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

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

Aims. The use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses. Patients and Methods. All patients who had a noninvasive growing endoprosthesis inserted at the time of a revision procedure were identified from our database. A total of 21 patients (seven female patients, 14 male) with a mean age of 20.4 years (10 to 41) at the time of revision were included. The indications for revision were mechanical failure, trauma or infection with a residual leg-length discrepancy. The mean follow-up was 70 months (17 to 128). The mean shortening prior to revision was 44 mm (10 to 100). Lengthening was performed in all but one patient with a mean lengthening of 51 mm (5 to 140). Results. The mean residual leg length discrepancy at final follow-up of 15 mm (1 to 35). Two patients developed a deep periprosthetic infection, of whom one required amputation to eradicate the infection; the other required two-stage revision. Implant survival according to Henderson criteria was 86% at two years and 72% at five years. When considering revision for any cause (including revision of the growing prosthesis to a non-growing prosthesis), revision-free implant survival was 75% at two years, but reduced to 55% at five years. Conclusion. Our experience indicates that revision surgery using a noninvasive growing endoprosthesis is a successful option for improving leg length discrepancy and should be considered in patients with significant leg-length discrepancy requiring a revision procedure. Cite this article: Bone Joint J 2018;100-B:370–7

Background. Lengthening over nail (LON) and the use of internal lengthening nails have been developed to minimize patients' time in a frame during femur lengthening. This study compares the outcomes of two techniques of femur lengthening, LON and Intramedullary Skeletal Kinetic Distraction (ISKD). Methods. In this retrospective study, 12 consecutive ISKD procedures were performed for femoral lengthening and followed for an average of 76 months. After the ISKD group, 20 consecutive femoral lengthening procedures were performed as an LON technique and followed for an average of 27 months. Results. There was no significant difference in achieving the lengthening goals between the two procedures. The healing index for the LON group averaged 1.4 months/cm, while the ISKD group was 3.2 months/cm (p=0.242). The distraction rates for the ISKD had a fast group (>1mm/day) with an average distraction rate of 1.7 mm/day and a slow group (<1mm/day) with a distraction rate of 0.84 mm/day. The LON group had an average distraction rate of 0.88 mm/day (p<0.001). The incidence of complications that required further unanticipated surgeries for the LON group was 1/20 (5%), while the ISKD group had complications in 6/12 femurs (50%, p=0.004). Conclusions. We concluded that the LON technique is a more predictable and reliable method for femoral lengthening than the ISKD

Introduction

The practice of limb lengthening using intramedullary nails has surged in popularity in recent years. Our study explores the relationship between femur lengthening and overall height gain in adults undergoing cosmetic limb lengthening with telescoping magnetic intramedullary lengthening nails (MILNs).

Introduction. The objective of this study is to report the first cases of femoral lengthening in children using Ilizarov fixator. Materials and Methods. We carried out a retrospective study about the cases of femoral lengthening done in 2010 to 2020 in our BARI-ILIZAROV Orthopaedic centre Dhaka. Results. 48 lengthening were done during this period using Ilizarov fixator. The procedure was done incongenital bone diseases in 20 cases and after a distal femoral epiphysiodesis in 10 cases. The mean age at surgery was 12.8 years. Lengthening was required in all patients and an axis correction was required in 16 of 26 cases. The mean lengthening was 5.9 cm. The healing index was 45.5 day/cm (25.5–62). We noticed 8 knee stiffness and 5 broken wires. Knee Stiffness were corrected by Judet'squadricepsplasty and 6 broken wires were replaced by new wires. The goal of lengthening was reached in all cases. The goal of axis correction was reached in 98.5% of cases. Conclusions. Ilizarov technique allows to do accurate lengthening and axis correction and it is a unique reliable external fixator for femoral lengthening in children

