Introduction. Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures. Materials & Methods. We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA). 137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups. Results. Mean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years. PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17). Conclusions. This pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures

Introduction. Despite all modern advances the indications and possibilities of treatment in Legg-Calvé-Perthes Disease (LCPD) are still controversial. In the past 15 years we started using arthrodiastasis of the hip creating negative pressure over the avascular femoral head in some selected cases of LCPD in the active phasis of the disease. Now we present our experience with distraction in LCPD using the original Ilizarov circular frame for the hip. Materials and Methods. From 2015 to 2021, eight patients with LCPD were submoitted to hip distraction; all male ranging from six to 12 years (avg 8.2 years). All patients with bad prognosis, in Catterall Groups III and IV. All patients in the active phasis of the disease. Our follow-up is ranging from two to six years, with an average of 3.4 years. Results. All the preliminary results are good with recovering of range of motion of the affected hip joint in allpatients. After the first month under distraction is possible to observe new bone formation specially in the lateral pillar of the femoral head. Complications were not observed in this group of patients. Conclusions. The main point of this prospective study is to find that is possible to achieve cartilaginous growth on the femoral head stimulated by the traction offered by the external fixator, in a very short period of time. Distraction may be one method for a good treatment in patients aged six years or older with Legg-Calvé-Perthes disease in the active phase of the disease

Introduction. Fully implantable distraction nails are frequently used for lengthening of the lower leg. What are the indications for humerus lengthening and which results can be expected?. Materials and Methods. The humerus as the best healing bone in the human body is suitable for lengthening with a nail as well but the indications are rare in comparison with the lower legs. Especially when driving a car or when working on a tablet length discrepancy of the arms of more than 4–5cm may cause severe hardening of the cervical muscles and induce chronical pain in the upper spine. Results. A distraction nail (FITBONE) was used in 5 cases for humerus lengthening. The nail was inserted in all cases from proximal. The mean age of the patients was 34 years. The mean lengthening amount was 58mm (55–100). In one case the system was exchanged to reach the desired length. There was no infection, no radial nerve irritation and no chronical shoulder pain. The system was removed in 4 cases in an average of 15 months the other nail will be removed soon as well. Conclusions. The preliminary results of our 5 cases demonstrate, that the FITBONE device is advantageous for lengthening the humerus, if the initial length is sufficient for implantation. In comparison with the use of external fixators the functional outcome, the comfort of treatment and the cosmetic result is amazing

Introduction. Fully implantable systems are used commonly only after maturity. What are indications to use fully implantable systems at the femur even in children?. Materials and Methods. Implantable lengthening nails (FITBONE) were used retrograde at the femur in minimal invasive technique to correct a limb length discrepancy of >6 cm. In 5 cases a relevant deformity was corrected in the same surgery. In all cases a final step of lengthening was planned at the femur and at the tibia with fully implantable devices at maturity. Results. 18 patients with the medium age of 10,3 years (8–14) were treated. In 17 cases the goal of lengthening was achieved without any complication. In one case of proximal femoral deficiency lengthening had to be stopped because of increasing tendency of knee joint luxation. Bone formation occurred circular around the nail in all cases. Full load bearing was possible in the average after 2,2 days/mm. No technical problems occur. In one case induced deformity in the lateral plane was observed which was corrected at the final step. At the end of treatment functional and cosmetical result was perfect in all cases. Conclusions. Fully implantable motorized distraction nails are a favorable option for lengthening and deformity correction of the femur even for children older than 10 years to correct limb length discrepancy of more than 6 cm. The treatment has a low pain level, is comfortable and nearly no scars are visible

