Introduction

The effect of lower extremity lengthening on physeal growth is still controversial. We aim to compare data of the patients who had bilateral simultaneous femur and tibia lengthening with the patients who underwent the lengthening surgery separately for the femur and tibia at the end of completed skeletal maturation in terms of the effect of physeal growth.

Introduction

This study aims to evaluate the effect of using different types of fixator on the quality of callus and complications during distraction osteogenesis in patients with achondroplasia.

This animal study compares different methods of performing an osteotomy, including using an Erbium-doped Yttrium Aluminum Garnet laser, histologically, radiologically and biomechanically. A total of 24 New Zealand rabbits were divided into four groups (Group I: multihole-drilling; Group II: Gigli saw; Group III: electrical saw blade and Group IV: laser). A proximal transverse diaphyseal osteotomy was performed on the right tibias of the rabbits after the application of a circular external fixator. The rabbits were killed six weeks after the procedure, the operated tibias were resected and radiographs taken.

The specimens were tested biomechanically using three-point bending forces, and four tibias from each group were examined histologically. Outcome parameters were the biomechanical stability of the tibias as assessed by the failure to load and radiographic and histological examination of the osteotomy site.

The osteotomies healed in all specimens both radiographically and histologically. The differences in the mean radiographic (p = 0.568) and histological (p = 0.71) scores, and in the mean failure loads (p = 0.180) were not statistically significant between the groups.

Different methods of performing an osteotomy give similar quality of union. The laser osteotomy, which is not widely used in orthopaedics is an alternative to the current methods.

Cite this article: Bone Joint J 2015;97-B:1628–33.

A retrospective study was performed in 18 patients with achondroplasia, who underwent bilateral humeral lengthening between 2001 and 2013, using monorail external fixators. The mean age was ten years (six to 15) and the mean follow-up was 40 months (12 to 104).

The mean disabilities of the arm, shoulder and hand (DASH) score fell from 32.3 (20 to 40) pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A mean lengthening of 60% (40% to 95%) was required to reach the goal of independent perineal hygiene. One patient developed early consolidation, and fractures occurred in the regenerate bone of four humeri in three patients. There were three transient radial nerve palsies.

Humeral lengthening increases the independence of people with achondroplasia and is not just a cosmetic procedure.

Cite this article: Bone Joint J 2015;97-B:1577–81.

Objectives: Total hip arthroplasty by minimal invasive anterolateral exposure is a technique which causes minimal damage on skin, muscles and bone and lead to early recovery. Current study compared the clinical and radiological results of total hip arthroplaties performed with two different exposure- minimal invasive anterolateral (MIA) and standard anterolateral exposure (SA).

Methods: Several parameters of total hip arthroplasty patients managed with two different exposures between 2005 and 2008 were evaluated retrospectively from medical records. First group was consisted of total hip arthroplasty patients managed with SA exposure. 26 hip of 25 patients were operated in this cohort. Mean age, follow up and body mass index was 57±12.45 year, 25.23±8.71 months and 32.52±5.77 respectively. Second group was consisted of total hip arthroplasty patients managed with MIA exposure.15 patients were operated in this cohort. Mean age, follow up and body mass index was 68.93±5.51year, 26.07±7.21 months and 28.69±2.72 respectively. Intraoperative, postoperative, total blood loss, operation time, blood transfusions, length of hospital stay were evaluated. Preoperative; postoperative 1,6,12,24 th hours VAS scores and Harris Hip Score (HHS) in preoperative; postoperative 1,6,12 th months and last controls were evaluated. Femoral component position (varus or valgus), inclination of acetabular component and signs of loosening were evaluated from the last follow up radiographies.

Results: Intraoperative, postoperative, total blood loss, blood transfusions, length of hospital stay were significantly reduced in MIA group as compared to SA group (p< 0.05). Average operation times were not different (p=0.259). Improving in VAS scores and HHS was significantly better in MIA group (p< 0.001). Postoperative SF-36 scores were significantly higher in both groups as compared to preoperative scores (p< 0.05). No sign of looseing, osteolysis, superficial or deep wound infection were detected in both groups.

Conclusion: Total hip arthroplasty by MIA exposure reduces length of hospital stay, leads to better pain control and rehabilitation in early period, causes less blood loss and leads to significant improvement in SF 36 scores. We suggest that after completion of learning curve, total hip arthroplasty by MIA exposure can be performed more effectively and with less complication.