Introduction. The purpose of this research is to compare the quality of life in children during gradual deformity correction using external fixators with intramedullary lengthening nails. Materials and Methods. Prospective analysis of children during lower limb lengthening. Group A included children who had external fixation, patients in group B had lengthening nails. Patients in each group were followed up during their limb reconstruction. CHU-9D and EQ-5DY instruments were used to measure quality of life at fixed intervals. The first assessment was during the distraction phase (1 month postop.), the second was during the early consolidation phase (3 months postop.) and the final one was late consolidation phase (6–9 months depends on the frame time). Results. Group B patients reported significantly better utility compared to Group A. This was observed during all the stages of the treatment. Group B children were less worried (P 0.004), less sad (P 0.0001), less pain (p <0.0001), less tired (P 0.0002), better school work (P0.0041), better sleep (p 0.016), more able to do sports activities (p 0.004) and, they were more independent (p <0.0001) compared to group B. QALYS was better for the nails group compared to external fixation group 0.44 compared to 0.36 for external fixators. Conclusions. Lengthening nails had the potential to improve the quality of life and utility compared to external fixation. This will help further economic evaluation to measure ICER to further explore the cost effectiveness of these devices

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

Purpose of Study. Lengthening of the gastrocsoleus for equinus deformity is commonly performed in orthopaedic surgery. The aim of this study was to describe the precise details of each surgical procedure and assess each biomechanically in cadaver models. Description of Methods. The surgical anatomy of the gastrocsoleus was investigated and standardized approaches were developed for the procedures described by Baumann, Strayer, Vulpius, Baker, Hoke and White. The biomechanical characteristics of these six procedures were then compared, in three randomized trials, in formalin preserved, human cadaver legs. The lengthening procedures were performed and a measured dorsiflexion force was applied across the metatarsal heads using a torque dynamometer. Lengthening of the gastrocsoleus was measured directly, by measuring the gap between the ends of the fascia or tendon. Summary of Results. The gastrocsoleus muscle-tendon-unit was divided into three zones. In Zone 1, it was possible to lengthen the gastrocnemius alone or to lengthen the gastrocnemius and soleus by different amounts. These procedures (Baumann, Strayer) were very stable but limited in the amount of lengthening achieved. Zone 2 lengthenings (Vulpius, Baker) of the conjoined gastrocnemius aponeurosis and soleus fascia were not selective but were stable and resulted in significantly greater lengthening than Zone 1 (p < 0.001) 4. Conclusion. Surgery for equinus deformity correction by lengthening of the gastrocsoleus varies in terms of selectivity, stability and range of correction with differing anatomical and biomechanical characteristics. Clinical trials are needed to determine whether these differences are of clinical importance. It may be appropriate for surgeons to select a procedure from a zone, best suited to the clinical needs of a specific patient. NO DISCLOSURES

Aims: Present our experience with a protocol for acute Ç gradual È femoral distraction for post- traumatic femoral shotening. Methods: Six females and four men with an average age of 35 y/o with al least one year follow-up and an average shortening of 4.5 cm (range 3–6). A butterßy osteotomy was performed at the diaphysary-subtrochanteric level. A femoral distractor was applied to the lateral side of the femur. An antegrade femoral intramedullary nail was then inserted and locked proximally. The patients were admitted to the orthopaedic ßoor and distraction started the same day under clinical monitoring of the neurovascular status. When the desired length was achieved, intrelocking was completed and the femoral distractor removed. Limb length was evaluated with scanograms. Radiographic healing was deþned as bridging callus at both sides of the osteotomy on AP, lateral and oblique views. Range of motion was evaluated at the one year follow-up visit. Results: Lenghening averaged 4.2 cm (range 2.7–6). Distraction period averaged 6 days (range 3–12). Distraction rate averaged 7 mm a day (range 3–11). Average healing time was 5 months (range 2–11). Shanz pins bent in 6 cases. Pin tract superþcial infections were identiþed in 3 cases. All infections subsided with oral antibiotics and no deep infection was detected. No nails or interlocking screws breakage were detected. Conclusion: Lengthening of the femur over a intramedullary nail is better to other tecniques. The butterßy osteotomy splits the distraction gap in halves, decreasing the risk of non-union and comlications reported for acute lengthenings. Lengthening of the femur up to 6 cm was possible in this series of patients following this protocol for acute Ç gradual Èdistraction over an intramedullary nail

