Increased lengthening frequency does not adversely affect the EOSQ scores in magnetically controlled growing rod surgeries in 133 subjects followed to final fusion.

PURPOSE: Magnetically Controlled Growing Rod (MCGR) allows frequent outpatient rod lengthening when treating Early Onset Scoliosis (EOS) patients. But there is lack of expert consensus on the optimal MCGR lengthening interval. EOS 24-Item Questionnaire (EOSQ) is validated for assessing health-related quality of life (HrQOL), family burden, and satisfaction. This is the first study assessing how MCGR lengthening intervals affects patient-perceived outcomes. METHODS: This is a multicentred cohort study with subjects recruited from 2012 to 2018 and followed till fusion. EOS subjects who underwent MCGR surgeries were grouped into high, medium or low lengthening interval subgroups based on 16 and 20 week cut-offs. Repeated measure analysis was performed on EOSQ's specified 12 domains. EOSQ results were taken: before index surgery, after index surgery, and prior to definitive treatment. Demographic, clinical and radiographic data were included in model adjustment. RESULTS: 133 subjects with mean follow-up of 3.5 (± 1.3) years were included, with 60 males and 73 females; 45 idiopathic, 23 congenital, 38 neuromuscular, and 27 syndromic patients. Mean Cobb angle at surgery was 67° (± 22°) with mean age of 8.3 (± 2.5) years. Between groups, clinical and radiographic parameters were comparable. Higher EOSQ scores in medium lengthening interval subgroup was present in fatigue (p = 0.019), emotion (p = 0.001), and parental impact (p = 0.049) domains, and overall score (p = 0.046). Trendline contrast between subgroups were present in general health (p = 0.006) and physical function (p = 0.025) domains. CONCLUSION: Patient-perceived outcome improvements appear similar between lengthening interval subgroups. All MCGR lengthening intervals were tolerated by patients and family, with no negative impact observed. LEVEL OF EVIDENCE: Prognostic Level III.

Lengthening in congenital posteromedial bowing of tibia: a follow-up series at skeletal maturity.

PURPOSE: Congenital posteromedial bowing (CPMB) of tibia is a rare, usually self-resolving condition that is present at birth. The data on the long-term outcome of lengthening, choice of fixator, outcome in early and late age groups, and complications is sparse, hence the need for this study. METHODS: This retrospective study included 93 patients with 94 affected legs from 1991 to 2023. The patients were categorized into early (under 10 years) and late (10 years or above) intervention groups. Eighteen patients with nineteen lengthening episodes who attained skeletal maturity made the basis of this study and will be discussed in detail. RESULTS: The outcome for the lengthening group at maturity was satisfactory, with 5.53 cm of average length gained per lengthening episode, a mean LLD of 0.31 cm at final follow-up, a mean age of 23.63 years (range 14-38 years), and an average follow-up of 12.51 years (range 3-28 years) post-lengthening, but the procedure was associated with difficulties like ankle stiffness, tibial valgus, pin tract infections, and fractures through regenerate. CONCLUSION: This study represents a large single-centre series on CPMB. We recommend that surgery for lengthening should be done at an older age, close to skeletal maturity, wherever possible to reduce the risk of repeat lengthening procedures. Based on our experience, we recommend the use of a circular fixator. Uniplanar distractors should have an adequate number and spread of Schanz screws in each segment to reduce the risk of valgus malalignment of distracting segments of bone.

Limb salvage reconstruction of the lower limb with complex ankle arthrodesis and magnetic internal lengthening nail.

