We describe two patients with a diffuse haemangioma of the lower limb complicated by pathological fracture of the femoral shaft, one of whom was treated by a bone graft and immobilisation in a cast, and the other by external fixation and injection of bone marrow. A review of the literature identified difficulty in control of bleeding and obtaining bony union

1. The distribution of the permanent paresis and paralysis in the muscles of 203 lower limbs affected by poliomyelitis is analysed and related to the destruction of motor nerve cells in the grey matter of the lumbo-sacral cord. 2. The tibialis anterior and tibialis posterior and the long muscles of the toes are more often paralysed than paretic; these muscles are innervated by short motor cell columns. Muscles such as the hip flexors and hip adductors that are more often paretic than paralysed are innervated by long cell columns. 3. Muscles innervated by the upper lumbar spinal segments are more frequently affected than those innervated by the sarcal segments. This agrees with the segmental incidence of motor cell destruction found in poliomyelitic spinal cords. 4. Each muscle or muscle group is associated in paralysis with other specific muscles. For instance, the long toe extensors with the peronei and the calf muscles (triceps surae) with the biceps femoris. Associated muscles are innervated by adjacent motor cell columns. The probability of recovery in a paralysed muscle can be determined by reference to the degree of involvement in its associated muscles. 5. The distribution of the paralysis in an individual lower limb is determined by the site and size of foci of motor cell destruction. The cell loss in certain common patterns of paralysis is described. 6. The practical application of these findings is discussed

Lengthening of the humerus is now an established technique. We compared the complications of humeral lengthening with those of femoral lengthening and investigated whether or not the callus formation in the humerus proceeds at a higher rate than that in the femur. A total of 24 humeral and 24 femoral lengthenings were performed on 12 patients with achondroplasia. We measured the pixel value ratio (PVR) of the lengthened area on radiographs and each radiograph was analysed for the shape, type and density of the callus. The quality of life (QOL) of the patients after humeral lengthening was compared with that prior to surgery. The complication rate per segment of humerus and femur was 0.87% and 1.37%, respectively. In the humerus the PVR was significantly higher than that of the femur. Lower limbs were associated with an increased incidence of concave, lateral and central callus shapes. Humeral lengthening had a lower complication rate than lower-limb lengthening, and QOL increased significantly after humeral lengthening. Callus formation in the humerus during the distraction period proceeded at a significantly higher rate than that in the femur. . These findings indicate that humeral lengthening has an important role in the management of patients with achondroplasia

This study evaluated the effect of limb lengthening on longitudinal growth in patients with achondroplasia. Growth of the lower extremity was assessed retrospectively by serial radiographs in 35 skeletally immature patients with achondroplasia who underwent bilateral limb lengthening (Group 1), and in 12 skeletally immature patients with achondroplasia who did not (Group 2). In Group 1, 23 patients underwent only tibial lengthening (Group 1a) and 12 patients underwent tibial and femoral lengthening sequentially (Group 1b). The mean lengthening in the tibia was 9.2 cm (59.5%) in Group 1a, and 9.0 cm (58.2%) in the tibia and 10.2 cm (54.3%) in the femur in Group 1b. The mean follow-up was 9.3 years (8.6 to 10.3). The final mean total length of lower extremity in Group 1a was 526.6 mm (501.3 to 552.9) at the time of skeletal maturity and 610.1 mm (577.6 to 638.6) in Group 1b, compared with 457.0 mm (411.7 to 502.3) in Group 2. However, the mean actual length, representing the length solely grown from the physis without the length of distraction, showed that there was a significant disturbance of growth after limb lengthening. In Group 1a, a mean decrease of 22.4 mm (21.3 to 23.1) (4.9%) was observed in the actual limb length when compared with Group 2, and a greater mean decrease of 38.9 mm (37.2 to 40.8) (8.5%) was observed in Group 1b when compared with Group 2 at skeletal maturity. In Group 1, the mean actual limb length was 16.5 mm (15.8 to 17.2) (3.6%) shorter in Group 1b when compared with Group 1a at the time of skeletal maturity. Premature physeal closure was seen mostly in the proximal tibia and the distal femur with relative preservation of proximal femur and distal tibia. We suggest that significant disturbance of growth can occur after extensive limb lengthening in patients with achondroplasia, and therefore, this should be included in pre-operative counselling of these patients and their parents