Introduction: The aim of the study is to assess the complication rate in lengthening of the femur and to analyze the main factors inducing complications. Materials & method: A retrospective study of 151 cases of lengthening with different methods (External Fixator of Judet 9, Callotasy with Orthofix :89, Ilizarov 9, External Fixator of Wagner 9, Lengthening Albizzia Nail 29) was investigated. The mean age was 13, 21 years (ET : 4,82, max : 38, min : 4). The aetiologies of femoral length discrepancy were congenital in 85 cases, post traumatic in 30, Post infectious in 22 and neurologic in 13 cases. One girl had Still’s Disease. The mean elongation was 55,17mm (ET : 17,3, Max ; 130, min : 20) except with the Ilizarov method with a mean lengthening of 91,8 mm. The mean percentage of elongation was 21 %. Classification of the Complications was in three grades :. - I : Benign complication without any unexpected surgery or anaesthesia. - II : Serious complication with unexpected surgery or anaesthesia. - III : Severe complication. The complications were recorded in four periods: surgery, elongation, consolidation and late complications. Results: There were 151 complications (78 Grade I, 59 grade III, 14 grade III). There were only three complications during first surgical procedure, 95 during elongation 49 during consolidation and 4 late complications. Analysis of the different pathologies shows that the rate of complications is the same for each etiology (around 100%) but the rate of complications of grade 2 and 3 shows a significant difference with a higher rate for neurological and congenital aetiologies. Benign complications are found in the post infection group. Analysis of the different methods used shows the same rate of complications in benign conditions except for the Albizzia Nail with a significant lower rate. Complications of grade 2 are seen in the ancient Judet method and in the Albizzia Nail due to the multiple general anaesthesia . Complications of grade 3 are seen in the Wagner method due to a high rate of congenital pathology and to a mean lengthening of 35 % of femoral initial length. Articular complications do not show any significant difference between the different methods. The main complications are seen in neurological and post infectious diseases. The mean percentage of lengthening in these complications is not different of the mean percentage of the series. Conclusion: Lengthening of the femur is still a difficult problem with a mean rate of complications of 100 % The type of method used is not the main determinant in the appearance of these complications. We want to emphazise the difficulties in performing lengthenings in neurological and congenital pathologies

1. Two inches of lengthening may be gained in the femur, and three inches in the tibia and fibula, without complication. 2. More than this may be secured at the risk of temporary external popliteal paresis. 3. Lengthening of the tibia and fibula is more certain and more easy to control than lengthening of the femur. 4. Traction, and counter-traction through the bone, with complete lateral rigidity, are essential to success. 5. In applying this technique to the femur there is a danger of knee stiffness. The farther from the knee the skeletal traction pins are inserted, the less is the risk. The operation should therefore be planned as high as possible in the shaft of the femur. 6. The most delicate structure, and the one least tolerant of stretching, is the external popliteal nerve. 7. An oblique osteotomy, started by closely spaced drill-holes, is the best. 8. Certain vascular complications experienced by other surgeons are attributable to subperiosteal bone exposure, and to dividing the periosteum and fascial structures transversely

Background:. Leg length discrepancy related to absence of the femoral head with proximal migration of the femur presents a treatment dilemma. Late sequelae of neonatal hip sepsis and chronic hip dislocation due to developmental dysplasia are the most common causes. Traditional teaching dictates that the hip is stabilised prior to limb lengthening. Reconstructive options alter the shape of the proximal femur which complicates future surgery. Methods:. We retrospectively reviewed 3 cases of femoral lengthening with an ‘unstable’ hip without prior stabilization. The aetiology was neonatal hip sepsis in 2 cases and chronic hip dislocation due to developmental dysplasia in 1 case. Lengthening was performed with the use of a retrograde Precice lengthening nail. Results and Discussion:. The desired length (range 5.5 to 6cm) was achieved in all patients without migration of the proximal femur. In all cases patient satisfaction was high with the lengthening and the ability to abort shoe raises. There was an improvement in gait pattern in all patients. Conclusion:. Femoral lengthening is possible without prior stabilisation of the hip in so called ‘unstable’ hip situations. The proximal femoral anatomy is not further altered and future salvage procedures such as a total hip replacement are not compromised

