a dedicated outreach pin-site care programme. Despite this our complication rates are comparable with western literature. We therefore recommend it as a safe and cost-effective tool for use in other developing world settings

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

Limb lengthening by means of distraction through the callus of a knee arthrodesis was performed in a 14-year-old boy with congenital hypoplasia of one lower limb. Knee arthrodesis was indicated because of destruction of the distal femoral epiphysis caused by a previous bone lengthening procedure

The frequent choice of treatment for tibial shaft fractures is intramedullary nailing. However there are cases where this treatment is problematic and alternative treatments are chosen with satisfied results. Twenty-nine patients with complex, unstable tibial shaft fractures (13 males and 16 females) aged 18 to 76 years (mean age 49 years) were treated using Ilizarov external fixation, the last decade in our Department by the same surgeon. The indications were open Gustillo III fractures, comminuted fractures of the proximal or distal third tibia near metaphysis, concomitant plateau or pillon fractures and fractures after total knee arthroplasty (TKA). All frames were applied the first day of injury. Patients without concomitant intraarticular fracture or bone deficit allowed to full weight bearing within2 weeks after surgery. Union and good to excellent alignment with full range of motion in the knee and ankle joints was obtained in all patients. Three patients needed bone lengthening using the initial applied frame after corticotomy in second operation. There were 7 delayed unions in fractures without bone deficit, 10 superficial pin tract infection treated with antibiotics and local care and 1 deep infection which needed surgical intervention. Ilizarov external fixation gives the solution in difficult and problematic tibial shaft fractures and allows early weight bearing

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

Introduction: the choice of treatment for tibial shaft fractures in adults is intramedullary nailing. However there are cases where this treatment is problematic and alternative treatments are chosen. Patients and Methods: 29 patients with unstable tibial shaft fractures (13 males and 16 females; aged 18 to 76 years) were treated using Ilizarov technique, last decade, by the authors. The indications were open fractures type III Gustillo, comminuted fractures of the proximal or distal third near metaphysis, concomitant plateau or pillon fractures and fractures after TNR. All frames were applied the first day of injury. Patients without concomitant intraarticular fracture or bone deficit allowed to full weight bearing within two weeks after surgery. Results: union and good to excellent alignment with full range of motion in the knee and ankle joints was obtained in all patients. Three patients needed bone lengthening using the initial applied frame after corticotomy in second operation. There were 7 delayed unions in fractures without bone deficit. As complications there were superficial pin tract infection in 10 patients treated with antibiotics and local care and one deep infection which needed surgical intervention. Conclusions: Ilizarov technique gives the solution in difficult and problematic tibial shaft fractures and allows early weight bearing

Five cases of congenital pseudarthrosis of the tibia successfully treated by a free vascularised fibular graft are described. Follow-up ranged from 5 to 34 months with a mean of 17.5 months. The technique, which includes radical excision of abnormal bone and soft tissue around the pseudarthrosis, also permits primary bone lengthening, and correction of deformity. The early results indicate that satisfactory bony union is achieved in a relatively short period of time

To study the use of TSF system in treating trauma and bone deformities in children. To determine the difficulties of this process and the risk factors that lead to complications. From January 2004, in 61 children (37 male and 24 female), 67 extremities, with a mean age 8.9 years children a TSF external fixator was applied for the treatment of trauma or bone deformities. 21 children were operated for angular deformity, 19 for bone lengthening, 10 for rotational deformity, 6 for combined angular deformity and lengthening and 11 for pseudoarthrosis. Intra and postoperative difficulties were classified using the Palay method in problems, obstacles and complications. The rate of difficulties was 22.2 %. Problems were presented in 5.9% (4/67) consisting of 2 non-axial deformities, 1 pin fracture and 1 subluxation of the knee. Obstacles were presented in 10.4% (9/67) including 3 cases with delayed bone healing that needed infusion DBM, 1 peroneal nerve palsy due to hematoma formation treated with decompression of the region, 1 early bone fusion that needed re-operation and 2 cases of percutaneous achilles lengthening. Complications presented in 5.9% of (4/67) the cases including 1 fracture, 1 pseudoarthrosis, 1 peroneal nerve palsy and 1 limitation of range of motion in the knee (0–45 0). The problems, obstacles and complications that presented during treatment influenced the final therapeutic objective. Initial deformity, preoperative planning and surgeon’s experience are associated with reducing the rate of all difficulties

We present an original method for the treatment of neglected Monteggia fractures using the Ilizarov technique. This method allows reduction without accessing the radial head by progressive ulnar lengthening after proximal subperiosteal osteotomy of the ulnar bone. We used this method in a six and a half year old girl and achieved excellent radiographical and functional results with normal joint amplitudes. In our opinion, the quality of the outcome is related to the progressiveness of the bone lengthening enabled by this technique which allows restoration of the ulnar length, preservation of the axes of both forearm bones, and controlled reduction of the radial head

We lengthened seven first metatarsals in four patients with short great toes by callus distraction using an external fixator. Good clinical and cosmetic results were obtained. Bone lengthening is effective in patients with short great toes not only for cosmesis, but also to relieve pain and callosities on the plantar aspect of the second and third metatarsal heads. Excessive lengthening of the first metatarsal resulted in limitation of the range of movement of the metatarsophalangeal joint of the great toe. To prevent this the amount of lengthening should not exceed 40% of the preoperative length of the metatarsal

Hig energy fractures of the lower limb are often associated with tibial or femoral bone loss, skin exposition with vascular and nervous injuries (Gustilo et al.). The surgical procedure is a real challenge, consisting in a temporary stabilization of the fracture associated with a plastic and/or vascular reconstruction. Once the skin and vascular injuries are recovered, the orthopaedic surgeon can remove the temporary stabilization performing a circular external fixation with bone lengthening by using the “bifocal” (one site of metaphiseal corticotomy and one site of compression) or “trifocal” (two sites of metaphiseal corticotomy and one site of compression) technique. We use to do a “docking site” treatment when bone fragments are nearly in contact. Our experience indicates that circular external fixation, by using the Orthofix system, is a very useful and safe technique in the management of severe lower limb injuries. Our good clinical results lead us to suggest this surgical technique that allow to obtain a limb reconstruction, avoiding segment amputation

Objective: The purpose of the present study was to assess whether clinicians are actually able to evaluate the mechanical status of lengthening callus from plain radiographs. Materials and Methods: 36 rats were employed in this study. Their left femurs were lengthened by 6 mm as a bone lengthening model. Rats were euthanized at 4 8 12 and 16 weeks after lengthening. Both femora were X-rayed and then bone density parameters (bone mineral content, bone mineral density and bone area) of lengthening callus were measured using pQCT. Three-point bending test was performed to determine the mechanical strength of the both bones. We defined the ratio of the strength of lengthening side to control side as estimated strength recovery rate (%). Then 20 orthopaedic surgeons evaluated only the X-ray photographs and tried to estimate the relative mechanical strength (%) of the affected side compared to the control side. Results: Between the recovery percentage of mechanical strength and bone mineral content, a positive simple correlation (R2=0.11, p< 0.05) was seen. No significant correlation was seen between the recovery percentage of mechanical strength estimated by orthopaedists and the mechanical strength measured by three-point bending test (qualified doctors: R2=0.0793 p=0.291 unqualified doctors: R2=0.0523 p=0.394). Discussion and conclusion: It became obvious that to estimate the strength of lengthening callus from plain radiographs alone is quite difficult as compared with the studies of the simple fracture model that have been reported until now