PURPOSE: With advances in orthopedic implants, the use of intramedullary lengthening devices has gained increasing popularity as an alternative technique compared to lengthening with external fixators, with alleged comparable or better outcomes. The aim of this study is to report our single-center technique and outcomes of combined ankle arthrodesis and proximal tibial lengthening using external fixator with a motorized intramedullary nail, respectively. METHOD: Fourteen patients with post-traumatic advanced ankle arthritis underwent staged ankle arthrodesis with external fixator and proximal tibial lengthening using the PRECICE® ILN. Amount of shortening, length achieved, bone healing index, infection rate, ankle fusion rate, and ASAMI score were evaluated. RESULTS: The average age was 44 years old (range, 30-62). The mean follow up is 70 months (range, 43-121.4). The average amount of limb shortening for patients after ankle fusion was 36.7 mm (18-50) while lengthening was 35.9 mm (range, 18-50). Patients had the nail implanted for an average of 479 days (range, 248-730). Ankle fusions were healed in an average of 178.3 days. There were no surgical infections. All osteotomy-lengthening sites healed after an average 202 days (106-365). The mean bone healing index (BHI) was 56.0 days/cm (21.2-123.6) among the whole cohort. There were no cases of nonunion. ASAMI bone scores were excellent or good among all patients. CONCLUSION: Ankle arthrodesis with external fixation along with proximal tibial lengthening using motorized IMN yielded high rates of fusion and successful lengthening. This technique could be offered as a reasonable alternative to using external fixation for both purposes. LEVEL OF EVIDENCE: Level IV, Retrospective cohort study.

Radiographs of 366 removed limb-lengthening nails reveal differences in bone abnormalities between different nail types.

AIMS: Limb-lengthening nails have largely replaced external fixation in limb-lengthening and reconstructive surgery. However, the adverse events and high prevalence of radiological changes recently noted with the STRYDE lengthening nail have raised concerns about the use of internal lengthening nails. The aim of this study was to compare the prevalence of radiological bone abnormalities between STRYDE, PRECICE, and FITBONE nails prior to nail removal. METHODS: This was a retrospective case series from three centres. Patients were included if they had either of the three limb-lengthening nails (STYDE, PRECICE, or FITBONE) removed. Standard orthogonal radiographs immediately prior to nail removal were examined for bone abnormalities at the junction of the telescoping nail parts. RESULTS: In total, 306 patients (168 male, 138 female) had 366 limb-lengthening nails removed. The mean time from nail insertion to radiological evaluation was 434 days (36 to 3,015). Overall, 77% of STRYDE nails (20/26) had bone abnormalities at the interface compared with only 2% of FITBONE (4/242) and 1% of PRECICE nails (1/98; p < 0.001). Focal osteolysis in conjunction with periosteal reaction at the telescoping interface was only observed in STRYDE nails. CONCLUSION: Bone abnormalities at the interface of telescoping nail parts were seen in the majority of STRYDE nails, but only very rarely with FITBONE or PRECICE nails. We conclude that the low prevalence of radiological changes at the junctional interface of 242 FITBONE and 98 PRECICE nails at the time of nail removal does not warrant clinical concerns. Cite this article: Bone Joint J 2021;103-B(11):1731-1735.

Early results from a single centre's experience with the STRYDE nail : a cause for concern?

AIMS: The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited regarding outcomes and potential problems. We report on our early experience and raise awareness for the potential of adverse effects from this device. METHODS: This is a retrospective review of prospective data collected on all patients treated in our institution using this implant. We report the demographics, nail accuracy, reliability, consolidation index, and cases where concerning clinical and radiological findings were encountered. There were 14 STRYDE nails implanted in nine patients (three male and six female) between June 2019 and September 2020. Mean age at surgery was 33 years (14 to 65). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies. RESULTS: At the time of reporting, eight patients (13 implants) had completed lengthening. Osteolysis and periosteal reaction at the junction of the telescopic nail was evident in nine implants. Five patients experienced localized pain and swelling. Macroscopic appearances following retrieval were consistent with corrosion at the telescopic junction. Tissue histology was consistent with effects of focal metallic wear debris. CONCLUSION: From our early experience with this implant we have found the process of lengthening to be accurate and reliable with good regenerate formation and consolidation. Proposed advantages of early load bearing and the ability for bilateral lengthening are promising. We have, however, encountered concerning clinical and radiological findings in several patients. We have elected to discontinue its use to allow further investigation into the retrieved implants and patient outcomes from users internationally. Cite this article: Bone Joint J 2021;103-B(6):1168-1172.

Pediatric Lower Limb Lengthening Using the PRECICE Nail: Our Experience With 50 Cases.