Introduction: Treatment of defected pseudoarthrosis tibia remains controversial due to bone loss with/without infection arises from previous interventions. In the present study we evaluated the results of acute shortening and distraction osteogenesis in the treatment of tibia pseudoarthrosis with bone loss.

Material and Methods: Eleven patients were treated with acute shortening and distraction osteogenesis. Mean age and bone loss was 27.5 years (range 10–44) and 8.9 cm (range 3.5–12) respectively. 7 of eleven patients is infected pseudoarthrosis. Enfected patients were type 4A according to Chierny-Mader classification. The 4 of infected patients were treated with two staged procedure. In the first stage antibiotic (teicoplanin) impregnated polymethylmetacrilate beads were placed to the space occurred as a result of excision of sclerotic bone segment and fixation was performed by external fixator or braces. Second stage composed of acute compression (shortening) and distraction osteogenesis. Other 3 infected and noninfected patients were treated with resection, acute shortening and distraction osteogenesis in one stage. In six cases docking site were grafted with autografts. Defects greater than 4 cm were gradually shortened 2mm/day in addition to acute shortening. Limb length inequality was solved with lengthening from proximal tibial corticotomy and achieving union of both sites about the same time.

Results: Mean follow up, external fixator time and external fixator index was 48.3 months (21–80), 8.9 months (6–13) and 1,3 month/cm respectively. results were evaluated according to Paley’s bone and functional evaluation scoring. Eleven patient revealed excellent results with regard to bone evaluation and 10 patient revealed excellent and 1 patient revealed good results in terms of functional evaluation. In one patient fracture at the pseudoartrosis site occurred due to new trauma after removal of the fixator which was treated with circular external fixator. In the another patient, the lengthening regenerate side was low quality bone which need intra-medullary fixation and grafted with autograft.

Conclusion: Acute shortening and distraction osteogenesis is a safe and successful procedure in the treatment of defected tibia pseudoarthrosis and is alternative to other treatments. Acute shortening and distraction osteogenesis was found to be successful and safe with regard to functional results in the treatment of defected tibia pseudoarthrosis. Besides we suggest it as an alternative due to lower rate of complications and less external fix-ator time compared to other Methods:

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment.

The use of intramedullary nails prevented recurrence of deformity and refracture.

Coblation is supposed to enhance healing due to increasing vascularity in the degenerated tendon. In the present study the effect of coblation treatment on tendon degeneration was investigated.

A total of 32 New Zealand rabbit were enrolled in the current study. Experimental degeneration was performed by injecting prostaglandin E1 (PGE1) to bilateral achilles tendons of rabbits. Four rabbits were excluded by different reasons. Coblation and control groups were composed of 12 rabbits in each. Coblation device only touched to tendon in the control group whereas in the coblation group coblation treatment was performed through 2 cm segment to form grids with 0.5 mm apart with level four energy lasted for 500 ms. 6 rabbits in control and coblation groups were sacrificed in 6th and 12th weeks. Achilles tendons were evaluated histopathologically by modified Movin scale and immunohistopathologic examination was performed using vascular endothelial growth factor (VEGF) and type 4 collagen.

After injection of PGE1, findings similiar to chronic tendinosis were revealed. Coblation group revealed significant increment in vascularity with histopathological and immunohistochemical examination. However difference regarding healing of tendon degeneration was not significant between control and coblation group.

Coblation treatment increases vascularity in degenerated tendon, but doesn’t increase healing process.

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: Reactive oxygen species (ROS) have important roles in the pathogenesis of ischemia reperfusion injury (I/R) of skeletal muscles Melatonin was proved to be an antioxidant agent and many experimental models showed that it reduces I/R injury in many tissues. The objective of present study was to detect protective antioxidant effect of melatonin on I/R injury of skeletal muscles.

Material and Methods: Albimino wistar rats were randomly allocated into 3 groups. There were 8, 10, 10 rats in sham, I/R and I/R + melatonin (Mel) groups respectively. Right hind limb ischemia was achieved by clamping femoral arteries in all groups except for control group. Melatonin (10 mg/kg) was administered intraperitoneally in I/R + Mel group 48, 24, 1 hour before reperfusion. After a period of 2 hour ischemia followed by 1.5 hour reperfusion, muscles and venous blood samples were collected for biochemical analysis and histopathological examination. Plasma antioksidant enzyme activities of süperoxide dismutase (SOD), glutathion peroxidase (GSH-Px), and levels of MDA and NO. were investigated. Enzyme activities of catalase (CAT), protein carbonyl (PC), SOD, GSH-Px and levels of MDA and NO. were analysed in muscle tissues.

