Comparing Relative Value Units for Intramedullary Limb Lengthening Procedures to Common Pediatric Orthopaedic Surgeries to Determine Adequate Compensation.

OBJECTIVE: Reimbursement for surgical procedures is determined by a computation of the relative value unit (RVU) associated with CPT codes. It is based on the amount of work required to provide a service, resources available, and level of expertise involved. Given the evolution of changes in the limb lengthening field, we wanted to evaluate whether the RVU values were comparable across different orthopaedic subspecialties. Consequently, this study compares the work relative value unit (wRVU) totals of 3 common pediatric orthopaedic surgeries-arthroscopic ACL reconstruction, spinal fusion for adolescent idiopathic scoliosis, and antegrade femoral intramedullary limb lengthening. METHODS: This was an IRB-approved, multicenter, retrospective chart review. Charts of subjects who had ACL reconstructions, including meniscal repairs; spinal fusion surgeries for adolescent idiopathic scoliosis (7 to 12 levels), including Ponte osteotomies, and femoral antegrade internal limb lengthening procedures, each completed by fellowship-trained orthopaedic surgeons were reviewed. Comparisons were carried out between several parameters, including mean duration per procedure, number of CPT codes billed per procedure, number of postoperative visits in the 90-day global period, and the wRVU for each procedure. RESULTS: Fifty charts (25 per center) per procedure were reviewed. The wRVU per hour was lowest in the antegrade femur lengthening group (P < 0.0001). The number of postoperative visits in the 90-day global postsurgery period was significantly higher in the antegrade femur lengthening group (P < 0.0001). Intramedullary limb lengthening also had the least number of CPT codes billed. CONCLUSIONS: RVUs per time are statistically lowest in the limb lengthening group and highest in the scoliosis group. The limb lengthening patient also requires significantly more visits and time in the postoperative period compared with the other groups. These extra visits during the global period do not add any RVU value to the lengthening surgeon and occupy clinic spots that could be filled with new patients. Based on these data, a review of the RVU values assigned to the limb lengthening codes may be necessary. LEVEL OF EVIDENCE: Level III-retrospective comparison study.

Pediatric Limb Lengthening and Reconstruction Surgical Coding Survey Results.

BACKGROUND: In surgical specialties like orthopaedics, documenting the surgery performed involves applying the appropriate current procedural terminology (CPT) code(s). For limb reconstruction surgeons, the wide-ranging types of surgeries and rapid evolution of the field create a variety of factors making it difficult to code the procedures. We sought to (1) assess whether appropriate limb reconstruction codes currently exist and (2) determine whether there is agreement among experienced pediatric orthopaedic surgeons when applying these codes to similar cases. METHODS: A REDCAP survey comprised of 10 common pediatric limb reconstruction cases was sent to experienced pediatric limb reconstruction surgeons in the United States. Based on the description of each case, the surgeons were asked to code the cases as they usually would in their practice. There were no limitations regarding the number or the types of codes each surgeon could choose to apply to the case. Nine additional demographic and general coding questions were asked to gauge the responding surgeon's coding experience. RESULTS: Survey participants used various codes for each case, ranging from only 1 code to a maximum of 9 codes to describe a single case. The average number of codes per case ranged from 1.2 to 3.6, with an average of 2.5 among all 10 cases. The total number of unique codes provided by the respondents for each case ranged from 5 to 20. Only 3 of the 10 cases had an agreement >75% for any single code, and only 2 of the 10 cases had >50% agreement on any combination of 2 codes. CONCLUSIONS: There are dramatic variations in coding methods among pediatric orthopaedic limb reconstruction surgeons. This information highlights the need to improve the current CPT coding landscape. Possible solutions include developing new codes that better represent the work done, developing standardized guidelines with the existing codes to decrease variation, and improving CPT coding education by developing limb reconstruction coding "champions." LEVEL OF EVIDENCE: Level V.