Purpose. Despite total knee arthroplasty (TKA) is a successful surgical procedure with end-stage knee osteoarthritis, approximately 20% of the patients who underwent primary TKA were still dissatisfied with the outcome. Thereby, numerous literatures have confirmed the relationship between soft tissue balancing and clinical result to improve this pressing issue. Recently, there has been an increased research interest in patient-reported outcome measures (PROMs) after TKA. However, there is little agreement on the association between soft tissue balancing and PROMs. Therefore, the purpose of this study was to determine whether intraoperative soft tissue balancing affected PROMs after primary TKA. We hypothesized that soft tissue balancing would be a predictive factor for postoperative PROMs at one-year post-surgery. Patients and Methods. The study included 20 knees treated for a varus osteoarthritic deformity using a cruciate-retaining TKA (Scorpio NRG) with a polyethylene insert thickness of 8 mm retrospectively. Following the osteotomy using the measured resection technique, the extension gap was measured with a femoral trial by using an electric tensor. This instrument could estimate the soft tissue balance applying continuous distraction force simultaneously from 0 to 40 lbf with an accuracy of the 0.1 lbf. We evaluated the association between a distraction force required for an extension gap of 8 mm, and the following potentially affected factors at one year postoperatively: knee flexion angle using a protractor with one degree increments; radiographic parameters of component alignment, namely the femoral and tibial component medial angle; and the Japanese Knee Osteoarthritis Measure (JKOM). This is a disease-specific and self-administered questionnaire, reflecting the specificity of the Japanese cultural lifestyle, consisting of 25 items scored from 0 to 100 points, with 100 points being worst. Outcomes. The median knee flexion angle was 130 degrees with the femoral and tibial component of 97 and 89 degrees, respectively. For an extension gap of 8 mm, a verified value of a distraction force did not demonstrate a correlation with, knee flexion angle (p = 0.29) or with the femoral (p = 0.20), and tibial component position (p = 0.09). The median JKOM totaled 20 points across 4 domains: pain and stiffness, condition in daily life, general activities, and health conditions with 5, 8, 2.5, and 2 points respectively. There was significant correlation between a required force and the JKOM (r. s. = 0.53, p = 0.02), and notably the domain of health conditions exhibited the highest coefficient of determination (r. s. = 0.54, p = 0.01). Discussion. This study highlights that distraction force for an extension gap of 8 mm is an independent variable in component position or knee flexion angle. We found that soft tissue balancing could influence short term postoperative PROMs. Our results will contribute to a better understanding of outcomes after TKA. This is a particularly critical issue as feasible strategies to avoid a persistent joint stiffness would improve long-term function after TKA and patient satisfaction

Acetabular distraction for the treatment of chronic pelvic discontinuity was first described by Sporer and Paprosky. The authors advocate the posterolateral approach for exposure of the posterior ilium and posterior column, The patient is secured in the lateral decubitus position. Following a systematic approach to surgical exposure, acetabular component removal should be performed with “cup out” osteotomes resulting in minimal iatrogenic bone loss. Following component removal and confirmation of a chronic discontinuity determine the integrity of the remaining AS and PI columns. If porous metal augments are needed for primary stabilization, the augments are placed prior to cup insertion for reconstruction of the AS and/or PI column. Next, Kirschner (K) wires (size 2.4) are placed in the remaining AS and PI bone so that the distractor can be secured in an extra-acetabular position. The distractor is placed over the K-wires allowing for lateral or peripheral acetabular distraction and resultant medial or central compression at the discontinuity. With the distractor in an extra-acetabular position, hemispherical reamers are used until an interference fit is achieved between the native or augmented AS and PI columns. The acetabulum should be reamed on reverse to avoid excessive removal of host bone. When the proper acetabular component size has been reached, the reamer will disengage from the reamer handle and the reamer can be used as a surrogate acetabular shell; when the acetabulum is maximally distracted, the entire construct will move as a unit. Crushed cancellous allograft is used to bone graft the discontinuity and reamed on reverse. A revision tantalum cup is inserted with continual distraction using the distractor. Cement is applied to the augment surface prior to cup insertion in order to utilise the construct. Following cup insertion, the distractor and K-wires are removed. Adjuvant screw fixation is performed, with a minimum of 4 screws, and placing at least one of the screws inferiorly for fixation in the superior public ramus or ischium to prevent abduction failure of the construct. In the setting of severely osteoporotic bone and inadequate screw fixation, an augment placed posterosuperiorly can be used for supplemental fixation. This augment is also unitised to the cup with cement at the same time as the liner is cemented into the cup. Bone wax is placed over the exposed tantalum surface of the posterosuperior augment to minimise soft-tissue ingrowth into the augment