Abstract

MAGnetic Expansion Control (MAGEC) rods are used in the surgical treatment of children with early onset scoliosis. The magnetically controlled lengthening mechanism enables rod distractions without the need for repeated invasive surgery. The CE certification of these devices was suspended in March 2021 due, primarily, to performance evidence gaps in the documents provided by the manufacturer to regulators and notified bodies. MAGEC rods are therefore not permitted for use in countries requiring CE marking. This was a survey of 18 MAGEC rod surgeons in the UK about their perception of the impact of the CE suspension on the clinical management of their patients. Unsurprisingly, virtually all perceived a negative impact, reflecting the complexity of this patient group. Reassuringly, these surgeons are highly experienced in alternative treatment methods.

Cite this article: Bone Jt Open 2022;3(2):155–157.

1. Experience with the McLaurin swivel walker for children with bilateral phocomelia of the lower limbs is described. 2. Modifications to the prosthesis and the method of fitting in stages are recorded

Sixteen severely haemophilic patients have undergone arthrodesis of one joint of the lower limb in the period 1966 to 1976. There have been nine arthrodeses of the knee and seven of the ankle. The follow-up period was from nine months to eight years. The arthrodeses were secured by internal fixation. The method was not without complications, but a satisfactory bony union resulted in all cases without further surgical intervention

We reviewed retrospectively the results in 211 consecutive patients who had undergone limb salvage for bone neoplasia with endoprosthetic reconstruction of the proximal femur (96), distal femur (78), proximal tibia (30) and total femur (7). Their mean age was 50 years (11 to 86) and the mean follow-up period was 37.3 months (1 to 204). A total of 35 (16.6%) prostheses failed. Overall, implant survival was 78% (95% confidence interval (CI) 0.29 to 0.54) at five years, 60% (95% CI 0.93 to 2.35) at ten years and 60% (95% CI 1.27 to 3.88) at 15 years. Survivorship of the limb was 97.6% (95% CI 1.73 to 3.35) at ten years. The gender, age, diagnosis and location of the tumour were not prognostic variables for failure. Modular endoprosthetic replacement in the lower limb is a durable long-term reconstructive option, with the implants generally outlasting the patient

We describe a retrospective review of 38 cases of reconstruction following resection of the metaphysiodiaphysis of the lower limb for malignant bone tumours using free vascularised fibular grafts. The mean follow-up was for 7.6 years (0.4 to 18.4). The mean Musculoskeletal Tumor Society score was 27.2 (20 to 30). The score was significantly higher when the graft was carried out in a one-stage procedure after resection of the tumour rather than in two stages. Bony union was achieved in 89% of the cases. The overall mean time to union was 1.7 years (0.2 to 10.3). Free vascularised fibular transfer is a major operation with frequent, but preventable, complications which allows salvage of the limb with satisfactory functional results

We compared lower limb coronal alignment measurements obtained pre- and post-operatively with long-leg radiographs and computer navigation in patients undergoing primary total knee replacement (TKR). A series of 185 patients had their pre- and post-implant radiological and computer-navigation system measurements of coronal alignment compared using the Bland-Altman method. The study included 81 men and 104 women with a mean age of 68.5 years (32 to 87) and a mean body mass index of 31.7 kg/m. 2. (19 to 49). Pre-implant Bland–Altman limits of agreement were -9.4° to 8.6° with a repeatability coefficient of 9.0°. The Bland–Altman plot showed a tendency for the radiological measurement to indicate a higher level of pre-operative deformity than the corresponding navigation measurement. Post-implant limits of agreement were -5.0° to 5.4° with a repeatability coefficient of 5.2°. The tendency for valgus knees to have greater deformity on the radiograph was still seen, but was weaker for varus knees. . The alignment seen or measured intra-operatively during TKR is not necessarily the same as the deformity seen on a standing long-leg radiograph either pre- or post-operatively. Further investigation into the effect of weight-bearing and surgical exposure of the joint on the mechanical femorotibial angle is required to enable the most appropriate intra-operative alignment to be selected