We studied the quantity and rate of formation of new bone during lengthening of 17 limb segments in 10 patients using dual-energy X-ray absorptiometry (DEXA), ultrasonography and radiography. Whereas new bone was detected by both DEXA and ultrasonography within 1 to 2 weeks of distraction, it was not visible on the radiographs until 4 to 8 weeks. Limb alignment and gap measurement were accurately assessed by DEXA without the need for standard radiographs or scanograms. With ultrasound the distraction gap appeared as an echolucent window which narrowed progressively producing a hyper-reflecting line after which further consolidation could not be assessed. As measured by DEXA the density of the new bone at this stage was approximately 45% of control values and did not represent normal cortication. Whereas ultrasound could be used to identify defects in mineralisation and to determine when to dynamise the fixator system, DEXA could measure the quantity and rate of formation of bone throughout lengthening

Low intensity pulsed ultrasound (SAFHS, Exogen Inc.) was used to treat 15 immature New Zealand white rabbits following a mid diaphyseal tibial osteotomy and 1cm bone lengthening using an Orthofix M-100 device. Fifteen matched controls underwent an identical procedure but the ultrasound transducer was not switched on. At 4 and 6 weeks postoperatively the tibiae were analysed using DXA, QCT and 4 point bend mechanical testing. There were no differences identified between the active and control groups at 4 or 6 weeks with respect to bone mineral content or cross-sectional area of the regenerate, nor the bone proximal and distal to it. No improvement in strength of the regenerate was identified in either group. We cannot, therefore, support the use of the SAFHS to accelerate bone healing in patients undergoing limb lengthening. Low intensity pulsed ultrasound has been shown to accelerate fracture healing in animals and humans. The mechanisms of action are discussed and we propose that the intensity of the ultrasound may need to be increased mechanically to stimulate a bone that is rigidly fixed using the M-100 fixator

We assessed the management of 11 neglected developmental dislocated hips in terms of shape of the acetabulum and femoral head pre-operatively and the level of the position of the reduction immediately post-operatively. We compared it with medium term clinical and radiological results. The shape of the acetabulum and the femoral head can be determined in two planes doing CT or MR of the pelvis. The studies were done to determine the development of the acetabulum and the anatomical fit of the femoral head in the acetabulum. Radius of curvature in the axial and coronal planes was determined of the acetabulum and the femoral head. MR spin echo specification for visualization of the cartilage bone was used. Post-operative radiological namely CT when still in spika, and Shenton’s line and central location of the hip in the direction of the triradiate were subsequently assessed. Radius of curvature was determined in 6 cases. It varied according to age, but for the older patients the acetabulum was 5mm smaller on average on the coronal views. Eight hips were treated with open reduction. Postoperatively one hip gradually subluxed and dislocated eventually. The hips that remained reduced were initially inferiorly located with an irregular Shenton’s line. Three were treated conservatively with pelvic support osteotomies and planned bone lengthening procedures. Shape of the femoral head and acetabulum is the most important determining factor in open reduction of neglected DDH. Axial plane MR radius of curvature is not necessarily a true reflection of the shape of the acetabulum. MR coronal views with cartilage enhancement are necessary in assessing the shape of the acetabulum. The inferior position of the reduced hip can be ascribed to the conical shape of the acetabulum and is associated with a maintained reduction

Purpose of the study: The process of bone lengthening involves three phases: a latence period, distraction, then healing. The healing phase required stability maintained by an external fixator (EF) for 1.16 months/cm lengthening. This time exposes the patient to serious complications. The objective is to accelerate the healing phase in order to shorten the time the patient has to wear the EF. The effect of BMP on osteogenesis in distraction remains a controversial issue. This work was conducted to evaluate the benefit provided by rhBMP-2 for healing the regenerate bone after distraction. Material and methods: Thirty-nine subadult male rabbits were selected at random. On day 0, a tibial osteotomy was performed followed by installation of a M101 EF. After the latency period of seven days, the distraction began at the rate of 0.5mm/12 h for 21 days. At day 28, at the end of distraction, a new operation was performed and three groups of 13 individuals were created at random. The first group received no material, the second a collagen type 1 sponge, and the third group a collagen type 1 sponge soaked in 100 μg/kg rhBMP-2. The animals were monitored with x-rays, absorptiometry and ultrasound for the qualitative and quantitative analysis. Histological and biomechanical analyses were performed at two months. Results: Our complication rate was 41%. Qualitative analysis of the x-rays showed, in group 3, the development of more or less voluminous and dense, sometimes hypertrophic calluses. The progression curves of the bone mineral content showed higher values in group 3. The bone mineral content curves remained nevertheless parallel for the three groups. The calluses were thus denser in group 3 but with an early peak density. Groups 1 and 2 had equivalent radiographic and absorptiometric results. The statistical analysis of the imaging findings is ongoing. The histology and biomechanical exams are being performed. Discussion: The preliminary results show that rhBMP-2 used early in the healing phase enables formation of more dense and hypertrophic calluses. rhBMP-2 does not acceleration the rate of callus formation but stimulates its mineralization. Use of a collagen sponge alone had no effect on healing. Analysis of the histological and mechanic properties observed in the three groups will provide a more precise description of the hypertrophic and strongly mineralized calluses. Conclusion: Our early results show superior bone mineralization in the treated group

Objective: The aim of this experimental study was to evaluate the effects of alpha-tocopherol on new bone formation by distraction osteogenesis. Materials and Methods: Tirthy New Zealand white rabbits were randomly divided into 2 groups. Bone lengthening was performed in the right tibia through distraction osteogenesis at a rate of 0,5 mm/day for 20 days with circular external fixator (CEF). While the experimental group rabbits were administered i.m. 20mg/kg alpha tocopherol daily starting at the first day of study lasting for 20 days, control group rabbits did not receive any corresponding treatment. Radiographic examination were performed at 20th, 30th and 40th days. Scintigraphic evaluation for osteoblastic activity was at 5th and 20th day of the study. Serum total antioxidant capacity (TAC) was measured at first day and 20th day of the study. All animals were sacrificed at the end of the consolidation period of 40 days. The right tibia of all animals were removed and evaluated by histopathologic examination. Results were compared between groups and statistically analysed. A p value less than 0.05 is considered as significant in 95% confidence interval. Results: At the 20th day, radiologic scores were statistically similar in both groups. However, at the 30th and 40th days, experimental group demonstrated statistically significant high radiologic scores and visible callus formation, maturation and remodelling. Scintigraphic baseline study at 5th day of study showed statistically similar osteoblastic activity in both groups. However, at the 20th day osteoblastic activity was significantly higher in experimental group. Serum TAC values were also significantly higher in experimental group at 20th day. At necropsy, experimental group rabbits got statistically significant high scores in histopathologic examination and showed the formation of mature bone. Conclusions: Results of this study showed that alpha-tocopherol had beneficial effects on new bone formation by distraction osteogenesis. Administration of supplemental alpha tocopherol in patients treated with distarction osteogenesis may shorthen the framing time and increase the quality of regenerated bone