Conservative management remains the gold standard for many fractures of the humeral diaphysis with union rates of over 90% often quoted. Success with closed management however is not universal. Phase 1. A retrospective review of all conservatively managed fractures between 2001 and 2005 was undertaken to investigate a suspected high non-union rate and identify possible causes. The overall non-union rate was 39.2% (11 of 28 cases). There was no difference in axial distraction at presentation, however following application of cast there was significantly more distraction in the non-union group (1.2 v 5.09mm, p<0.01). Changes to practise. All humeral fractures were admitted, lightweight U-slabs were applied by a technician, distraction was avoided, patients abstained from NSAIDS, consultant reviewed radiographs before discharge and patients were converted early to functional brace. Phase 2. Prospective collection of data over the following two year period showed a decrease in the amount of distraction when first placed in cast (2.73 v 0.74, p<0.05), a reduction in NSAID use (89% v 38%, p<0.01) and earlier conversion to brace (37 v 20 days p<0.01). These changes to practise led to a dramatic reduction in non-union rate from 39.2% to 4.9% (p<0.01). Conclusion. Over-distraction at first application of cast is a causal factor in the development of non-union. Lightweight cast, avoidance of distraction, abstinence from NSAIDS and early conversion to functional brace is recommended. The initial surgical management of the patient who displays evidence of distraction will prevent evolution of non-union with conservative management. This will avoid lengthy delays in the treatment of the non-union and also help to prevent secondary stiffness in adjacent joints and disuse osteopenia

Stabilisation of a pelvic discontinuity with a posterior column plate with or without an associated acetabular cage sometimes results in persistent micromotion across the discontinuity with late fatigue failure and component loosening. Acetabular distraction offers an alternative technique for reconstruction in cases of severe bone loss with an associated pelvic discontinuity. We describe the technique of acetabular distraction with porous tantalum components and evaluate its survival, function and complication rate in patients undergoing revision surgery for chronic pelvic discontinuity. Between 2002 and 2006, we treated 28 patients with a chronic pelvic discontinuity acetabular reconstruction using acetabular distraction. A porous tantalum elliptical acetabular component was used alone or with an associated modular porous tantalum augment in all patients. Three patients died and five patients were lost to follow-up before two years. The remaining twenty patients were followed semiannually for a minimum of two years (average, 4.5 years; range, 2–7 years) with clinical pain and walking scores as well as radiographic evaluation for loosening, migration or failure. In the remaining twenty patients available for follow-up, one patient did require re-revision for aseptic loosening. Fifteen patients remained radiographically stable at last follow-up. Four patients had early migration of their acetabular component but thereafter remained radiographically stable and clinically asymptomatic. The average improvement using the modified Merle d'Aubigne – Postel pain and ambulation score was 6.6 (range, 3.3–9.6). There were no postoperative dislocations; however, we did encounter one infection, one vascular injury and one bowel injury. In this series, the use of acetabular distraction with porous tantalum components provides a biologic alternative to cage constructs with more predictable clinical results (average follow-up 4.5 years) for reconstruction of severe acetabular defects with associated pelvic discontinuity

Stabilisation of a chronic pelvic discontinuity with a posterior column plate with or without an associated acetabular cage sometimes results in persistent micromotion across the discontinuity with late fatigue failure and component loosening. We believe that these chronic discontinuities are really chronic fracture non-unions incapable of healing. Acetabular distraction offers an alternative technique for reconstruction in cases of severe bone loss with an associated pelvic discontinuity. We describe the technique of acetabular distraction with porous tantalum components and evaluate its survival, function and complication rate in patients undergoing revision surgery for chronic pelvic discontinuity. Between 2002 and 2006, we treated 28 patients with a chronic pelvic discontinuity acetabular reconstruction using acetabular distraction. A porous tantalum elliptical acetabular component was used alone or with an associated modular porous tantalum augment in all patients. Three patients died and five patients were lost to follow up before two years. The remaining twenty patients were followed semiannually for a minimum of two years (average, 5.5 years; range, 2–9 years) with clinical pain and walking scores as well as radiographic evaluation for loosening, migration or failure. In the remaining twenty patients available for follow up, one patient did require re-revision for aseptic loosening. Fifteen patients remained radiographically stable at last follow up. Four patients had early migration of their acetabular component but thereafter remained radiographically stable and clinically asymptomatic. The average improvement using the modified Merle d'Aubigne – Postel pain and ambulation score was 6.6 (range, 3.3–9.6). There were no post-operative dislocations; however, we did encounter one infection, one vascular injury and one bowel injury. In this series, the use of acetabular distraction with porous tantalum components provides a biologic alternative to cage constructs with more predictable clinical results (average follow up 5.5 years) for reconstruction of severe acetabular defects with associated pelvic discontinuity

