Simultaneous correction of leg length discrepancy and angular deformity of the distal femur with retrograde Precice nails: a retrospective analysis of 45 patients.

BACKGROUND AND PURPOSE: Magnetically controlled motorized intramedullary lengthening nails (ILNs) can be employed for simultaneous correction of angular deformities of the distal femur and leg length discrepancy. This spares typical complications of external fixators but requires precise preoperative planning and exact intraoperative execution. To date, its results are insufficiently reported. We aimed to elucidate the following questions: (i) Is acute angular deformity correction and gradual femoral lengthening via a retrograde ILN a reliable and precise treatment option? (ii) What are the most common complications of treatment? METHODS: Acute angular deformity correction and subsequent gradual lengthening of the distal femur with retrograde ILN was retrospectively analyzed in 45 patients (median patient age: 15 years, interquartile range [IQR] 13-19 and median follow-up: 40 months, IQR 31-50). Outcome parameters were accuracy, precision, reliability, bone healing, and complications of treatment. RESULTS: The median distraction was 46 mm (IQR 29-49), median distraction and consolidation index 0.9 mm/day (IQR 0.7-1.0) and 29 days/cm (IQR 24-43), respectively. The median preoperative mechanical axis deviation (MAD) was 30 mm (IQR 23-39) in the varus cohort and -25 mm (IQR -29 to -15) in the valgus cohort and reduced to a mean of 8 mm (standard deviation [SD] 8) and -3 (SD 10), respectively. Accuracy, precision, and reliability of lengthening were 94%, 95% and 96%, respectively. Accuracy and precision of deformity correction were 92% and 89%, respectively. In total, 40/45 of patients achieved distraction with a difference of less than 1 cm from the initial plan and a postoperative MAD ranging from -10 mm to +15 mm. In 13/45 patients unplanned additional surgeries were conducted to achieve treatment goal with nonunion being the most frequent (4/45) and knee subluxation (3/45) the most severe complication. CONCLUSION: Acute deformity correction and subsequent lengthening of the distal femur with retrograde ILN is a reliable and accurate treatment achieving treatment goal in 89% but unplanned additional surgeries in 29% of patients should be anticipated.

Endoprosthetic Reconstruction of the Proximal Humerus with an Inverse Tumor Prosthesis.

Reconstructing the proximal humerus after tumor removal is challenging due to muscle and bone loss. The current methods often result in poor shoulder function. This study assessed the long-term functional and oncological outcomes of using an inverse proximal humerus prosthesis in 46 patients with bone tumors. The results showed a mean range of motion of 62° in anteversion, 28° in retroversion, and 55° in abduction. Notably, 23 patients achieved over 90° of shoulder abduction, with an average of 140°. The median Musculoskeletal Tumor Society Score was 25. Complications included infection in two radiotherapy patients and single dislocations in seven patients. One patient with recurrent dislocations needed revision surgery. In conclusion, the use of the inverse proximal humerus prosthesis in bone tumor treatment yields excellent shoulder function and high patient satisfaction. This approach is especially beneficial for those with metastatic disease.

Preliminary results of two novel devices for epiphysiodesis in the reduction of excessive predicted final height in tall stature.