Retrograde Extramedullary Lengthening of the Femur Using the PRECICE Nail: Technique and Results.

BACKGROUND: Lengthening of long bones by distraction osteogenesis is now possible using intramedullary lengthening nails. Constraints of bone size, medullary canal obstruction, and the presence of an open physis are contraindications in skeletally immature patients. We present a technique describing the "off-label" use of a magnetic lengthening nail placed extramedullary and in retrograde manner, for lengthening of the femur in skeletally immature patients. METHODS: A retrospective review of 5 skeletally immature patients with significant length discrepancy of the femur are presented along with a description of the surgical technique. Data collected included age, sex, date of surgery, diagnosis, presence of associated deformities, the magnitude of length discrepancy, the amount of length gained, the amount of time to achieve full weight-bearing, the time to hardware removal, and any complications. RESULTS: There were 5 patients (3 females). The mean age was 7.2±2.7 years (4 to 10 y). The mean limb length discrepancy was 6.5±3.7 cm (3.5 to 11 cm). A mean length of 3.46±0.4 cm (3.1 to 4 cm) was achieved which represents 12.9±1.8% (10.32 to 13.47%) of the bone length. The time taken to achieve full weight-bearing ambulation was 89.2±19.3 days (60 to 109 d) or 12.7 weeks. All hardware was removed 247.6±215.6 days (99 to 628 d) after surgery. Patients were followed up for a mean duration of 19.2 months (11 to 30 mo). No supplemental fixation was required and no complications were noted. Acute deformity correction was also performed at the time of surgery in 2 patients who had distal femur valgus deformity. CONCLUSIONS: Retrograde extramedullary lengthening of the femur is an option that should be considered for limb length equalization in skeletally immature patients. It avoids the inconvenience of external fixation and can be used to simultaneously correct deformities of the distal femur. Although the total amount of length gained is modest, we believe it is a promising limb lengthening technique that merits further investigation. LEVEL OF EVIDENCE: Level III.

The Gait Outcomes Assessment List for Children With Lower Limb Difference (GOAL-LD): Assessment of Reliability and Validity.

BACKGROUND: The Gait Outcomes Assessment List for children with Lower Limb Difference (GOAL-LD) is a patient and parent-reported outcome measure that incorporates the framework of the International Classification of Functioning, Disability, and Health. This prospective multicenter cohort study evaluates the validity and reliability of the GOAL-LD and the differences between parent and adolescent report. METHOD: One hundred thirty-seven pediatric patients aged over 5 years attending limb reconstruction clinics at the participating sites were assessed at baseline, and a self-selected cohort also completed an assessment 2 to 6 weeks later. Construct and criterion validity were assessed by comparing GOAL-LD scores with a measure of limb deformity complexity (LLRS-AIM) and the Pediatric Outcomes Data Collection Instrument, using Spearman correlation coefficients. Face and content validity were determined through ratings of item importance. Test-retest reliability was reported as an intraclass correlation coefficient and internal consistency using Cronbach α. Adolescent reports were compared with their parents using paired t tests. RESULTS: The GOAL-LD demonstrated a moderate negative correlation with the LLRS-AIM (r=-0.40, P<0.001) and was able to discriminate between deformity complexity groups as defined by the LLRS-AIM (χ2=11.43, P=0.022). Internal consistency was high across all domains (α≥0.68 to 0.97). Like domains of the Pediatric Outcomes Data Collection Instrument and the GOAL-LD were well correlated. Parents reported a lower total GOAL-LD score when compared with adolescents (mean difference 3.04; SE 1.06; 95% confidence interval, 0.92-5.16; P<0.01); however this difference was only significant for body image and self-esteem (Domain F) and gait appearance (Domain D). Test-retest reliability remained high over the study period (intraclass correlation coefficient 0.85; SE 0.03; 95% confidence interval, 0.77-0.91). CONCLUSIONS: The GOAL-LD is a valid and reliable self and parent-reported outcome measure for children with lower limb difference. Parents report a lower level of function and attribute a higher importance to items when compared with their children. The GOAL-LD helps to communicate parent and child perspectives on their function and priorities and therefore has the capacity to facilitate family centered treatment planning and care. LEVEL OF EVIDENCE: Level II-diagnostic. Prospective cross-sectional and a longitudinal cohort design.