Purpose: Use of six-axis analysis and computer assisted deformity correction via a circular external fixator is a new method for deformity correction. We investigated its accuracy and safety in reconstruction of femoral deformity in children and young adults. Method: We retrospectively reviewed all cases including the indications for use and the methodology of application of the computer assisted six-axis analysis and circular external fixator for reconstruction of 22 femora in 20 patients. Twelve patients were female, and 8 were male. The average age was 13.9 (range, 5.9–24.6). Etiology included traumatic (7), idiopathic (6), multiple enchondromatosis (2), rickets (2), congenital femoral deficiency (2), spondyloepiphyseal dysplasia (1), congenital pseudohypoparathyroidisim (1), and multifocal osteomyelitis (1). Clinical and radiographic data were analyzed. Results: Average follow-up was 14.4 months (range, 4.5–32). Average time in frame was 6.2 months (range, 2.6–19). Bone lengthening of 3.9 cm (range, 1–8.5) was performed in 12 femora. In genu valgum patients, the mLDFA improved from a mean of 73.7° to a mean of 89°. In genu varum patients, the mLDFA improved from a mean of 99.8° to a mean of 89.5°. Complications included pin tract infection in 6, knee stiffness in 3, delayed union in 2, skin irritation in 1, posterior knee subluxation in 2, both of which had stable knees preoperatively. One patient was lost to follow-up and returned back with deformity. No complications occurred in 8 patients. Conclusion: Computer assisted femoral deformity correction with six-axis analysis and application of circular external fixator is a useful technique with the advantage of managing multiplanar deformities in children and young adults. It has the potential complications of the use of any external fixator. Close follow-up is necessary to avoid subluxation of the knee joint even in patients with stable knees. Accurate and safe correction can be achieved in almost all patients

Purpose: To present our clinical experience of intramedullary nail application during the consolidation phase after bone lengthening or bone transport. Material and method: Thirty patients (33 cases) with secondary intramedullary nailing during consolidation phase after callus distraction with an external devise (Ilizarov frame or unilateral system) were evaluated. Docking site nonunion (17 patients), angular deformity or fracture of the lengthened area (8 patients) or intolerance of the external device (5 patients), in combination or not with a delayed distracted callus maturation, were the main reasons for this replacement. Results: Average follow-up time was 4 (2–12 years). Average external fixation index was 40 days/cm of distraction. Intramedullary infection afterwards the placement of the nail was presented in one case (3,03%), and slight callus length loss in 5 cases (15,2%). Failure of union at the docking site with nail breakage was happened in 1 case (3,03%). In the other patients, ossification was achieved in the lengthened callus area as well as at the docking site, in an average time of 5,9 months from the moment of the nail insertion. All the patients were satisfied after the abstraction of the external devise, while their joint mobility and functionalism were improved rapidly. Conclusions: The use of intramedullary nailing during consolidation phase after callus distraction, is a treatment option for delayed callus maturation or docking site nonunion, reducing the prolonged use of the external fixator

We report the treatment in 17 patients of 27 angular deformities of the long bones by progressive opening-wedge osteotomy. The technique consists of percutaneous osteotomy and progressive angular correction using a modified Wagner distractor. Ten patients (20 bone segments) had adolescent bilateral idiopathic tibia vara with a mean angular deformity of 12 degrees varus (10 to 16). Seven other adolescent patients had secondary angular deformities either at the distal femur or the distal tibia. One of the femoral deformities had an associated 5.5 cm of shortening which was treated simultaneously. The patients with idiopathic tibia vara achieved a final mean angular correction of 15 degrees (mechanical axis from 12 degrees varus to 3 degrees valgus). In patients with secondary angular deformities the mean angular correction was 17 degrees. The Wagner device was removed in an average period of 12 weeks (9 to 27), and no major complications were observed. Progressive opening-wedge osteotomy is an alternative to conventional osteotomies for the treatment of angular deformities of the long bones in adolescent patients, and has the advantage of requiring less invasive surgery, allowing progressive and adjustable correction with bone lengthening if needed

Distraction osteogenesis (DO) is useful for bone lengthening and deformity correction. Unfortunately, this often requires prolonged use of an external fixator with concomitant morbidities. This study investigates whether low-magnitude, high-intensity vibrations (Dynamic Motion Therapy, DMT) can accelerate maturation of regenerate bone in DO, thus reducing the duration of external fixation. 28 NZ White Rabbits underwent a right mid-tibial osteotomy with application of an Orthofix M-103 fixator (Orthofix, Busselengo, Italy). Distraction commenced on day 3 at 0.5 mm every 12 hours for 12 days. All animals were sacrificed on day 45. Animals were randomly assigned into 4 groups:. control group;. DMT only during distraction period;. DMT only during consolidation period;. DMT during distraction and consolidation periods. DMT was applied with the Juvent platform (Juvent, Somerset, NJ) for 10 minutes/day. X-ray and CT scans were taken prior to mechanical testing. All specimens were processed for histology. X-rays and CT scans showed evidence of cortical remodelling and re-establishment of the medullary canal in animals treated with DMT (groups 2, 3 and 4). This was most pronounced in animals treated during the distraction and consolidation phases (group 4). Regenerate bone in the control group (group 1) was more disorganised, with a delayed union evident in 1 animal. Group 1 achieved peak torque and stiffness values of 70% and 50% of the contralateral (unoperated) tibia respectively. No significant difference was seen in peak torque and stiffness between groups 2, 3, and 4, however each was significantly higher than group 1 (P< 0.05). H& E staining revealed less porosity in the newly formed cortical bone and a more defined medullary canal in animals treated with DMT than in the control group. Low-magnitude, high-intensity vibrations appear to accelerate cortical remodelling and reestablishment of a medullary canal. Regenerate bone in animals treated with DMT was also mechanically superior. The timing of DMT therapy did not appear to be important. Further studies are required to determine the optimal timing and duration of DMT therapy