Introduction: Lengthening for congenital femoral hypoplasia is associated with a significant refracture rate and problems in recovery of knee motion. We present a series of 7 patients where two techniques of lengthening were used and recovery of knee motion compared. Methods: This is a retrospective study. The outcome of interest was recovery of knee motion. All children were diagnosed to have congenital femoral hypoplasia. In two patients (group A), conventional metaphyseal osteotomies of the femur and tibia, with ankle and knee bridging fixators were applied. In the remaining five (group B), a combination of soft tissue releases, patella ‘capture’, a modified external fixator configuration and early conversion to internal fixation was used. Osteotomies of tibia and femur were performed in the mid-shaft and lengthening progressed at 0.75 mm per day. At 4 months, before regenerate consolidation, both femur and tibia were plated using a submuscular technique. The limb was supported in a cast, which was replaced by a brace at 3 weeks and knee motion exercises started. Lengthening was kept to within 15% in both groups. Results: Recovery in knee flexion to greater than 90 degrees was accomplished by 4 of the 5 Group B patients by 4 months. One patient failed to attend for physiotherapy and did not progress with knee motion recovery. One patient sustained a fracture proximal to the submuscular plate which needed revision surgery. This did not hinder progress with knee motion recovery. In comparison, patients in group A reached 90 degrees of flexion at 12 months with one patient not exceeding 85 degrees at final follow up and subsequently needing a quadricepsplasty. Conclusion: Recovery of knee motion may be assisted by soft tissue releases in combination with early conversion to internal fixation

Forearm lengthening in children is controversial. Paley (1990) and Peterson (1994) advocate aggressive treatment of the deformity for cosmetic and functional reasons. Scoenecker (1997) has shown that mature patients are comfortable with their appearance and functional deficit. We reviewed 8 forearm lengthenings performed in 8 children in the 14 year period from 1991 to 2004. Five patients had ulnar shortening (osteochondromata = 4, growth arrest due to trauma = 1). Of the three patients with radial shortening, one was due to a congenital short radius and two following growth arrest (post trauma and meningococcal septicemia). The shortening resulted in a cosmetically unacceptable ulnar or radial tilt with absent radial or ulnar deviation of the wrist and decreased supination and/or pronation. One patient with a proximal ulnar osteochondroma had a dislocation of the radial head with cubitus varus. Excision of the osteochondroma was done 6 months prior to lengthening. Lengthening was accomplished with two Ilizarov rings and a distal corticotomy for radial and proximal for ulnar shortening. Reduction of the dislocated radial head was achieved with an olive wire. Associated procedures were: hemiepiphyseal stapling of the distal radius for an increased radial articular angle in 3 patients with osteochondroma, and corrective osteotomy of the distal radius in 1 patient with growth arrest. The average lengthening obtained was 23 mm (range 13–40 mm) with an average lengthening index of 1.45 months per cm. At an average follow-up of six years (range 2–15 years; 7 to maturity) all patients were satisfied with the cosmetic improvement and had full radial and ulnar deviation. Except for two patients the supination/pronation was improved. We concluded the forearm lengthening is warranted for cosmetic and functional reasons