Influence of Insurance Type on the Access to Pediatric Care for Children With Distal Radius Torus Fractures.

BACKGROUND: Previous literature has demonstrated that pediatric orthopaedic patients with private insurance have less difficulty obtaining appointments than those with Medicaid. Not all injuries of an orthopaedic nature, however, require specialist care. This study evaluated the willingness of pediatricians to provide care for minor orthopaedic injuries and whether or not the patient's insurance status influenced the decision to provide care. METHODS: Ninety-nine pediatric primary care offices were randomly selected from 2 regions in Florida. Each office was contacted twice, 2 to 3 months apart, and presented with a fictionalized account of a patient that had sustained a torus ("buckle") fracture of the distal radius. In the first call, the patient was presented as having private insurance, and in the second call as having Medicaid insurance. If the patient was denied an appointment, the reason was recorded. RESULTS: Of the 99 offices, 100% were willing to treat the patient's injury if the child had private insurance, compared with 76% if the child had Medicaid. All Medicaid patient refusals were based on the insurance status of the patient. No office refused to see the patient due to the nature of the injury. Ninety-four percent of offices in South Florida were willing to see the Medicaid patient, compared with 58% in Central Florida. These differences were statistically significant (P<0.0001). CONCLUSIONS: It was previously unknown whether pediatricians felt comfortable managing minor orthopaedic injuries. This study demonstrates that 100% of the pediatricians surveyed were willing to treat a child with a distal radius buckle fracture with proper insurance. This information potentially can provide additional avenues for patients to achieve timely access to care. However, as seen in previous studies, there was a statistically significant difference in access to care for the same child with Medicaid. Until reimbursement rates for Medicaid improve, these patients will continue to have difficulty obtaining access to care to both primary care providers and specialists. LEVEL OF EVIDENCE: Prospective survey study.

Femoral Derotational Osteotomy Using a Modified Intramedullary Nail Technique.

When persistent rotation of the femur remains into adolescence, it can cause functional limitations such as fatigue, anterior knee pain, and frequent tripping. In these cases, derotation of the femur via osteotomy is often performed. We report preliminary results of bilateral derotational osteotomy for excessive femoral anteversion or retroversion using the modified intramedullary nail technique. A retrospective review of 8 patients was performed. Patients were excluded if additional procedures were performed or if the femoral osteotomy included any deformity correction other than rotation. Each patient had simultaneous bilateral femoral osteotomies for a total of 16 limb segments to review. The average age was 12 years, with 4 boys and 4 girls in the group. Seven patients had a preoperative diagnosis of femoral anteversion, and 1 had femoral retroversion. Average amount of derotation performed averaged 30 degrees. Average length of follow-up was 10 months (range, 9 to 12 mo). Average surgical time to complete the bilateral ostetomies was 139 minutes with an average total blood loss of 106 mL. The patients returned to full weight bearing with assistance at 13.75±1.39 days, without assistance at 37.12±5.69 days, and demonstrated full radiographic healing of the femur at 76.13±20.92 days. A modified intramedullary nail technique provides a biologically sound method for rapid healing of the femoral osteotomy site by providing autograft directly to a stable osteotomy site with minimal disruption of the surrounding soft tissue envelope, resulting in faster healing and a quicker return to full, unassisted weight bearing.

Intra-Operative Bone Stability Test.