The Ilizarov frame is a circular external fixator, invented by Professor Ilizarov in Siberia during the 1950’s. It uses the principle of distraction osteogenesis to form new bone in a variety of clinical situations where bone lengthening or realignment is needed. The Ilizarov frame began to be used in western medicine during the 1980’s and by 1993 over 6000 cases had been performed in Europe. Plain x-ray is one of the methods used to monitor the progress of patients fitted with an ilizarov frame. The aim of this study is establish a pattern of healing over time in patients with the Ilizarov frame using plain x-ray films. This will improve understanding of the procedure, aid clinicians in deciding when frame removal is appropriate and provide a method of early detection should healing not be progressing appropriately. This is a retrospective study looking at a series of 58 digitised anterior-posterior x-ray films of the tibia and fibula, taken at set time points post-operatively, from 17 patients fitted with an ilizarov frame (19 separate legs with ilizarov frames in total). Image J, an image analysis system, was used to measure pixel density from vertical slices down the centre of each fracture gap and at set intervals horizontally across the fracture gap. A mean pixel density value for each fracture gap was also calculated. The x-rays were standardised using a standard step wedge. Promising preliminary results show pixel density to be greater towards the medial aspect of the tibia, but this difference in pixel value decreases with time. This suggests that calcification of the new bone occurs medially to laterally across the tibia. Full results will be available in April and aim to build a picture of the fracture gap at set time points post-operatively, showing a pattern of calcification in patients with the Ilizarov frame that will become a useful clinical tool for deciding time of frame removal as well as affording early knowledge of problems with the healing process

Fracture or periosteal elevation near epiphysis induces inflammatory vascularity which is reported in early bone lengthening literature. In this study, corticotomy and periosteal elevation were put to use to induce new inflammatory vessels as collaterals in an ischaemic limb. In this prospective investigation between May 1990 and May 2000, seventy-two patients suffering from severe occlusive arterial disease (44 TAO, 13 atherosclerosis, 11 Raynaud’s disease, and 4 diabetics), who had not responded to previous non-surgical or failed surgical treatment, and had progressively deteriorating ischemic limbs, were subjected to corticotomy near major neurovascular bundles and the periosteal elevation along the whole length of the bone. There was complete relief from rest pain and an indefinite postponement of amputation in sixty-one out of seventy two patients. Longest follow up is ten years and shortest is six months. This new approach is based on principle of inflammation which is the universal reparative biological process. Digital Subtraction Angiography (DSA) studies before and after operation convincingly showed the continuance of a new vascular collateral network across the affected arteries, a process, which saved the ischemic limbs from certain amputation. This new Inflammatory vascular leash acts as a biological ‘bypass’ and appears to be an answer to small and diffuse artery disease, where vascular reconstruction is otherwise impossible

We appraised whether deformity of the inferior limbs, routinely treated with external fixation (EF), can be corrected when synthesis with locked intramedullary nails is associated with the synthesis and what the indications are. In all, 24 patients with a deformity of the inferior limbs treated between 1997 and 2003 were included in the study and divided into two groups: (1) patients with external fixation, average 23 years, deformity axial 20° (9–28°); and (2) patients with osteotomy and interlocked nailing. average 35 years, deformity axial 16° (10–25°). The indications for treatment with interlocked nail were set according to the following criteria: (a) possibility to correct the deformity with only restoration of the anatomical axis without necessity of lengthening; (b) previous use of EF; (c) EF refused by the patient, and (d) physeal closure. In both groups complete correction of the deformity was achieved. In the group of patients treated with EF the time of consolidation was on average 5.5 months (range 4–8 months). In this group the time of consolidation proportionally increased to time required to effect a bone lengthening. In the group of patients treated with osteotomy and nailing the times of consolidation were different with respect to age, to the side and the type of osteotomy and to the type of deformity. The time of consolidation was 7 months (range 3–12 months). The most rapid consolidation corresponds to the congenital deformities treated with oblique osteotomy. Correction of deformities by osteotomy and interlocked nail introduces the advantage of not limiting joints and immediate correction of the angular and rotatory deformity. The indication for this technique is that there is no residual hypometry. In this case the treatment of choice is corticotomy and external fixation

Aims: The purpose of this study was to describe the histologic adaptation of the femoral artery wall to the strechtening derived from femoral lengthening by callus distraction. Methods: In 32 New Zealand white rabbits a left femoral bone lengthening was carried out with a total distraction of 30% of initial length. The study was divided into eight progressives stages and at the end of each stage both femoral arteries were excised and prepared for light microscopy and ultrastructural analysis. Results: Light microscopy: Changes in the media layer architecture were observed since lengthening of the 15% of the initial length, reaching its maximum by lengthening of 30% of initial length. Six month after the end of the distraction, the media layer still showed morphologic changes compared to the unlengthened group. U.E.: During the greatest distraction period and one month thereafter the Smooth Muscle cells of the media lost its contractile characteristics and greatly increased their syntesis organelles, and mytosis and isolated binuclear cells are observed representing and accelerated cell proliferation. Six months after the end of the distraction the muscular cells returned almost completely to the normal contractile state. Conclusions: The response of the arterial wall against the strechtening is more a regenerative response due to the muscle cells than a reparative response of the connective tissue. This study suggest that with the greatest distraction, and one month later, the muscle cells change from the original contractile phenotype to a synthetic phenotype, that is a prerequisite for cellular proliferation. The return to the original characteristics six months thereafter could support the reversibility of the cellular phenotype opposite to the progressive elongation

We developed a rat model of limb lengthening to study the basic mechanism of distraction osteogenesis, using a small monolateral external fixator. In 11-week-old male rats we performed a subperiosteal osteotomy in the midshaft of the femur with distraction at 0.25 mm every 12 hours from seven days after operation. Radiological and histological examinations showed a growth zone of constant thickness in the middle of the lengthened segment, with formation of new bone at its proximal and distal ends. Osteogenic cells were arranged longitudinally along the tension vector showing the origin and the fate of individual cells in a single section. Typical endochondral bone formation was prominent in the early stage of distraction, but intramembraneous bone formation became the predominant mechanism of ossification at later stages. We also showed a third mechanism of ossification, ‘transchondroid bone formation’. Chondroid bone, a tissue intermediate between bone and cartilage, was formed directly by chondrocyte-like cells, with transition from fibrous tissue to bone occurring gradually and consecutively without capillary invasion. In situ hybridisation using digoxigenin-11-UTP-labelled complementary RNAs showed that the chondroid bone cells temporarily expressed type-II collagen mRNA. They did not show the classical morphological characteristics of chondrocytes, but were assumed to be young chondrocytes undergoing further differentiation into bone-forming cells. We found at least three different modes of ossification during bone lengthening by distraction osteogenesis. We believe that this is the first report of such a rat model, and have shown the validity of in situ hybridisation techniques for the study of the cellular and molecular mechanisms involved in distraction osteogenesis