BACKGROUND: In the treatment of tall stature, the reduction of excessive predicted final height can either be achieved by hormonal treatment or surgically by temporary (tED) or permanent (pED) epiphysiodesis. The present study evaluates the preliminary results of two novel devices for tED and pED around the knee to reduce the predicted final height. MATERIALS AND METHODS: A retrospective analysis was performed to evaluate the clinical and radiographic outcome after bilateral epiphysiodesis for the treatment of tall stature. A cohort of 34 patients (16 girls, 18 boys) who underwent either tED or pED between 2015 and 2020 were eligible for analysis based on the electronic patient records and picture archiving and communication system of our orthopaedic teaching hospital. tED was conducted in 11 patients (32%) through bilateral implantation of four RigidTacks™ (Merete, Berlin, Germany) around the knee. Twenty-three patients (68%) received pED, performed with an EpiStop™ trephine (Eberle, Wurmberg, Germany). The mean overall follow-up time was 2.9 years. RESULTS: The mean age at surgery was 12.3 years in girls and 13.2 years in boys. Patients had a mean body height of 175.2 cm in girls and 184.7 cm in boys at surgery. The mean predicted final height was 191.4 cm in girls and 210.4 cm in boys. At the last follow-up, 26 patients (76.5%) had achieved skeletal maturity. The mean height of skeletally mature patients was 187.2 cm in girls and 198.5 cm in boys. A mean reduction of the predicted final height of 5.9 cm in girls and 8.7 cm in boys was achieved, corresponding to a reduction in remaining growth of 46% in girls and 38% in boys. Secondary frontal plane deformities of the knee were detected in 5/11 patients (45.5%) in the tED group and 1/23 treatments (4.3%) in the pED group. CONCLUSIONS: tED and pED have both proven to be efficient at achieving growth inhibition to reduce excessive predicted height. However, tED has been associated with an increased risk of secondary angular deformities of the knee. Furthermore, the risk of implant-related complications and the necessity of a subsequent surgical intervention for implant removal have led our study group to abandon tED when treating tall stature. Long-term results of both procedures are pending.

Giant cell tumor of bone: A single center study of 115 cases.

BACKGROUND: Giant cell tumor of bone (GCTB) is a locally aggressive bone tumor that represents about 4-5% of all primary bone tumors. It is characterized by aggressive growth, possible recurrence after surgical treatment and, in rare cases, metastasis. Surgical management is the primary treatment and may include intralesional curettage with adjuvants or, in rare cases, wide resection. In recent years the monoclonal antibody denosumab has been introduced as a potential (neo-)adjuvant systemic treatment option for patients with borderline resectable or unresectable lesions. Currently several studies reported that the use of denosumab prior to curettage possibly increase the risk of local recurrence. METHODS: In this retrospective study we reviewed 115 cases of GCT with a mean follow-up of 65.6 (24-404) months who underwent a surgical treatment with or without preoperative denosumab therapy in our institution. Potential risk factors for LR and complications were analyzed. RESULTS: The study includes 47 male (40.9%) and 68 female (59.1%) patients with a mean age of 33.9 (10-77) years and a mean follow-up of 65.6 (24-404) months. Denosumab was used in 33 (28.7%) cases, in 14 cases (12.2%) in a neoadjuvant setting and in 17 cases preoperatively before re-curettage (14.8%) after LR. In 105 cases (91.3%) an intralesional curettage was performed. The overall LR rate was 47.8% (55 cases). Patients who underwent intralesional curettage and bone cement augmentation without neoadjuvant denosumab treatment had LR in 42.2% (38/90) of the cases. Patients who underwent neoadjuvant denosumab treatment prior to curettage had LR in 28.6% (4/14). Re-recurrence was frequent in patients with neoadjuvant denosumab treatment who had LR after initial curettage (50%, 8/16). After wide resection and endoprosthetic replacement one case (20%) of local recurrence was detectable (1/5 cases). CONCLUSIONS: GCTB recurs frequently after intralesional curettage and cement augmentation. While denosumab is a potential (neo-)adjuvant treatment option that might be used for lesions that are difficult to resect, surgeons should be aware that LR is still frequent.

Reconstructive Approaches in Surgical Management of Congenital Pseudarthrosis of the Tibia.