Fractures of the supercondylar humerus are the most common elbow fracture in pediatrics. Management of this injury would be aided if surgeons could reliably test fracture stability intraoperatively after pinning. A transverse supracondylar humerus fracture model was created using 3 adult cadaver upper-extremity specimens with an intact soft tissue envelope. Using the lateral entry technique, three 2.0 mm pins were then drilled using lateral entry technique to create an "A" pinning. Pins were checked in anteroposterior and lateral views with the C-arm to confirm accurate placement in both planes. The pinning configuration was then tested by holding the proximal fragment steady with one hand and applying stress to the distal fragment with the other hand. The amount of movement of the distal fragment relative to the proximal fragment was recorded for each specimen. Distraction did not produce any substantial displacement of the osteotomy. The most valuable maneuvers were (in order of effectiveness): external rotation, lateral translation, posterior translation, valgus, and apex posterior. The results of this study indicate that external rotation, lateral translation, posterior translation, and valgus stresses created the most temporary deformity to the construct. A combination of these maneuvers should help the surgeon to decide if the fixation is stable. Our study demonstrates a possible technique to determining intraoperatively the stability of fixation of supracondylar humerus fractures, which could prevent the need for postoperative radiographs to assess stability.

New Trends in Ring Fixators.

Multiple versions of ring fixators are currently available to orthopaedic surgeons. Although the traditional Ilizarov-type ring fixator is still available, many surgeons are now using computer-assisted hexapod frames. There has been a recent surge in the number of different hexapod ring fixators on the market. This article will review some of the new trends in ring fixator hardware and software as well as discuss possible future directions of ring fixator development.

Assessing Quality and Safety in Pediatric Supracondylar Humerus Fracture Care.

BACKGROUND: Recently, there has been an emphasis on improving quality, safety, and value in the delivery of health care in the United States. The American Board of Orthopedic Surgery (ABOS) has developed a performance improvement questionnaire (PIQ) for orthopaedic surgeons managing pediatric supracondylar humerus fracture (PSCHF). Using the supracondylar PIQ as a guide, this study evaluates the process of measuring the outcomes and variations in care to PSCHF patients among pediatric orthopaedic surgeons. METHODS: An 88-question survey incorporating the ABOS PIQ was administered to 35 pediatric orthopaedic surgeons at 3 institutions. A retrospective chart review of patients who received operative management of a PSCHF during 2013 was performed. Each of the 17 eligible surgeons supplied 5 patients for a total of 85 patients. Medical records and radiographic imaging were reviewed using the ABOS PIQ data collection sheet. This data collection sheet encompasses the preoperative assessment, intraoperative treatment and assessment, and clinical and radiographic outcomes of patients with PSCHF. RESULTS: A total of 35 surgeons from 6 hospitals completed the online PSCHF survey. Uniform consensus among all 35 surgeons was identified in 21/79 of the questions (27%). Consensus among surgeons within a hospital group but not with surgeons from the other groups was identified in 39/79 (49%) of the questions. No consensus among the surveyed surgeons could be identified in 19/79 (24%) of the questions. For the 85 PSCHF patients the average age was 6 years, and 37% of fractures were type II, 57% of fractures were type III, and there was 1 flexion type. Ninety percent of the patients received a preoperative dose of antibiotics and the postoperative immobilization placed in the operating room was changed in the clinic before pin removal in 58% of the cases. Pins were removed at 3 weeks in 60%, 4 weeks in 30%, 5 weeks in 7%, and after 5 weeks in 3% of the patients and no malunions occurred. Pin tract infection occurred in 2 patients (2.4%). The procedure time ranged from 13 to 171 minutes, with a median time of 37 minutes. Total anesthesia time ranged from 32 to 233 minutes, with a median of 72 minutes. The number of outpatient follow-up visits ranged from 2 to 7 visits, with a median of 3 visits. The number of postoperative radiographs obtained ranged from 1 to 14, with a median of 3 studies. Four patients (5%) returned to the operating room for a repeat surgery. CONCLUSIONS: The survey responses from the surgeons at 6 different hospitals demonstrate that there is still considerable variation in care among surgeons, even for such a routine injury. Our chart review also revealed substantial variation in care with subsequent quality and cost-implications. The variations in operating room time, anesthesiology time, number of postoperative visits, number of radiographs ordered, and the initial intraoperative immobilization, all point to opportunities for standardization and lowering of costs. LEVEL OF EVIDENCE: Level IV.