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

Introduction: In the growth plate, chondrocyte swelling (hypertrophy) is a crucial event during endochondral ossification and bone lengthening, accounting for ~80% of the increase in bone length (. 1. ,. 3. ). The swelling is dramatic (~10x) and closely regulated. Failure of chondrocyte hypertrophy may underlie the chondrodysplasias of the vertebrate skeleton (. 1. ). However, the mechanisms which control cell swelling are poorly understood although there must be a key role for chondrocyte osmolyte transporters which are sensitive to an increase in cell volume. We have used confocal scanning laser microscopy (CLSM) to study volume regulation by living in situ growth plate chondrocytes at varying degrees of hypertrophy. Methods: Bovine growth plates were taken from the ends of young (~12d) bovine ribs. In situ growth plate chondrocytes at the proliferative through to hypertrophic stages were fluorescently-labelled (calcein-AM; 5μM), imaged (Zeiss CLSM510) and volumes determined quantitatively as described (. 2. ). An acute osmotic challenge (280-140mOsm) was delivered by perfusion to determine volume-regulatory capacity by cells in the various zones. Results: The resting volumes of proliferative and hypertrophic cells were 550±63μm. 3. and 5227±1974μm. 3. respectively. Reducing osmolarity resulted in a rapid (within ~1min) cell swelling, proliferative and hypertrophic chondrocytes increasing in volume by 126±2% and 146±5% (n=5) respectively. Chondrocytes within the proliferative zone then recovered in volume by ~60% over the following 20mins (p=0.04), whereas no volume recovery was detected in hypertrophic cells (p=0.94). Conclusions: For the increase in growth plate chondrocyte volume to produce hypertrophy it is essential that the membrane transporters which normally prevent cell swelling are suppressed, otherwise the increase in volume will be compromised. These results suggest that chondrocyte hypertrophy is associated with reduced activity of the swelling-stimulated osmolyte transporter whereas the pathway is active in proliferating chondrocytes. Changes in the activity of this pathway are likely to be an important component in the control of chondrocyte hypertrophy. It is clear that the contributions of other membrane transporters in mediating chondrocyte swelling must be identified in order to understand the overall hypertrophic process

We have reviewed, retrospectively, all children with a lower limb deformity who underwent an acute correction and lengthening with a monolateral fixator between 1987 and 1996. The patients were all under the age of 19 years and had a minimum follow-up of eight months after removal of the fixator. A total of 41 children had 57 corrections and lengthening. Their mean age was 11.3 years (3.2 to 18.7) and there were 23 girls and 18 boys. The mean maximum correction in any one plane was 23° (7 to 45). In 41 bony segments (either femur or tibia) a uniplanar correction was made while various combinations were carried out in 16. The site of the osteotomy was predominantly diaphyseal, at a mean of 47% (17% to 73%) of the total bone length and the mean length gained was 6.4 cm (1.0 to 17.0). Univariate analysis identified a moderately strong relationship between the bone healing index (BHI), length gained, maximum correction and grade-II to grade-III complications. 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 outcome were then analysed by calculating odds ratios with 95% confidence intervals. This analysis suggested a dose response between increasing angular correction and poor BHI which only reached statistical significance for corrections of larger magnitude. Longer lengthenings were associated with a better BHI while age and the actual bone lengthened had little effect. Those patients with a maximum angulatory correction of less than 30° in any one plane had an acceptable consolidation time with few major complications. The technique is suitable for femoral deformity and shortening, but should be used with care in the tibia since the risk of a compartment syndrome or neurapraxia is much greater

Improvement in coverage achieved by double or triple osteotomies is limited by the size of the acetabular fragment and the ligaments connected with the sacrum. Correction is achieved with the notable asymmetry of the pelvis. In periacetabular Ganz osteotomy (PAO) the acetabular fragment has no connection with the sacrum, which creates enormous possibilities for correction, leaving the pelvic ring untouched. The aim of the study is to present our experience and early results of using PAO in the treatment of hip dysplasia in adolescents and young adults who were previously treated operatively in childhood, and to find the technical and clinical impact of previous operations on our Results: In the years 1998–2005 262 periacetaubular osteotomies were performed in our hospital. All the patients were operated by one surgeon (JC). From this group 41 patients (43 hips) had previously been operated in childhood for the treatment of hip dysplasia. The previous treatment consisted of: open reduction in 10 hips, DVO in 14 hips, pelvic osteotomy (Salter, Dega, Chiari) in 8 hips, combined: open reduction+DVO+pelvic osteotomy in 10 hips, greater trochanter transfer in 3 hips, bone lengthening in 4 hips, acetabular cyst removal in 1 hip. The age at the primary operation ranged from 1–20.. The follow-up period ranged from 1–7,5 ys av. 2 ys. In 31 hips the Smith-Petersen, and in 12 hips ilioinguinal approach were performed. Methods. In clinical pre-op, and post-op examination the following factors were considered: pain, limping, Trendelenburg sign, range of motion, length discrepancy. Radiographic pre-op and post-op examination consisted of: AP view of the pelvis, false profile and AP view with the leg in abduction. Classic and anterior CE angle were measured. During the last examination Harris Hip Score was used. Results. Flexion slightly decreased from pre-op. 90–140° (av. 118°) to 80–130° (av. 104°) post-op. abduction remained unchanged 15–60° (av. 40°) and 15–60° (av. 40°) respectively, adduction slightly increased 15–40° (av. 31) and 20–50° (av. 33°). The range of rotation did not change after the operation. The sign of Trendelenburg was found in 27 hips before operation and in 8 hips post-op. Pain (acetabular rim syndrome) was found in 40 hips before operation and in 4 hips after the surgery. Either classic or anterior CE angle increased after the surgery in all cases from −14° to 34° and from −10° to 35° respectively. We had a rather low complication rate. But in cases previously operated and in males we strongly recommend Smith-Petersen approach extended into the frontal part of the hip for a better exposure in the scarred and hardened tissues. We find the technique of PAO as a safe, and effective tool for treating hip joint pathology increasing treatment possibilities for hip joint preservation

Introduction and Aims: With a great progress in bone regeneration, muscle is currently regarded as a largest limiting factor for successful limb lengthening leading to joint contractures and fractures of distraction regenerate. The purpose of this study was to evaluate muscle architectural changes and potential mechanisms of joint contractures during limb lengthening. Method: Nine mature goats underwent 20% unilateral tibial lengthening (0.25 mm x 3/day) and were sacrificed immediately upon completion of distraction. With the stifle (knee) and hock (ankle) joints fixed at similar angles, both limbs were disarticulated at the hip joint and submerged into 10% buffered formalin. Following tissue fixation, all tibial muscles were sequentially dissected and changes in muscle origin-to-incretion length, belly length, tendon length, myofibers length, and sarcomere length were analysed relative to the muscle measurements on the contralateral limb and bone lengthening. Muscle fiber length was assessed under stereoscopic magnification and sarcomere analysis was performed using laser diffraction. Results: Thirteen muscles were identified for each limb. Anterior compartment consisted of two longitudinal and four pennate muscles, whereas posterior compartment had one longitudinal and six pennate muscles. Origin-to-insertion length measurements showed disproportion between the amounts of muscle and bone length increase with muscle-to-bone lengthening ratio ranging from 0.2 to 1.0. When assessed separately, muscle belly stretched more substantially (range, 11–24%) than muscle tendon (range, 3–14%). Longitudinal muscles showed better compliance to limb lengthening than pennate muscles. Origin-to-insertion, muscle belly, and tendon length increase for longitudinal muscles averaged 15%, 21%, and 11%, respectively, whereas for pennate muscles these parameters averaged 10%, 15%, and 6%, respectively. Although anterior pennate muscles showed higher proportion of muscle length increase than posterior pennate muscles, this difference was not significant. Lengthening of muscle fibers varied greatly, ranging from 0% to 88%. Fiber length of posterior muscles increased tremendously (average, 42%). This was associated with comparable increase in sarcomere length (average, 39%). Anterior muscles showed only 10% lengthening of the fibers. However, 12% reduction in sarcomere length indicated addition of new sarcomeres in series to accommodate increase in fiber length. Conclusion: Different response of anterior and posterior muscles to distraction contributed greatly to the development of joint contractures. Posterior tibial muscles were predominantly pennate, larger in volume, and thus showed higher resistance to lengthening. Moreover, posterior muscle fibers incurred lengthening by sarcomere stretching, whereas anterior muscle fibers showed evidence of neosarcomerogenesis