The purpose of this study is to describe the use of intramedullary distraction coupled with an additional osteotomy to achieve union with simultaneous deformity correction and lengthening in femoral non-union. Femoral non-union is a difficult problem often associated with shortening, angulation, and mal-rotation. We report the use of an intramedullary distraction device, with additional osteotomy, to achieve union, restore femoral length and alignment. Simple distraction in femoral non-union is often ineffective, possibly because the non-union site is relatively avascular. Osteotomy is known to increase blood flow and, with lengthening, promote union through distraction histiogenesis. 7 patients with posttraumatic diaphyseal femoral non-union with shortening were studied. Pre-operative planning included long leg standing views, with CT to measure mal-rotation. 6 patients were treated with the Intramedullary Skeletal Kinetic Distractor (ISKD) with an osteotomy distant from non-union site within the parameters required for the device. One patient underwent distraction without osteotomy. Patients were followed to union. Complications and adjuvant interventions were recorded. All 7 patients with femoral non-union treated with ISKD were included and followed up. Patients treated with osteotomy united at average of 9 months with satisfactory deformity correction and lengthening. However patient who underwent pure distraction failed to unite. Complications included failure to lengthen, requiring manipulation, and delayed consolidation of regenerate requiring bone graft. The procedure was well tolerated. The initial results of the management of femoral non-union with deformity by intramedullary distraction coupled with osteotomy are encouraging. Complications were minor and readily manageable. We believe there is an important role for this method in the management of femoral non-unions associated with deformity and length discrepancy

The aim of this study was to assess the incidence of fibula non-union in patients undergoing distraction osteogenesis, and the incidence of symptoms following this. A consecutive series of 58 patients undergoing distraction osteogenesis at a tertiary centre under a single surgeon were included. Data was collected prospectively. Plain radiographs were reviewed retrospectively by a blinded reviewer. Union was defined as the presence of bridging callous on two views. There were 58 distraction procedures performed. The mean age was 37.2 years (range 16.0 to 80.6). There were 36 males and 22 females. The mean follow-up was 23.4 months (4–70 months). 9 (15.5%) went onto non-union at frame removal. 3 (33.3%) of the 9 fibulas that did not unite developed symptoms. 2 (66.7%) of these required surgery in the form of fibula plating. Both of these patient's symptoms resolved following surgery. 3 (33.3%) of the 9 non-united fibulas also had tibial non-union compared to 1 of the 49 where the fibula united. There was no association between location of fibula osteotomy and development of non-union. 35 fibula osteotomies were performed in the third quarter. Of the fibulas that united, the mean fibula lengthening was 9.25 mm (range 1.2–27.8 mm). In the fibulas that went onto non-union the mean lengthening was 23.66 mm (range 5.1–51.5 mm) (P = 0.004). 54 (93.1%) of the tibias united following osteotomy and distraction, whilst 4 (6.9%) went onto non-union requiring operative treatment. Of the 4 tibias that did not unite, 3 (75%) also had fibula non-union (P = 0.01). Fibula non-union is a relatively common complication following osteotomy in distraction osteogenesis. The length of fibula distraction and tibia non-union are significant risk factors for the development of a fibula non-union. We recommend surgical intervention for those patients who have symptomatic fibula non-unions