Plate-assisted Lengthening of the Femur and Tibia in Pediatric Patients.

BACKGROUND: Limb lengthening over a percutaneous plate can be used during pediatric distraction osteogenesis to decrease the time of external fixation. METHODS: A retrospective, consecutive 2-surgeon experience of pediatric femoral and tibial lengthenings with a plate-assisted lengthening (PAL) technique was performed. The plate was placed at the time of index corticotomy. The primary outcome measures of external fixation index, consolidation index, and complications were assessed for each lengthening. RESULTS: From 2005 to 2012, 38 lengthenings (23 femur, 15 tibia) in 30 patients were performed by a PAL technique. All patients experienced successful distraction and consolidation. The average achieved lengthening was 3.80±0.98 cm (range, 2.2 to 6.4) with an average consolidation index of 27 days/cm and a mean external fixation index of 13.1±4.29 days/cm (range, 7.8 to 30). Patients returned to full weight-bearing activity after an average of 98.3±28.5 days. There were an average of 1.08±1.05 total complications and 0.39±0.75 severe complications per lengthening. Complications were encountered most commonly during femoral lengthening, including procurvatum and varus deformity through the regenerate. These deformities were usually corrected by frame adjustment before removal. CONCLUSIONS: PAL is a safe technique that minimizes time of external fixation, accelerates rehabilitation and weight-bearing, and can be successfully used on the femur or tibia. The most common complications are angular deformities of the regenerate that can be treated with adjustment before or at the time of plate locking. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Hexapod External Fixation of Tibia Fractures in Children.

Most tibia fractures in children can be treated nonoperatively. For fractures that do require surgery, however, the most common methods of management include plating or flexible nail insertion. Some fracture patterns, such as periphyseal fractures, fractures with bone and/or soft tissue loss, or fractures with delayed presentation, are not easily amenable to these techniques. Hexapod external fixators are especially helpful in these difficult cases. The purpose of this review is to discuss the principles of performing hexapod circular external fixation applied to pediatric tibia fractures. Some of the additional capabilities of the hexapod external fixator will also be highlighted.

Correction of Cubitus Varus After Pediatric Supracondylar Elbow Fracture: Alternative Method Using the Taylor Spatial Frame.

BACKGROUND: Cubitus varus is a well-reported complication of supracondylar fracture of the humerus potentially resulting in cosmetic problems, impaired function, and malpractice claims. Traditional methods of correcting malunited distal humeral fractures involve complex osteotomies that have a high complication rate, require a large exposure, and challenging fixation. We present a technique of gradual correction using a percutaneous transverse osteotomy and 3 dimensional correction with a Taylor Spatial Frame. METHODS: This was a retrospective, IRB-approved study of 12 patients between 2006 and 2010, with cubitus varus after a malunited pediatric supracondylar fracture. The average age at initial injury was 5+8 years. The average age of the patients at surgery was 8+8 years. We measured technical (radiographic parameters and complications), functional (clinical carrying angle, range of motion, QuickDash), and satisfaction domain (questionnaire) outcomes at a minimum follow-up of 6 months. RESULTS: The osteotomy healed in all patients by 10 weeks after the index surgery. The mean external fixator time was 10 weeks. The average preoperative and postoperative humeroulnar angles for the affected elbow were 23 degrees varus and 5.8 degrees valgus, respectively. This was statistically significant (P<0.001). The mean preoperative and postoperative carrying angles were 22 degrees of varus and 5.8 degrees of valgus. This was statistically significant (P<0.001). The results of the QuickDash assessment showed that patients were doing very well with regard to the use of their upper extremity. The mean symptom/disability score was 0.80. No major complications or neurovascular complications were encountered. Overall satisfaction with the procedure was high. CONCLUSIONS: The Taylor Spatial Frame as used in this case series provides the experienced surgeon another safe, accurate, and reliable method to correct cubitus varus after pediatric supracondylar fracture. We used in 7 of our 12 cases, a previously unreported pattern of distal humeral pin fixation that allows for a very distal metaphyseal osteotomy, close to the deformity apex. This is a biplanar delta configuration that straddles the olecranon fossa and is appropriate for both children and adults. LEVEL OF EVIDENCE: Level IV.