Introduction and Aims: Although skeletal muscles have remarkable potential for adaptation, the amount of muscle length increase during gradual limb lengthening is always less than the amount of bone lengthening. The purpose of this study was to analyse gene expression in skeletal muscle undergoing adaptation to limb lengthening. Method: Ten adult goats were randomly divided into two groups of five animals. Group 1 underwent 20% (43–47mm) standard Ilizarov tibial lengthening and group 2 served as un-operated control. Muscle tissues from proximal myotendenous junctions of Peroneus Longus were harvested from the lengthened limb in the distraction group and corresponding limb in the control group and immediately snap frozen in liquid nitrogen. To screen for genes potentially associated with sarcomerogenesis, microarray technology was employed. Biotin labeled cRNA was hybridised to Affymetrix HU133A GeneChips, containing 22,284 gene transcripts. All created data files were analysed using computer software GeneSpring 5.0. Results: In both groups, 5092 (23%) gene transcripts flagged present. Thirty-two of these transcripts were differentially expressed between distracted and control groups (p < 0.05). Represented by these transcripts were 12 known and three unknown genes, which were up-regulated in lengthened muscles by more than 2.0 fold. The substantially up-regulated genes identified were MYOZ2 (myozenin 2), MYL4 (embryonic myosin alkali light chain), MYL6 (myosin light polypeptide 6), CRYAB (crystalline), PFN2 (profiling 2), ARPP-19 (cyclic AMP phosphorprotein), TUBB2 (tubulin beta 2), PPP1R12 (protein phosphatase 1), RCOR (REST corepressor), LIM (LIM protein), FN1 (fibronectin 1), ACTC (alpha-actin), and hypothetical protein FLJ10111. Among the genes found to be up-regulated are genes involved in the myogenesis pathway. Myozenin 2 gene is associated with the signalling and activity of Calcineurin/Calsarcin that plays a significant role in muscle cell proliferation and myofiber type differentiation. Crystallin gene may be involved in promoting muscle survival during differentiation. The functionality of the remaining genes range from cytoskeletal organisation (TUBB2), cyto-skeletal structure (PFN2, MYL4, MYL6), cell adhesion and motility (FN1), muscle development and differentiation (FHL1 and LIM), intercellular adhesion and intermediate filament organisation (PNN), muscle contraction and relaxation (PPP1R12A), neuronal-specific gene silencing (RCOR), and PKA-dependent intracellular messaging (ARPP-19). Conclusion: The findings suggest that tension stress observed during gradual limb lengthening using standard Ilizarov distraction protocol activates expression of genes involved in skeletal muscle growth, differentiation, and neogenesis. On-going studies involving immunohistochemistry, RT-PCR, and in situ hybridisation to confirm cellular localisation of up-regulated genes are underway

The June 2014 Oncology Roundup. 360 . looks at: Infection still a problem in endoprosthetic reconstruction; massive allografts not as successful as we perhaps think; curopsy for aneurysmal bone cysts?; lengthening prosthesis: days are numbered; new WHO classification in brief; proximal tumours and fluid levels: bad news; infection is predictable in orthopaedic oncology; psychosocial support key in oncological outcomes

We performed nine metatarsal and three proximal phalangeal lengthenings in five patients with congenital brachymetatarsia of the first and one or two other metatarsal bones, by a one-stage combined shortening and lengthening procedure using intercalcary autogenous bone grafts from adjacent shortened metatarsal bones. Instead of the isolated lengthening of the first and the other metatarsal bones, we shortened the adjacent normal metatarsal and used the excised bone to lengthen the short toes, except for the great toe, to restore the normal parabola. One skin incision was used. All the operations were performed bilaterally and the patients were followed up for a mean period of 69.5 months (29 to 107). They all regained a nearly normal parabola and were satisfied with the cosmetic results. Our technique is straightforward and produces good cosmetic results. Satisfactory, bony union is achieved, morbidity is low, and no additional surgery is required for the removal of metal implants

Objectives

Distraction osteogenesis (DO) mobilises bone regenerative potential and avoids the complications of other treatments such as bone graft. The major disadvantage of DO is the length of time required for bone consolidation. Mesenchymal stem cells (MSCs) have been used to promote bone formation with some good results.

1. An experimental study of the effects of nerve and muscle lesions upon the growth of bone has been made. In each case animals were subjected to unilateral lesions in the hind limb, the other limb serving as a control. The growth of the tibia was measured by calculating the difference between the length of the bone on a radiograph at the beginning of the experiment and the length of the dried bone after necropsy. The weights of the dried bones were compared. 2. In the young rabbit simple exposure of the common peroneal nerve, or division of the sural nerve, produced no change in the growth rate of the tibia. Division of both peroneal nerves, producing paralysis of the muscles below the knee, led to lengthening of the affected tibia, and this lengthening persisted until maturity several months later. A similar lengthening was seen after division of the tendons around the ankle. In spite of this lengthening the tibia on the side of the operation was almost always lighter than its fellow. 3. In the puppy division of the anterior nerve roots supplying the hind limb produced a significant lengthening of the tibia of the affected limb three months after operation. No significant changes in limb length occurred after lumbar sympathectomy in the puppy. 4. The significance of these experimental nerve lesions has been considered together with recent observations upon the growth of bone in the presence of lower motor neurone lesions in the child. From this analysis it is suggested that the initial effect of paralysis is to produce lengthening of the affected bone. This lengthening is probably due to the hyperaemia of disuse. In the presence of persistent paralysis the growth of the limb is ultimately depressed. This depression is rarely seen in the experimental animal because the growing period is relatively short. The possible causes of this secondary depression of bone growth have been considered

We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistant pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35).

Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications.

We reviewed 25 patients who had undergone resection of a primary bone sarcoma which extended to within 5 cm of the knee with reconstruction by a combination of a free vascularised fibular graft and a massive allograft bone shell. The distal femur was affected in four patients and the proximal tibia in 21. Their mean age at the time of operation was 19.7 years (5 to 52) and the mean follow-up period 140 months (28 to 213). Three vascularised transfers failed. The mean time to union of the fibula was 5.6 months (3 to 10) and of the allograft 19.6 months (10 to 34). Full weight-bearing was allowed at a mean of 21.4 months (14 to 36). The mean functional score at final follow-up was 27.4 (18 to 30) using a modfied 30-point Musculoskeletal Tumour Society rating system. The overall limb-salvage rate was 88%. The results of our study suggest that the combined use of a vascularised fibular graft and allograft is of value as a limb-salvage procedure for intercalary reconstruction after resection of bone tumours around the knee, especially in skeletally immature patients.