Sclerostin is a negative regulator of osteoblast differentiation and bone formation, probably through inhibition of the Wnt pathway. Distraction osteogenesis (DO) can be complicated by osteopenia and poor anabolic response, which may benefit from anabolic therapy. Sclerostin antibody (Scl-Ab) has been reported to stimulate bone formation and restore bone mass and strength in aged ovariectomised rats as well as to enhance fracture healing. We sought to examine the effects of Scl-Ab in a rat model of DO. A femoral osteotomy was stabilised with an EBI fixator in male Sprague Dawley rats, with distraction of 0.25mm twice daily to a total 7mm. Saline or Scl-Ab was administered twice weekly throughout distraction and/or up to 4 or 6 weeks post-commencement of distraction. Three groups were examined, Saline, Delayed Scl-Ab (D Scl-Ab, post distraction only) and Continuous Scl-Ab (Cont Scl-Ab). Radiographs demonstrated a trend for increased union rates with Scl-Ab at 6 weeks, with 50% of animals for D Scl-Ab or Cont Scl-Ab versus 20% of control animals. DEXA scans at 2 weeks revealed a 63% increase in regenerate BMD in the Cont Scl-Ab group (p< 0.01) and a 41% increase in the D Scl-Ab group (p< 0.05), compared to Saline. In addition, an increase of 116% in BMC was seen in the Cont Scl-Ab group (p< 0.01). At 6 weeks regenerate bone area was increased 18% in D Scl-Ab and 23% in Cont Scl-Ab. μCT scans of the regenerate revealed an 85%-89% increase in bone volume with Scl-Ab treatment at 6 weeks (p< 0.05). Bone volume ratio (BV/TV) was increased 77%-82% (p< 0.05). Scl-Ab treatment enhanced the amount of bone formed in this distraction model, when given throughout or post-distraction. Histological assessment of dynamic bone formation parameters will reveal the mechanism behind the enhanced repair, and its mechanical consequences will be examined

Purpose:. This study attempts to establish whether biomechanical manipulation through distraction can result in fracture union. Method:. A retrospective clinical audit of 15 patients with delayed or hypertrophic non-unions treated successfully with closed distraction in circular external fixation. Average time to union, complications and complication rates were also reviewed. Inclusion criteria: all patients with delayed or hypertrophic non-union, treated by closed distraction between 2004 and 2011. Results:. Fifteen patients included in the study. The average time to union was 188 days. The most common complication was local pin tract sepsis. The most serious complication was a broken fixation ring that needed replacement. Conclusion:. Biomechanical fracture strain is calculated by dividing the fracture gap distance by the change in the fracture distance i.e. FRACTURE STRAIN = DIFFERENCE IN L/L Hypertrophic non-union occurs when the fracture strain is more than 10 %. This formula shows that by increasing the fracture gap, the fracture strain will decrease This concept is contrary to the current practice of compressing the fracture. This study shows that distraction can be used to manipulate the biomechanical circumstances that dictate the development of fracture non-union. Furthermore ring fixators are ideal devices to use for biomechanical manipulation

Sclerostin is a negative regulator of osteoblast differentiation and bone formation. Expressed by osteocytes, it acts through antagonising the Wnt/â-catenin pathway and/or BMP activity. Distraction osteogenesis, used for limb lengthening and reconstruction, can be complicated by disuse osteopenia and poor healing response, both of which would benefit from pro anabolic therapy. We examined the effects of Sclerostin Antibody (Scl-AbIII, Amgen Inc.,) in a rat model of distraction osteogenesis. A femoral osteotomy was stabilized with an external fixator in male Sprague Dawley rats. After a week of latency, the gap was distracted twice daily for 14 days to a total of 7 mm. Saline or Scl-Ab was administered twice weekly throughout the distraction period and up to 4, 6 or 8 weeks post commencement of distraction. Three groups were examined: Saline, Continuous Scl-Ab throughout the study (C Scl-Ab), and Delayed Scl-Ab with commencement of Scl-Ab after distraction (D Scl-Ab). Regenerate bone mineral content (BMC), determined by DEXA, was increased 36% at 4 weeks and 86% at 6 weeks with C Scl-Ab, resulting in a 65% increase in bone mineral density (BMD) at 6 weeks, compared with Saline (p<0.01). D Scl-Ab treatment showed a 41% increase in BMC and a 31% increase in BMD compared with Saline at 6 weeks (p<0.05). At 8 weeks, C Scl-Ab remained significantly increased over Saline (72% in BMC; 60% in BMD). Micro-CT scans of the regenerate revealed increases in bone volume of 88% with C Scl Ab and 65% with D Scl-Ab compared with Saline at 6 weeks (p<0.05). By 8 weeks, these increases were 36% for C Scl-Ab (p<0.05) and 37% for D Scl-Ab compared with Saline (p<0.01). Importantly, mean moment of inertia was increased over two-fold in both Scl-Ab groups at 6 weeks compared with Saline (p<0.05). Histology at 6 weeks confirmed micro-CT data with 85–88% increases in bone volume/tissue volume (BV/TV) in the regenerate with both C Scl-Ab and D Scl-Ab compared with Saline (p<0.05). Analysis of bone formation at 6 weeks revealed increases in mineral apposition rate of 56% in C Scl-Ab and 52% in D Scl-Ab compared with Saline (p<0.05). Scl-Ab treatment increased bone formation in this model of distraction osteogenesis, resulting in a larger regenerate callus (increased BMC and BV/TV). We expect further studies to reveal increases in mechanical strength. Scl-Ab may hold promise as a therapeutic to accelerate regenerate formation and consolidation in distraction osteogenesis for limb reconstruction