Limb Lengthening and Reconstruction Society AIM index reliably assesses lower limb deformity.

BACKGROUND: Although several systems exist for classifying specific limb deformities, there currently are no validated rating scales for evaluating the complexity of general lower limb deformities. Accurate assessment of the complexity of a limb deformity is essential for successful treatment. A committee of the Limb Lengthening and Reconstruction Society (LLRS) therefore developed the LLRS AIM Index to quantify the severity of a broad range of lower extremity deformities in seven domains. QUESTIONS/PURPOSES: We addressed two questions: (1) Does the LLRS AIM Index show construct validity by correlating with rankings of case complexity? (2) Does the LLRS AIM Index show sufficient interrater and intrarater reliabilities? METHODS: We had eight surgeons evaluate 10 fictionalized patients with various lower limb deformities. First, they ranked the cases from simplest to most complex, and then they rated the cases using the LLRS AIM Index. Two or more weeks later, they rated the cases again. We assessed reliability using the Kendall's W test. RESULTS: Raters were consistent in their rankings of case complexity (W = 0.33). Patient rankings also correlated with both sets of LLRS AIM ratings (r(2) = 0.25; r(2) = 0.23). The LLRS AIM Index showed interrater reliability with an intraclass correlation (ICC) of 0.97 for Trial 1 and 0.98 for Trial 2 and intrarater reliability with an ICC of 0.94. The LLRS AIM Index ratings also were highly consistent between the attending surgeons and surgeons-in-training (ICC = 0.91). CONCLUSIONS: Our preliminarily observations suggest that the LLRS AIM Index reliably classifies the complexity of lower limb deformities in and between observers.

Magnetically Driven Intramedullary Limb Lengthening in Patients with Pre-existing Implanted Programmable Devices: A Case Series.

Aim: The aim of the study is to demonstrate the safety and efficacy of the use of magnetically controlled intramedullary nails in patient with programmable implantable devices. Background: Magnetically driven intramedullary limb lengthening devices have revolutionised the field of limb reconstruction. Because the system is powered by strong magnets, there are warnings to avoid the use of the device in patients with implanted programmable devices, such as cardiac pacemakers. Materials and methods: Four patients with three different types of programmable implanted devices presented to two centres for limb lengthening and limb reconstruction. Each patient had a limb length discrepancy and desired correction using an intramedullary lengthening device. After thorough counselling about the potential risks and benefits of the procedure as well as discussions with each patient's medical team, the decision to proceed with surgery was made. Results: All four patients underwent osteoplasty with insertion of a magnetically driven intramedullary lengthening nail. Goal length was achieved with successful consolidation and subsequent nail removal in all patients. There were no malfunctions of the implantable devices during the distraction phase in any of the patients. Conclusion: With proper precautions, intramedullary lengthening can be performed safely and successfully using a magnetically driven nail in patients with previously implanted programmable devices. Clinical significance: This initial experience suggests use of magnetically controlled intramedullary nails in patient with programmable implantable devices can be undertaken safely within constraints of precautions. How to cite this article: Iobst CA, Hatfield DN, Forro SD, et al. Magnetically Driven Intramedullary Limb Lengthening in Patients with Pre-existing Implanted Programmable Devices: A Case Series. Strategies Trauma Limb Reconstr 2023;18(2):111-116.

Acute Intentional Deformation of Open Tibial Fractures for Complex Soft Tissue Closure in the Pediatric Patient.