This study was undertaken to elucidate the mechanism of biological repair at the tendon-bone junction in a rat model. The stump of the toe flexor tendon was sutured to a drilled hole in the tibia (tendon suture group, n = 23) to investigate healing of the tendon-bone junction both radiologically and histologically. Radiological and histological findings were compared with those observed in a sham control group where the bone alone was drilled (n = 19). The biomechanical strength of the repaired junction was confirmed by pull-out testing six weeks after surgery in four rats in the tendon suture group. Callus formation was observed at the site of repair in the tendon suture group, whereas in the sham group callus formation was minimal. During the pull-out test, the repaired tendon-bone junction did not fail because the musculotendinous junction always disrupted first.

In order to understand the factors that influenced callus formation at the site of repair, four further groups were evaluated. The nature of the sutured tendon itself was investigated by analysing healing of a tendon stump after necrosis had been induced with liquid nitrogen in 16 cases. A proximal suture group (n = 16) and a partial tenotomy group (n = 16) were prepared to investigate the effects of biomechanical loading on the site of repair. Finally, a group where the periosteum had been excised at the site of repair (n = 16) was examined to study the role of the periosteum. These four groups showed less callus formation radiologically and histologically than did the tendon suture group.

In conclusion, the sutured tendon-bone junction healed and achieved mechanical strength at six weeks after suturing, showing good local callus formation. The viability of the tendon stump, mechanical loading and intact periosteum were all found to be important factors for better callus formation at a repaired tendon-bone junction.

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing.

The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy.

Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.

We report the results of intramedullary leg lengthening conducted between 2002 and 2009 using the Intramedullary Skeletal Kinetic Distractor in 69 unilateral lengthenings involving 58 femora and 11 tibiae. We identified difficulties that occurred during the treatment and assessed whether they were specifically due to the implant or independent of it. Paley’s classification for evaluating problems, obstacles and complications with external fixators was adopted, and implant-specific difficulties were continuously noted. There were seven failures requiring premature removal of the device, in four due to nail breakage and three for other reasons, and five unsuccessful outcomes after completion of the lengthening. In all, 116 difficulties were noted in 45 patients, with only 24 having problem-free courses. In addition to the difficulties arising from the use of external fixators, there were almost the same number again of implant-specific difficulties.

Nevertheless, successful femoral lengthening was achieved in 52 of the 58 patients (90%). However, successful tibial lengthening was only achieved in five of 11 patients (45%).

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75).

All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°.

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed.

The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60).

One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation.

We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.

Arrest of growth of the distal radius is rare but will produce deformity of the wrist. We corrected angular deformity and shortening of the distal radius by epiphysiolysis and gradual lengthening without a corrective osteotomy.

We present a retrospective review of a single-surgeon series of 30 consecutive lengthenings in 27 patients with congenital short femur using the Ilizarov technique performed between 1994 and 2005.

The mean increase in length was 5.8 cm/18.65% (3.3 to 10.4, 9.7% to 48.8%), with a mean time in the frame of 223 days (75 to 363). By changing from a distal to a proximal osteotomy for lengthening, the mean range of knee movement was significantly increased from 98.1° to 124.2° (p = 0.041) and there was a trend towards a reduced requirement for quadricepsplasty, although this was not statistically significant (p = 0.07). The overall incidence of regenerate deformation or fracture requiring open reduction and internal fixation was similar in the distal and proximal osteotomy groups (56.7% and 53.8%, respectively). However, in the proximal osteotomy group, pre-placement of a Rush nail reduced this rate from 100% without a nail to 0% with a nail (p < 0.001). When comparing a distal osteotomy with a proximal one over a Rush nail for lengthening, there was a significant decrease in fracture rate from 58.8% to 0% (p = 0.043).

We recommend that in this group of patients lengthening of the femur with an Ilizarov construct be carried out through a proximal osteotomy over a Rush nail. Lengthening should also be limited to a maximum of 6 cm during one treatment, or 20% of the original length of the femur, in order to reduce the risk of complications.

The potential harm to the growth plate following reconstruction of the anterior cruciate ligament in skeletally-immature patients is well documented, but we are not aware of literature on the subject of the fate of the graft itself. We have reviewed five adolescent males who underwent reconstruction of the ligament with four-strand hamstring grafts using MR images taken at a mean of 34.6 months (18 to 58) from the time of operation. The changes in dimension of the graft were measured and compared with those taken at the original operation. No growth arrest was seen on radiological or clinical measurement of leg-length discrepancy, nor was there any soft-tissue contracture. All the patients regained their pre-injury level of activity, including elite-level sport in three. The patients grew by a mean of 17.3 cm (14 to 24). The diameter of the grafts did not change despite large increases in length (mean 42%; 33% to 57%). Most of the gain in length was on the femoral side. Large changes in the length of the grafts were seen.

There is a considerable increase in the size of the graft, so some neogenesis must occur; the graft must grow.

We studied the safety of external fixation during post-operative chemotherapy in 28 patients who had undergone distraction osteogenesis (17, group A) or vascularised fibular grafting (11, group B) after resection of a tumour. Four cycles of multi-agent post-operative chemotherapy were administered over a mean period of 14 weeks (6 to 27). The mean duration of external fixation for all patients was 350 days (91 to 828). In total 204 wires and 240 half pins were used.

During the period of post-operative chemotherapy, 14 patients (11 in group A, 3 in group B) developed wire- and pin-track infection. A total of ten wires (4.9%) and 11 half pins (4.6%) became infected. Seven of the ten infected wires were in periarticular locations.

External fixation during post-operative chemotherapy was used safely and successfully for fixation of a vascularised fibular graft and distraction osteogenesis in 27 of 28 patients. Post-operative chemotherapy for malignant bone tumours did not adversely affect the ability to achieve union or cause hypertrophy of the vascularised fibular graft and had a minimal effect on distraction osteogenesis. Only one patient developed osteomyelitis which required further surgery.

Ollier’s disease is characterised by severe deformity of the extremities and retarded growth because of multiple enchondromas. For correction of deformity, the Ilizarov method has been used although it has many complications. A 17-year-old boy with Ollier’s disease had a limb-length discrepancy of 17.4 cm, with a valgus deformity of the right knee and recurvatum of the femur of 23°. He had undergone three unsuccessful attempts to correct the deformities by using external fixators. We used a fully implantable, motorised, lengthening and correction nail (Fitbone) to achieve full correction of all the deformities without complications. We decided to carry out the procedure in three stages. First, we lengthened the femur by 3.6 cm and the tibia by 4 cm. We then exchanged the femoral nail for a longer implant and achieved a further 6 cm of length. This reduced the shortening to 3.8 cm. When the boy has finished secondary school we will adjust the remaining discrepancy.