Aim. The treatment of relapsed clubfeet presents a significant challenge. The Ilizarov method of gradual correction has been shown to provide satisfactory outcome. Since 2001 we have employed a newer differential soft tissue distraction using an Ilizarov frame in relapsed feet based on the Ponseti principles. The aim of our study was to analyse the outcome of this treatment. Material and Methods. All feet treated with soft tissue distraction only were studied. The feet were assessed using international clubfoot study group evaluation, pedobarography, and gait analysis, X-rays and ASK (activity scale for kids) questionnaire. Results. Out of 35 feet, 16 children with 27 feet attended for follow-up. The indications for surgery were failed multiple surgeries in 19 feet and failed Ponseti in 8 feet. The average age at operation was 5 years and the median follow-up was 5 years. The average duration of the frame was 5 months. Using international club foot scoring evaluation 25 feet scored ‘good’ and 2 scored ‘fair’. The pedobarography and gait analysis showed improvement when compared to the pre-operative assessment. The ASK functional questionnaire showed all 16 children were able to be independent most of the time. Grade 1 infection was noted in all cases. There were no physeal disruptions, growth arrest or joint subluxations. Five feet needed tibialis anterior transfer, 2 underwent supramalleolar osteotomy, 1 needed percutaneous tendo achilles lengthening and 1 needed scar revision as further surgical procedures. The deformity has recurred in 1 foot and is waiting for bony correction. Conclusion. We conclude that the Ponseti principles of soft tissue differential distraction with Ilizarov frame give reasonable results

We report our early experience with distracting external fixation used to offload the hip after avascular necrosis (AVN) of the femoral head secondary to severe slipped upper femoral epiphysis (SUFE). A case series of five patients treated in a tertiary centre is reported. Electronic case records and radiographs were reviewed. Data recorded included demographics, initial presentation, timing of head collapse, timing and duration of distraction and outcome including referral to adult arthoplasty services. Mean age at presentation was 12 years (range 12–15). 4 were females. Initial treatment in 4 cases was a delayed cuneiform osteotomy and pinning, one patient underwent serendipitous reduction and percutaneous pinning. Mean duration to initial surgery was 10 days (range 5–16). All patients had femoral head collapse at a mean of 148 days from time of presentation. 2 patients required backing out of screws due to intra-articular protrusion. All patients underwent distraction at a mean 193 days from presentation. Average distraction achieved was 10 mm and duration of application was 125 days (range 91–139). All patients experienced improvement or resolution of pain but persistence of poor function, characterised by fixed adduction and limb length discrepancy. 3 patients were referred to adult arthroplasty services. This may be an effective treatment option for pain associated with AVN post SUFE. However, in our experience normal anatomy and function of the hip is not restored if performed after collapse of the femoral head. Consideration should be given to application of the distractor either at the time of initial fixation or prior to femoral head collapse. Authors believe that timing of the application of the distractor is critical for a successful outcome and recommend a prospective study with large numbers