Treatment of congenital pseudarthrosis of the tibia remains a major challenge in pediatric orthopedics. Ideal timing and preference of surgical procedures are discussed controversially. A variety of reconstructive treatment strategies have been described in literature, but so far none has proven its superiority. The aim of treatment is to obtain long-term bone union, to prevent refracture, and to correct angular deformities and leg length discrepancies. This study retrospectively evaluates the outcome of different reconstructive strategies. Sixty-nine patients were identified who presented to our outpatient department between 1997 and 2019. Twenty-six of these patients underwent reconstructive surgical treatment and were included in this study. The study cohort was divided into three groups. Excision of the pseudarthrosis was performed in all patients in Group A and B, and in two patients of Group C. Group A (six/26 patients) received subsequent bone transport through external fixation maintaining original length. In Group B (15/26 patients), patients underwent either previous, simultaneous, or subsequent extrafocal lengthening through external fixation to reconstitute length. In Group C (five/26 patients), internal fixation with intramedullary nails was applied. Radiological and clinical evaluation was performed to assess bone union and complication rates. Results varied considerably between the study groups. Overall, the primary bone fusion rate was 69.2%. There were four refractures, all occurring in Group B. The long-term bone union rate without refracture was 53.8%. The overall complication rate was 53.8% and 23.1% showed persistent pseudarthrosis. Two secondary amputations were performed due to failed bone fusion. In conclusion, excision of the pseudarthrosis and extrafocal lengthening achieves a satisfying bone union rate and limb reconstruction, while bone transport does not offer significant advantages but shows higher complication rates. Intramedullary stabilization should be applied to maintain bone union, but shows lower bone union rates when used as a stand-alone treatment regimen. Regardless of the primary bone fusion rates, the probability of long-term bone union remains unpredictable.

Reconstruction of Total Bone Defects following Resection of Malignant Tumors of the Upper Extremity with 3D Printed Prostheses: Presentation of Two Patients with a Follow-Up of Three Years.

Wide tumor resection is the local treatment of choice for patients with primary malignant bone tumors and a prerequisite for long-term survival. We present two patients that underwent total bone resection in the upper limb because of primary malignant bone tumors. The defects were then reconstructed by a 3D printed prosthesis, a procedure that, to our knowledge, has not been reported for bone defects of the upper extremity so far. Complete resection of the affected bone was required in a five-year-old girl with a high-grade osteoblastic osteosarcoma of the humerus and a 53-year-old man with a dedifferentiated leiomyosarcoma of the radius, due to the tumor's extent. Following neoadjuvant chemotherapy, resection of the entire affected humerus including the axillary nerve took place in the first case and the entire affected radius including parts of the radial nerve in the second case. Approximately three years after surgery, both patients are alive and pain-free. Despite a postoperative drop hand that affected the now 56-year-old man, he is able to carry out everyday activities such as brushing his teeth, writing, and eating. The now eight-year-old girl is also able to engage in normal activities with her left arm such as eating and carrying lightweight objects. Both patients are tumor-free to date.

Femoro-pedal distraction in staged reconstructive treatment of tibial aplasia.

AIMS: The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery. METHODS: This was a retrospective study involving ten patients (12 limbs) with tibial aplasia, who underwent staged reconstruction. During the first operation a circular hexapod external fixator was applied and femoro-pedal distraction was undertaken over several months. Subsequent surgery included reconstruction of the knee joint and alignment of the foot. RESULTS: The mean follow-up was 7.1 years (2 to 10). The mean age of the patients at the time of the application of the fixator was 2.3 years (1.1 to 5.0). The mean time under distraction was 139.7 days (81.0 to 177.0). A mean fibular distalization of 38.7 mm (14.0 to 67.0) was achieved. Pin infections occurred in four limbs (33.3%) and osteitis in one. A femoral fracture occurred in one patient. Premature removal of the frame was not required in any patient. Sufficient realignment of the leg as well as soft tissue lengthening was achieved in all patients, allowing subsequent reconstruction. All patients were able to mobilize fully weight bearing after reconstruction. Functional outcome was limited in all limbs, and five patients (50.0%) required additional reconstructive operations. CONCLUSION: Regarding the functional results in the treatment of tibial aplasia, amputation remains superior to limb salvage. The latter procedure should only be performed in patients whose parents refuse amputation. Femoro-pedal distraction efficiently prepares the limb by realigning the leg and soft tissue lengthening. Minor complications are frequent, but usually do not hinder the continuation of distraction. Even though a fully weight-bearing limb is achieved, the functional outcome of reconstructive treatment remains limited. Recurrent deformities frequently occur and may require further operations. Cite this article: Bone Joint J 2020;102-B(9):1248-1255.