We investigated the effect of locally administered bisphosphonate on distraction osteogenesis in a rabbit model and evaluated its systemic effect. An osteotomy on the right tibia followed by distraction for four weeks was performed on 47 immature rabbits. They were divided into seven equal groups, with each group receiving a different treatment regime. Saline and three types of dosage of alendronate (low, 0.75 μg/kg; mid, 7.5 μg/kg and high 75 μg/kg) were given by systemic injection in four groups, and saline and two dosages (low and mild) were delivered by local injection to the distraction gap in the remaining three groups. The injections were performed five times weekly during the period of distraction.

After nine weeks the animals were killed and image analysis and mechanical testing were performed on the distracted right tibiae and the left tibiae which served as a control group. The local low-dose alendronate group showed a mean increase in bone mineral density of 124.3 mg/cm³ over the local saline group (analysis of variance, p < 0.05) without any adverse effect on the left control tibiae.

The findings indicate that the administration of local low-dose alendronate could be an effective pharmacological means of improving bone formation in distraction osteogenesis.

We reviewed 78 femoral and tibial nonunions treated between January 1992 and December 2003. Of these, we classified 41 in 40 patients as complex cases because of infection (22), bone loss (6) or failed previous surgery (13). The complex cases were all treated with Ilizarov frames. At a mean time of 14.1 months (4 to 38), 39 had healed successfully.

Using the Association for the Study and Application of the Methods of Ilizarov scoring system we obtained 17 excellent, 14 good, four fair and six poor bone results. The functional results were excellent in 14 patients, good in 14, fair in two and poor in two. A total of six patients were lost to follow-up and two had amputations so were not evaluated for final functional assessment. All but two patients were very satisfied with the results. The average cost of treatment to the treating hospital was approximately £30 000 per patient.

We suggest that early referral to a tertiary centre could reduce the morbidity and prolonged time off work for these patients. The results justify the expense, but the National Health Service needs to make financial provision for the reconstruction of this type of complex nonunion.

The effect of zoledronic acid on bone ingrowth was examined in an animal model in which porous tantalum implants were placed bilaterally within the ulnae of seven dogs. Zoledronic acid in saline was administered via a single post-operative intravenous injection at a dose of 0.1 mg/kg. The ulnae were harvested six weeks after surgery. Undecalcified transverse histological sections of the implant-bone interfaces were imaged with backscattered scanning electron microscopy and the percentage of available pore space that was filled with new bone was calculated. The mean extent of bone ingrowth was 6.6% for the control implants and 12.2% for the zoledronic acid-treated implants, an absolute difference of 5.6% (95% confidence interval, 1.2 to 10.1) and a relative difference of 85% which was statistically significant. Individual islands of new bone formation within the implant pores were similar in number in both groups but were 69% larger in the zoledronic acid-treated group. The bisphosphonate zoledronic acid should be further investigated for use in accelerating or enhancing the biological fixation of implants to bone.

We present our experience of forearm lengthening in children with various conditions performed by a single surgeon between 1995 and 2009. A total of 19 children with a mean age of 9.8 years (2.1 to 15.9) at the time of surgery had 22 forearm lengthenings using either an Ilizarov/spatial and Ilizarov circular frame or a monolateral external fixator. The patients were divided into two groups: group A, in whom the purpose of treatment was to restore the relationship between the radius and the ulna, and group B, in whom the objective was to gain forearm length. The mean follow-up after removal of the frame was 26 months (13 to 53).

There were ten patients (11 forearms) in group A with a mean radioulnar discrepancy of 2.4 cm (1.5 to 3.3) and nine patients (11 forearms) in group B. In group A, the mean lengthening achieved was 2.7 cm (1.0 to 5.5), with a lengthening index of 11.1 weeks/cm. Equalisation or overcorrection of the discrepancy was achieved in seven of 11 forearms, but lengthening was only partially successful at preventing subluxation or dislocation of the radial head. In group B, the mean lengthening achieved was 3.8 cm (1.9 to 6.8), with a lengthening index of 7.25 weeks/cm. Common complications in both groups were pin-site infection and poor regenerate formation.

Forearm lengthening by distraction osteogenesis is a worthwhile procedure in children that can improve cosmesis and function, particularly in patients with shortening of both radius and ulna.

In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient.

We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication.

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5).

All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly.

This study reports our experience with total elbow replacement for fused elbows.

Between 1982 and 2004, 13 patients with spontaneously ankylosed elbows were treated with a linked semi-constrained non-custom total elbow implant. The mean age at operation was 54 years (24 to 80). The stiffness was a result of trauma in ten elbows, juvenile rheumatoid arthritis in one, and rheumatoid arthritis in two. The patients were followed for a mean of 12 years (2 to 26) and were evaluated clinically using the Mayo Elbow Performance Score, as well as radiologically.

A mean arc from 37° of extension to 118° of flexion was achieved. Outcomes were good or excellent for seven elbows at final review. Ten patients felt better or much better after total elbow replacement. However, there was a high complication rate and re-operation was required in over half of patients. Two developed peri-operative soft-tissue breakdown requiring debridement. A muscle flap with skin grafting was used for soft-tissue cover in one. Revision was undertaken in one elbow following fracture of the ulnar component. Three patients developed a deep infection. Three elbows were manipulated under anaesthesia for post-operative stiffness. Prophylactic measures for heterotopic ossification were unsuccessful.

Total elbow replacement for the ankylosed elbow should be performed with caution. However, the outcome can be reliable in the long term and have a markedly positive impact on patient function and satisfaction. The high potential for complications must be considered. We consider total elbow replacement to be an acceptable procedure in selected patients with reasonable expectations.

We present a retrospective study of 27 patients treated by callus distraction using a unilateral external fixator of our own design for nonunion with bone loss and shortening of the femur caused by suppurative osteomyelitis. The unilateral external fixator was used either alone or in combination with an intramedullary nail. The mean age of the patients was 13.6 years (8 to 18). The fixator was used alone in 13 patients and with an intramedullary nail in 14. The bone results at a mean follow-up of 88 months (37 to 144) were excellent in 16 patients and good in 11.

The functional results were excellent in 18 patients and good in nine. However, four patients still had draining sinuses at the latest follow-up. A residual deformity greater than 7° was present in seven femora, but this did not adversely affect function or require further treatment.

Despite worldwide clinical use of bio-absorbable devices for internal fixation in orthopaedic surgery, the degradation behaviour and tissue replacement of these implants are not fully understood.

In a long-term experimental study, we have determined the patterns of tissue restoration 36 and 54 months after implantation of polyglycolic acid and poly-laevo-lactic acid screws in the distal femur of the rabbit.

After 36 months in the polyglycolic acid group the specimens showed no remaining polymer and loose connective tissue occupied 80% of the screw track. Tissue restoration remained poor at 54 months, the amounts of trabecular bone and haematopoietic elements being significantly lower than those in the intact control group. The amount of trabecular bone within the screw track at 54 months in the polyglycolic acid group was less than in the empty drill holes (p = 0.04). In the poly-laevo-lactic acid group, polymeric material was present in abundance after 54 months, occupying 60% of the cross-section of the core area of the screw track.

When using absorbable internal fixation implants we should recognise that the degradation of the devices will probably not be accompanied by the restoration of normal trabecular bone.