Thirteen patients suffering from rheumatoid arthritis had 19 stress fractures of the tibia or fibula. These patients characteristically presented with sudden, severe, unexplained pain with localised tenderness just below the knee or above the ankle. In seven patients examination of the adjacent joint indicated a flare-up of disease activity or a pyogenic arthritis. In six patients the diagnosis was delayed by the late appearance of callus in minute fractures. All patients had rheumatoid deformities of the ipsilateral lower limb: valgus deformities of the knee and subtalar joints occurred most frequently. All patients had osteoporosis; all except two had received steroid treatment and five had abnormalities of calcium metabolism. We suggest that deformities of the knee and ankle predispose patients with rheumatoid arthritis and osteoporosis to stress fractures of the tibia and fibula

1. Volkmann's ischaemia of the lower limb is more common in adults than in children and occurs with sufficient frequency after injuries of the femur, knee and leg to warrant a more determined effort to prevent it. 2. The first and most essential step is to recognise the early signs of ischaemic damage. Incision of the deep fascia may then save the threatened underlying muscle, though it may also be necessary to seek for and evacuate a haematoma beneath the muscle. When the femoral or popliteal artery is injured, exploration and repair may be imperative. 3. The treatment of established ischaemic contracture is by whatever measures are necessary to correct the deformity. These are lengthening of shortened tendons, or excision of them if they are involved in dense fibrosis at the periphery of the ischaemic mass; and excision of all totally destroyed muscle. Amputation may be necessary

Deep vein thrombosis is a common complication of immobilising the lower limb after surgery. We hypothesised that intermittent pneumatic compression (IPC) therapy in outpatients who had undergone surgical repair of acute ruptures of the Achilles tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of the Achilles tendon were randomised to either treatment with IPC for six hours per day (n = 74) under an orthosis or treatment as usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively, the incidence of deep vein thrombosis was assessed using blinded, double-reported compression duplex ultrasound. At this point, IPC was discontinued and all patients were immobilised in an orthosis for a further four weeks. At six weeks post-operatively, a second compression duplex ultrasound scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in the treated group and 37% in the control group (p = 0.042). Age over 39 years was found to be a strong risk factor for deep vein thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI) 2.14 to 10.96). Treatment with IPC, corrected for age differences between groups, reduced the risk of deep vein thrombosis at the two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks, the incidence of deep vein thrombosis was 52% in the treated group and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC appears to be an effective method of reducing the risk of deep vein thrombosis in the early stages of post-operative immobilisation of outpatients. Further research is necessary to elucidate whether it can confer similar benefits over longer periods of immobilisation and in a more heterogeneous group of patients. Cite this article: Bone Joint J 2015;97-B:675–80

The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.

We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (φ = 0.71; p = 0.019), leading to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application. Cite this article: Bone Joint J 2013;95-B:1227–31

I. Five cases of fracture and dislocation in the lower limb complicated by vascular injury are described and discussed. 2. Suspicion of arterial injury is an urgent indication for exploration. Conservative measures must not be undertaken without radiological evidence of an undamaged main limb artery. 3. The eventual outcome of arterial reconstruction cannot be forecast, but it is always worth while attempting unless the limb is obviously beyond hope of survival

Vascular malformations are rare congenital lesions which often have associated skeletal changes. Over a period of ten years, 90 patients at our clinic had a vascular anomaly of the lower limb, examined by either CT or MRI. Of these, 18 (20%) had bony involvement. A questionnaire was sent to these patients (8 men, 10 women) to evaluate their age of presentation, initial symptoms and current complaints. Radiological imaging revealed 15 low- and three high-flow lesions. The mean age at presentation to a physician was six years of age. Pain was the most common complaint. Disparity in leg length of 2 cm or more was observed in ten patients. Of the 16 patients with muscle infiltration, 13 had four or more muscles involved. Treatment by resection alone would require radical surgery

We report the successful use of tissue expansion in the lower limbs of five children and one young adult. It was possible to replace dense adherent skin grafts by expanded skin and subcutaneous tissue. Such expansion needs to be undertaken slowly, but expanded tissue matches the normal local tissue and has normal sensation. These qualities were particularly important in three amputations which were revised

A method is described which provides standardised reproducible radiographic images of the lower limb. Anteroposterior and lateral radiographs are digitised and processed by computer to provide graphic/numeric displays of angles and linear measurements, relating the centre points of the hip, knee, and ankle. Two cases illustrate how surgical planning is facilitated when standardised data are available. These data confirm the close relationship between postoperative limb alignment and positioning of prosthetic elements