Shortness of an extremity due to different causes is an issue that may adversely affect human life functional and psychologically. In this study, in the light of previous studies, it is aimed to develop a new expandable intramedullary system, providing lengthening in order to remove previous problems and complications and to annihilate leg length discrepancies at present and future without second surgical intervention as far as possibble by lenghtening the intramedullary nail. To this end, a new electromechanically activated intramedullary nail has been designed and generated. The intramedullary nail was designed to perform extremity lengthening electro-mechanically. The 3D design of the system is performed with computer software and the rapid and metal prototype of the system has been produced. The intramedullary nail system is comprised of three main units; Mechanical transmission unit, Electronic unit, Lengthening unit. The nail system is designed to function both mechanically and electronically complying with the requirement. This also provides an advantage that if any one (mechanic or electronic) fails, the lengthening process can continue with the other. Compression tests are applied in order to evaluate the strength of the system. The deformation values of the parts are recorded and stress values of each parts were calculated. The new system needs only 300N loading for mechanical lengthening. When 800N is considered as average human weight, the implant must withstand minumum 2400N load. Considering the safety conditions, we applied 4000N load on the new system. At 4000N, the whole system shows only 1.465 mm deformation which is less than the gap between the two bone parts. Also, when the system is implanted inside the bone, the loads are distributed proportionally between the bone and the implant. So, except for extraordinary conditions, the newly developed system is highly rigid and safe. In each applied method, lots of complications whether general or method-specific are seen. When the methods like Albizzia, ISKD and FITBONE avaliable and widely used today are examined separately, complications specific to these methods can be clearly observed [1–12]. Bliskunov Nail, Albizzia Nail and ISKD [13–18] have mechanical working principles and in these systems, lengthening process is obtained by rotational movement of the extremity. This rotational movement causes complications like pain, dislocation and uncontrolled lengthening [11,13,16,19–21]. In our newly developed system, only axial stimulation is needed for the activation of the mechanism. This is one of the advantages of our system. Both the mechanical unit and the electronical units are designed to be extended 0.1 mm at each activation. This means that the optimal amount of distraction (1mm/day) can be achieved in a controlled way. In other systems, the distraction amount can not be fully controlled and complications seen on other systems [1, 6, 8–10], like distruption of callus due to the excessive distraction and nonunion of the bone can be encountered. The success of the system at practice will be examined with in-vivo animal experiments and according to the results, it will be ready for use on human by performing necessary restorations

Introduction

There is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation.

Deformity of the forearm is common in patients with hereditary multiple exostoses, producing cosmetic and functional impairment in which shortening of the ulna is a significant factor. The results of ulnar lengthening in 10 forearms of eight patients are reported. Lengthening was performed by osteotomy of the shaft followed immediately by a bone graft and internal fixation, or by gradual distraction with an external fixator. In all patients the appearance was improved and the range of radial deviation at the wrist was increased. In most patients forearm movement and radial head stability were improved. Partial recurrence of the deformity was seen during the follow-up of skeletally immature patients, but in general ulnar lengthening was found to be a useful operation

Introduction. Hallux valgus surgical correction has a variable but significant risk of recurrence. Symptoms result from an iatrogenic first brachymetatarsia following the index surgical procedure. First metatarsal shortening has been shown to correlate with the onset of transfer metatarsalgia. We describe the use of the scarf osteotomy to both correct the recurrent deformity and lengthen the shortened first metatarsal. Methods. 36 lengthening scarf osteotomies were undertaken in 31 patients. Clinical (AOFAS and SF12 scores) and radiographic measures (IMA, HVA) were taken pre- and post-operatively. The maximum theoretical lengthening was 10mm, to prevent first MTP joint stiffness post-operatively. The actual lengthening was determined and measured intra-operatively. Results. There were 28 female and three male patients, with mean age at presentation 53.4 years. The mean follow-up was 3.9 years. Four cases were lost to follow-up. The mean first metatarsal lengthening achieved was 4.9mm (range 1–8mm). All of the osteotomies united without complication. The mean IMA reduction was 4.0° (p<0.001) and HVA 13.0° (p<0.001). The mean AOFAS score increase was 33.8 (p<0.001). There was no correlation between change in IMA and AOFAS score (r=−0.13) or between improvement in HVA and AOFAS score (r=−0.02). There was a positive trend but no correlation (r=0.28) between amount of metatarsal lengthening and change in AOFAS score. The inter- and intra-observer correlation was excellent. The SF12 physical sub-domains improved more than the mental sub-domains. Conclusion. We describe the largest series of lengthening scarf osteotomies for recurrent hallux valgus and symptomatic iatrogenic first brachymetatarsia. The significant improvement in both clinical and radiographical measures suggests the procedure is successful, with a low complication rate. Lengthening did not reduce the MTPJ range of movement. We hypothesise that restoring both the length and alignment enables greater weight-bearing under the first metatarsal head, reducing biomechanical transfer metatarsalgia

Introduction

The recent introduction of Chatbots has provided an interactive medium to answer patient questions. The accuracy of responses with these programs in limb lengthening and reconstruction surgery has not previously been determined. Therefore, the purpose of this study was to assess the accuracy of answers from 3 free AI chatbot platforms to 23 common questions regarding treatment for limb lengthening and reconstruction.