Results: Antioxidant enzyme activities and levels of MDA and NO. in plasma were significantly higher in I/R group compared to control group (p< 0,001). Muscle tissues of I/R groups revealed significant higher antioxidant enzyme activity and MDA, NO. levels with respect to control group (p< 0,001). Levels of these parameters in muscle and plasma revealed significant reduction in I/R + Mel group with respect to I/R group (p< 0.001). Histopathological examination of ischemic muscles in I/R group showed significant degeneration and inflammation compared to control group whereas melatonin administered ischemic muscles showed significant reduction of degeneration and inflammation with respect to I/R group (p< 0.001).

Conclusions: Levels of NO. and MDA and antioxidant enzyme activity were significantly higher and also revealed significant degeneration and inflammation in I/R group. These results support the opinion that ROS is an important factor in the pathogenesis of I/R injury in skeletal muscles. We attribute the increasing enzyme activities in I/R group to a compensatory mechanism against ROS. Levels of NO. and MDA and antioxidant enzyme activity in tissue and plasma of I/R + Mel group were significantly lower and additionally revealed significant improvement in inflammation and degenaration. This proves the potential ROS scavenging effect of melatonin in reduction of I/R injury. In conclusion we suggest that melatonin may be used in the treatment of I/R injury due extremity injuries with vascular compromise, extremity surgery with prolonged tourniquet time and compartment syndrome.

Introduction: Medial laxity is an important problem in knees with mono-compartmental gonarthrosis. Medial laxity can cause the progression of the gonarthrosis if it is left uncorrected. Therefore, managing of medial laxity during high tibial osteotomy is very important. In this study, the effect of openning focal-dome type osteotomy on the medial laxity was investigated.

Materials-Methods: Four knees of two cadavers (74-year-old male and 52-year-old female) were used in this study. For the creating pseudo-medial laxity in the knee, while total medial menisectomy was performed in two knees of male cadaver, 5 mm osteochondral resection of both joint surfaces of the medial femoral condyle and medial tibial plateau was performed in two knees of female cadaver.

Results: After creation of the pseudo-medial laxity, opening focal-dome type osteotomy extending to proximal to the insertion of superficial medial collateral ligament was applied with circular fixator in all knees and 15° valgus effect was applied on the osteotomy line by motor unit of the circular fixator. By applying 15° valgus effect on the osteotomy, average reduction of medial laxity was measured as 70% in all knees.

Conclusions: Opening focal-dome type osteotomy decreases medial laxity effectively by tightening the superficial medial collateral ligament.

Cubitus varus and valgus are the most common complications of supracondylar and lateral condylar fractures. Various combinations of osteotomy and fixation have been described to correct these deformities but each is associated with significant complications. In this study, we used distraction osteogenesis and Ilizarov frame fixation to treat 24 elbows in 23 patients with cubitus varus or valgus. Their clinical outcome was evaluated using the protocol of Bellemore et al. The mean time to follow-up was 18.3 months (10 to 36) and the mean time to frame removal was 13.5 weeks (8 to 20). The mean carrying angle was corrected from −18.7° (−10° to −30°) to 6.1° (2° to 10°) in patients with cubitus varus and from 36.5° (25° to 45°) to 9.4° (4° to 15°) in patients with cubitus valgus. There were 18 excellent and six good results.

The Ilizarov method with gradual distraction is a safe, stable, adjustable and versatile method of treating deformities at the elbow without the problems of an unsightly scar or limited range of movement, and gives a good clinical and radiological outcome. Tardy ulnar nerve palsy should be treated first by anterior transposition.

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.

Objectives: Hyaluronic acid (HA) is used in osteoarthritis especially for the control of pain. In this animal study, we investigated the effects of HA on the early stage of osteoarthritis.