UK Objective. To evaluate the technique of transverse debridement, acute shortening and subsequent distraction histiogenesis in the management of open tibial fractures with bone and soft tissue loss thus avoiding the need for flap coverage. Methods. We present a retrospective review of 18 patients with Gustillo grade III open tibial fractures between 2006 and 2011. Initially managed with debridement to provide bony apposition through transverse wound excision. This allowed primary wound closure without tension, or mobilization of local muscle followed by split skin graft to provide cover. Temporary mono-lateral external fixation was utilized to allow soft tissue resuscitation, followed by Ilizarov frame for definitive fracture stabilization. In some cases it was possible to apply an Ilizarov frame at the time of initial debridement. Leg length discrepancy was subsequently corrected by corticotomy and distraction histiogenesis. Union was evaluated radiologically and clinically. Results. Mean age 36.4 years (18.4–59.2 years). Mean bone defect 3.5 cm (0.5–10 cm). Mean soft tissue defect 4.1 cm (1.8–10 cm). Mean follow up was 81 weeks (30–174 weeks). 16 fractures united, with a mean time to union of 38 weeks (24–79 weeks). There was one hypertrophic nonunion which united after a second frame. One patient was lost to follow up before fracture union. Three patients had pin site infections, two of which required intravenous antibiotics. One patient developed chronic osteomyelitis but manages with a discharging sinus. There were no amputations. Conclusion. Acute shortening followed by distraction histiogenesis is a safe method for the treatment of severe open tibial fractures with bone and soft tissue loss. The technique also avoids the morbidity, cost and logistical issues associated with the use of local or free tissue flaps

Limb lengthening by callus distraction and external fixation has a high rate of complications. We describe our experience using an intramedullary nail (Fitbone) which contains a motorised and programmable sliding mechanism for limb lengthening and bone transport. Between 2001 and 2004 we lengthened 13 femora and 11 tibiae in ten patients (seven men and three women) with a mean age of 32 years (21 to 47) using this nail. The indications for operation were short stature in six patients and developmental or acquired disorders in the rest. The mean lengthening achieved was 40 mm (27 to 60). The mean length of stay in hospital was seven days (5 to 9). The mean healing index was 35 days/cm (18.8 to 70.9). There were no cases of implant-related infection or malunion

Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with mean age 15 years (9 to 23) and mean follow-up 21 months (8 to 51). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with torticollis, congenital myopathy and Noonans syndrome and obstetric brachial plexus injury. Mean length gained was 31 mm (15 to 41) which represens an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263) and mean external fixation index was 56 days/cm. Two patients required internal fixation following fixator removal to consolidate union and one required additional internal fixation for atrophic regenerate. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin site infections. Clavicular lengthening by distraction osteogenesis for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury following acute correction. It has the potential to improve shoulder pain, function, range of movement and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union

Aim. In our Bone Infection Unit, epidural anaesthesia and sedation (EA+Sed) is the technique of choice for complex orthoplastic surgery involving lower limb free tissue transfer (LLFTT) (1) as it avoids complications of prolonged general anaesthesia (GA). Following our initial reports of successful use of audio-visual distraction (AVD) as an adjunct to regional anaesthesia we wished to evaluate the AVD effect on the patients’ experience during long duration, complex orthoplastic surgery for chronic osteomyelitis under EA+Sed. Method. Our AVD equipment consists of a WiFi connected tablet and noise reducing head phones, providing access to downloaded music, films and the internet. Patients are also allowed to use their own equipment. All patients were fully informed about AVD and EA+Sed as a choice of anaesthesia. EA was established in the anaesthetic room and continued perioperatively. Sedation with propofol was titrated to the patients’ requirements to ensure comfort during surgery. All patients were followed up postoperatively with a structured questionnaire. Results. Ten patients underwent LLFTT surgery for chronic bone infection under EA+Sed+AVD (picture). Mean duration of surgery was 550 min (480 −600 min). Patients used the AVD to listen to music, watch movies, play internet games and use e-mail and social media. All 10 patients were very satisfied, and 9 reported feeling comfortable or very comfortable intraoperatively. All rated their experience better than previous GAs, with quicker general recovery. All patients would recommend this technique to others. Conclusions. Our case series of patients undergoing prolonged surgery for osteomyelitis under EA+Sed has shown very positive impact of AVD on patients’ experience and confirmed our earlier encouraging observations. This clinical service improvement deserves further evaluation and funding