Paediatric tibial fractures, unlike femoral fractures do not have much potential for overgrowth. In simple factures of the tibial shaft treated non-operatively the major problems are shortening and malunion. In complex injuries with extensive soft tissue disruption and bone loss, the long-term aim of reconstruction is to achieve union with a fully functional limb without limb-length inequality. Four children (Age range 6-12 years) who sustained high-energy grade III open fractures of the tibia were treated with acute shortening and bone transport. Any soft tissue reconstructive and secondary grafting procedures for delayed union were recorded. The children were prospectively followed up to fracture union. Distraction ostegenesis proceeded until limb length equality was achieved and the regenerate allowed to consolidate.Introduction
Methods
Limb lengthening is described by means of external fixator in limb length discrepancy. Intramedullary distraction is a relatively new procedure undertaken infrequently. We present our initial results following the use of the ISKD for lower limb lengthening. Methods: A retrospective review, over a three year period, revealed six patients (five femurs and one tibia) underwent lengthening by ISKD. Four of the femoral cases were secondary to trauma. The other femoral case and tibial case were secondary to congenital shortening. All cases were male with mean age of 35 years (20 – 54 years). The mean total distraction was 42mm (10 – 65mm) and a mean daily distraction of 0.96mm/day (0.78 – 1.75mm). Mean time to full weight bearing was 12.5 weeks. The planned length of distraction was achieved in all patients undergoing femoral lengthening. Four of these patients regained full movement of the knee at 6 months and the other regained an arc of 5 – 105 degrees. The tibial lengthening only achieved 28.5% of the desired length as a result of premature consolidation and poor patient compliance. There were no cases of infection, DVT, non-union or hardware failure. Three patients experienced no complications. One patient experienced premature consolidation and required repeat corticotomy. Two patients experienced inappropriate lengthening. One experienced distraction at the previous fracture site and as a result required 5 further operations and application Ilizarov frame. The other was as a result of a runaway nail achieving 56mm distraction in 32 days (1.75mm/day). This review, although with small numbers, highlights that the ISKD is a satisfactory treatment for femoral lengthening although we experienced difficulties with tibial lengthening. Following our experience all patients require a CT scan preoperatively to confirm union at the fracture site. ISKD has been considered an option for femoral lengthening only.
In complex injuries with extensive soft tissue disruption and bone loss, the long-term aim of reconstruction is to achieve union with a fully functional limb without limb-length inequality.
Analysis revealed no significant difference in complication rates between the calendar years. However, there was a significant difference between complication rates in frames applied for acute trauma, late presentation of trauma, and elective surgery. This difference did not appear to relate to time spent in the frame, and therefore seems to represent a separate variable. There was a disproportionate increase in complications in Ilizarov frames applied for upper limb problems.
We report the results of application of a strategy for deformity correction in hypophosphataemic rickets using careful preoperative planning, multiple osteotomies where appropriate and acute or gradual correction using internal or circular external fixation or a combination. 7 patients with 25 limb segments (14 femur and 11 Tibia) had deformity correction with either intramedullary nailing (10 Femur and 3 Tibia) or llizarov ring fixator (4 femur and 8 Tibia). The average age was 18 years (7–39 years), 5 were female and 2 male, had an average follow up of 36 months (10–77 months). All patients had adequate control of rickets pre operatively. Clinical examination and analysis of pre and post-operative X-rays were carried out by an observer not involved in the surgical procedures. Standardised X-rays were analysed using the method of Paley and Tetsworth ( Satisfactory correction of deformity was achieved in both frontal and sagittal plane. There were total 8 episodes of soft tissue infection with no long-term consequence. Average ankle ROM was 7–44 and knee ROM was 0–128. There is no recurrence of the deformity. All patients were happy with outcome and are prepared to undergo same treatment if required, even though some were restricted in terms of sport and leisure activities. We conclude that satisfactory correction of deformity in VDRR can be achieved and maintained with nailing or llizarov fixator in short term with minimal complications, no recurrence and excellent outcome.
Seven patients with osteoid osteoma of the proximal femur were treated by percutaneous excision of the nidus. The combination of preoperative localisation by tomography and intraoperative localisation by image intensifier resulted in a curative procedure with minimal bone resection in all cases, although a second operation was required in one patient.