Background. Lower extremity injuries in the pediatric population that are associated with Gustillo 3B/3C fractures require special consideration. Limb salvage should be attempted in the pediatric patient if at all possible, and oftentimes the soft tissue defect that is present over the bony fracture is substantial. The traditional algorithm used in the management of Gustillo 3B/3C fractures in plastic surgery, referred to as the reconstructive ladder, would recommend flap reconstruction with free tissue transfer in most cases because regional options are often unavailable or do not provide adequate coverage. Free tissue transfer procedures are extensive and necessitate a donor site; they often require multiple procedures and subsequent revisions. Furthermore, when concomitant injuries or medical conditions are present, a patient may not be an appropriate candidate for a free flap. Another option, however, does exist for the pediatric patient with a significant lower extremity injury that is often overlooked by the plastic surgeon. Several articles in the orthopedic literature describe the utility of temporary limb deformation to allow for soft tissue closure, with gradual correction of the bony deformity over time. Although the healing process for these procedures take several months, there is no need for extensive soft tissue reconstruction and the ultimate result is a leg that is functional with adequate coverage. This article reports a case where this type of bone and soft tissue reconstruction was performed in a patient with an excellent overall outcome. This technique could be useful in select cases as an option in pediatric lower extremity reconstruction.

Early Weight-bearing Accelerates Regenerate Bone Mineralisation: A Pilot Study Comparing Two Post-operative Weight-bearing Protocols Following Intramedullary Limb Lengthening Using the Pixel Value Ratio.

Introduction: Limb lengthening is increasingly accomplished by internal lengthening nails. Previous versions of the magnetic lengthening nails made from titanium alloy allowed limited weight-bearing. In contrast, the newer nails made of stainless steel allow increased weight-bearing. An objective comparison of the rate of healing of the regenerate bone based on the weight-bearing capabilities of these two types of lengthening nails has not been evaluated. The hypothesis for the study is that earlier commencement of full weight-bearing in patients treated with the stainless steel STRYDE® nail will lead to faster healing of the regenerate bone during intramedullary limb lengthening compared with those treated with the titanium PRECICE® nail. Materials and methods: Thirty patients, divided into two groups of 15 each, underwent antegrade intramedullary lengthening of the femur using a magnetic lengthening nail between May 2017 and November 2020. The pixel value ratio (PVR) obtained from serial digital radiographs was used to quantitatively determine the regenerate bone's mineralisation rate. We compared the rate of healing of the regenerate bone in both groups of patients using the PVR. Results: Patients treated with the STRYDE® nail achieved unassisted full weight-bearing significantly earlier than patients treated with the PRECICE® nail (12 weeks vs 17 weeks for STRYDE® and PRECICE® nail-lengthened patients, respectively, p = 0.003). There was no difference in the PVR between both groups of patients at the time of full weight-bearing (p = 0.0857). However, patients treated with the STRYDE® nail attained a PVR of 1 significantly earlier than those treated with the PRECICE® nail (0.0317). Conclusion: The STRYDE® nail provides an earlier return of function and full weight-bearing compared with the PRECICE® lengthening nail. Earlier commencement of weight-bearing ambulation leads to more rapid mineralisation of the regenerate bone in patients undergoing intramedullary limb lengthening. How to cite this article: Bafor A, Duncan ME, Iobst CA, et al. Early Weight-bearing Accelerates Regenerate Bone Mineralisation: A Pilot Study Comparing Two Post-operative Weight-bearing Protocols Following Intramedullary Limb Lengthening Using the Pixel Value Ratio. Strategies Trauma Limb Reconstr 2022;17(3):148-152.

A novel way to dynamize a spatial frame and optimize fracture healing.