Methods: The experimental osteoarthritis model was constituted on 10 rabbits by the way of anterior cruciate ligament transection. In HA group, HA was injected 0.6 ml (15mg/ml) dosage per week for 3 weeks in right knees of ten rabbits and in SF group, saline was injected 0.6 ml dosage per week for 3 weeks in left knees of rabbits. Because three rabbits died in experimental period, fourteen knees of seven rabbits were taken into account for the study. The knees of rabbits, which were sacrified at 12th weeks after index operation, were measured according to cartilage area and Mankin scale.

Results: The mean cartilage area of HA and SF groups were measured 1.097 mm2 and 0.477 mm2, respectively. The difference of mean cartilage area between HA and SF groups was statistically significant (p< 0.05). According to Mankin scale, the mean total point of scale was measured 3.57 in HA group and 11.14 in SF group and the difference between mean total points of groups was significant (p< 0.05). Although, there is no significant difference in cellular abnormality, matrix staining, and tidemark continuity criteries of scale, we found the significant difference between total point and structure of cartilage criteria of scale.

Conclusions: HA has a retarder effect on progression of cartilage injury in early stage osteoarthritis.

Purpose: Kotz osteotomy (polygonal pelvic osteotomy) is performed for hip dysplasia especially with deficient acetabular coverage . One of the important problems of this osteotomy is Trendelenburg limping due to detachment of abductor muscles from their origin at the iliac bone during the surgical approach. In order to solve this problem, the surgical approach of Kotz osteotomy was modified and iliac osteotomy was made from the medial side of iliac bone instead of lateral side without detaching the abductor muscles and two skin incision were used instead of three skin incisions. We present the results of nine hips in seven patients who were operated using this modified surgical approach.

Materials and Methods: In this study, CE angle, VCE angle, Sharp angle, Harris hip score, trendelenburg test, and abductor muscle strength (at first and third postoperative monts) of nine hips of seven patients (6 female, 1 male and mean age 19.2 year) who underwent the modified surgical approach were evaluated.

Results: Preoperative average CE angle, VCE angle, Sharp angle and Harris hip score were −0.22°(−9 to 13°), 8.22°(−13 to 20°), 53.11°(44 to 58°), and 63.55(51 to 71), respectively. Trendelenburg test was positive in 7 of 9 hips. The mean follow-up time is 6.5 months (3 to 17 months). Postoperatively, average CE angle, VCE angle, Sharp angle and Harris hip score were measured 33.66°(12 to 54°), 36.00°(18 to 51°), 34.33°(26 to 54°), and 91.66(74 to 100), respectively and there was statistically significant difference (p< 0.05). Trendelenburg’s test was negative in 8 of 9 hips postoperatively. The abductor muscles strength was measured clinically and was determined 3.4/5 at first and 4.2/5 at third postoperative month. Union was achieved at all osteotomy sites . In the postoperative period, in one hip, positive Trendelenburg test was continued because of inadequate coverage and superior migration of the femoral head.

Conclusions: This modified Kotz osteotomy achieves adequate acetabular coverage as the original technique and furthermore it provides recovery of abductor muscle strength in the early postoperative period and decreases the rate of Trendelenburg limping.

Introduction: The management of post-traumatic, tibial, segmental, skeletal defects is a difficult problem that often requires complex approaches for successful limb salvage. Bone transport and acute shortening with subsequent relengthening are two techniques that have been made possible using Ilizarov’s methods.

Aim: To determine whether either technique offers any intrinsic advantage relative to the other.

Methods: We carried out a retrospective review of charts and radiographs of 42 patients with post-traumatic tibial defects that had been managed using Ilizarov’s methods. The follow-up period averaged 26 months. We selected patients with defects between 3 cm and 10 cm to provide a suitable comparison. The patients were divided into two groups of 21 each, treated either by bone transport or acute shortening.

Results: The defects averaged 7.0 cm in the transport group and 5.8 cm in the acute shortening group. The transport group averaged 12.5 months in the fixator; the acute shortening group averaged 10.1 months. However, the external fixation index was virtually identical in the two groups (mean 1.8 months/cm in the transport group and 1.7 months/cm in the acute shortening group). The complication rate, radiographic results, and functional results were slightly better in the acute shortening group.

Conclusions: Both techniques demonstrated excellent results overall and the external fixation index was nearly identical for these related methods. The final results after treatment by acute shortening were found to be slightly better than the final results following bone transport. There may be a slight advantage to the use of this technique for smaller defects in properly selected patients.