BACKGROUND: Fracture site motion creates mechanical strains on the healing tissues which influences bone formation. Axial micro-motion maximizes dilatational strains, whereas shearing motions maximize deviatoric strains on the healing tissues. Dilatational strains optimize bone healing, deviatoric strains retard bone healing. Dynamization of external fixation using either an Ilizarov or Spatial Frame platform is used to increase loading on the limb which increases the mechanical stress and strain on the tissues to improve healing. The scientific literature does not address how dynamization of the spatial frame effects fracture site motion. The purpose of this study is to assess the effect of modified shoulder bolts incorporated into a spatial frame during dynamic loading. METHODS: Five identical two-ring spatial frame constructed were mounted on Sawbones tibias with an osteotomy performed distal to the tibial tubercle. Sinusoidal load was applied at a rate of 0.25 Hz. Axial force and displacement, in addition to motion of the proximal and distal tibia segments were recorded. Eight constructs were tested: 1) All struts of the Spatial Frame rigid, 2) Strut #1 loose, 3) Struts #1 and #3 loose, 4) Struts #1, #3 and #5 loose, 5) All struts loose, 6) All struts rigid with dynamization bolts on the proximal end, 7) All struts rigid with dynamization bolts on alternating sides, 8) Threaded rods between the rings with two millimeters of dynamization. RESULTS: No difference in vertical displacement was observed between the Ilizarov and all struts locked. No significant difference in shear values between all struts locked and modified shoulder bolt struts was observed. Increase in vertical movement with the modified shoulder bolts was an average of 1.83 mm. Significant shear forces at the fracture site were observed with unlocking single or multiple struts of the spatial frame. CONCLUSION: Modified shoulder bolts can be used for spatial frame dynamization without increasing shear motion.

Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE).

BACKGROUND: Intramedullary lengthening nails have shown excellent short-term results. The FITBONE and the PRECICE nail are the two most commonly used intramedullary lengthening nails. The manufacturer of each nail recommends the removal of the implant after the completion of the treatment. Despite the need for removal of each nail, the authors are not aware of any prior publications documenting the results of standard intramedullary lengthening nail removal. Therefore, the aim of this study was to examine the intraoperative and postoperative complications of elective intramedullary lengthening nail removals. MATERIALS AND METHODS: We performed a retrospective chart review of patients operated with intramedullary lengthening nails at two limb reconstruction centres (one in the United States, and the second in Denmark). Data retrieved from the patient charts included patient demographics, nail information and any complications occurring at or after nail removal. Only lower limb lengthening with FITBONE and PRECICE or STRYDE nails that had an elective nail removal was included. RESULT: A total of 271 elective nail removals were included in the study. Complications occurred during 3% of the nail removals and in 13% after nail removal. There were 18 reported cases with postoperative knee pain. All these patients had nail removal through the knee joint, representing 8% of the retrograde femur nail removals and 7% of the tibia nail removals. Four postoperative fractures occurred, of which two needed surgery. Eleven percent of femur removals and 26% of tibial removals sustained a complication. CONCLUSION AND CLINICAL SIGNIFICANCE: This study emphasises the importance of adequate follow-up of the bone lengthening patient even after the nail has been removed. It also shows that the recommended removal of the intramedullary nail (IMN) lengthening nails must be included in studies reporting on the overall risks of complications using bone lengthening nails. HOW TO CITE THIS ARTICLE: Frost MW, Kold S, Rahbek O, et al. Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE). Strategies Trauma Limb Reconstr 2021;16(2):110-115.

Evolving Surgical Management for Early-Onset Scoliosis in Spinal Muscular Atrophy Type 1 Given Improvements in Survival.

CASE: We present a case of an 18-month-old child with early-onset scoliosis in the setting of spinal muscular atrophy (SMA) type 1 whose rapidly progressive scoliosis is successfully managed with magnetic growing rods, the youngest age of implantation in a patient with SMA we are currently aware of. Technical challenges, complications, and outcome are described in this case presentation. CONCLUSION: Patients with SMA type 1 and early-onset scoliosis can be managed with growing-rod constructs given dramatic improvements in medical care that have expanded life expectancy.