BACKGROUND: Limb lengthening using intramedullary externally controlled motorized devices is becoming increasingly popular. There is limited literature regarding their use in the pediatric and adolescent population. This study reviews outcomes on 50 consecutive cases of intramedullary lower limb lengthening surgery in this population. METHODS: A retrospective review of all pediatric and adolescent patients treated in our institution by intramedullary lengthening for lower limb length discrepancy using the PRECICE and STRYDE intramedullary lengthening nails between 2013 and 2019. All patients were operated by a single surgeon. Data were prospectively recorded. We report on nail accuracy and reliability, consolidation index, time to full weight-bearing from completion of lengthening, joint range of movement, ASAMI bone and functional scores, presence of problems, obstacles and complications, and patient reported outcome measures (PROMS). RESULTS: Fifty cases (43 femoral and 7 tibial nails) were performed in 42 patients (20 males, 48% and 22 females, 52%). Six patients had bilateral lengthening and 2 patients had sequential lengthening. There were 28 antegrade femoral, 13 retrograde femoral and 5 tibia PRECICE nails, 2 tibial and 2 femoral PRECICE STRYDE nails. Mean age at surgery was 15 years old (12 to 17). Mean preoperative length discrepancy was 49 mm (20 to 90). Mean achieved lengthening was 46.5 mm (20 to 80). Mean percentage lengthening was 12.6% (5% to 25%). Nail accuracy was 96% and reliability 90%. Average distraction rate was 0.92 mm/d for femur and 0.64 mm/d for tibias. Consolidation index was 28 d/cm (18 to 43) and 39 d/cm (20 to 47), respectively. Time from completion of lengthening to independent full weight-bearing as observed in clinic was 45 days (21 to 70) and 34.2 days (23 to 50), respectively. ASAMI bone and functional scores were favorable and PROMS demonstrated high patient satisfaction levels. No significant complications were observed. CONCLUSIONS: We have demonstrated excellent clinical results and high patient satisfaction with intramedullary lengthening in a pediatric/adolescent population. We highly recommend thorough preoperative preparation, patient education, and a multidisciplinary approach. LEVEL OF EVIDENCE: Level IV.

Extracorporal noninvasive acute retraction of STRYDE® for continued lengthening in cases with limited nail stroke: a technical less invasive solution to reload the STRYDE®.

With STRYDE® nails (NuVasive Specialized Orthopedics, San Diego, CA), lengthening nails for full weight-bearing during callus distraction have been available CE-certified since February 2019 in Europe. At present only antegrade femur nails and tibia nails with various lengths and diameters are available. Due to a mismatch of bone length and realizable (implantable) nail length e.g., in cases of skeletal dysplasia or achondroplastic dwarfism, it may happen that a desired lengthening of 6-8 cm cannot be realized because of a nail stroke from only 5 cm. Retrograde usage of antegrade piriformis nails is technically possible as an individual (off label use) procedure since so far no retrograde implants are available. A new method of surgical intervention for retraction of the STRYDE nails at the end of the nail stroke with ongoing callus distraction in patients with bilateral femoral extension under anesthesia with extracorporeal use of the fast distractor device is described in detail. It is safe and with low risk for a reload of a capacity of 3-4 cm for antegrade and retrograde femoral implantation situation for the patient. The acute reload of the STRYDE nail stroke for further distraction is possible without skin incision or invasive soft tissue approaches. Application of the fast distractor extracorporeal within a few minutes is described in detail. The intervention is technically reproducible and can be performed for the proximal femur with antegrade STRYDE nails as well as for the distal femur with retrograde STRYDE nails in adult patients.

Alargamiento óseo con clavo intramedular magnético experiencia preliminar y lecciones aprendidas / Bone lengthening with magnetic intramedullary nail preliminary experience and learned lessons

OBJETIVOS: Mostrar resultados, complicaciones y lecciones aprendidas utilizando el clavo intramedular magnético (IML, Intramedullary Magnetic Lengthener) en un grupo de pacientes sometidos a alargamiento óseo. PACIENTES Y MÉTODOS: Entre enero 2017 y diciembre 2019, 9 pacientes (15 segmentos), edad entre 15 y 39 años, fueron sometidos a alargamiento óseo con IML: 5 pacientes tuvieron alargamiento femoral bilateral por talla baja, 1 paciente se sometió a alargamiento de Piernas bilateral por Tibia vara y acortamiento mesomélico y 3 recibieron alargamientos femorales unilaterales por discrepancia de longitud de extremidades. Todos fueron operados por el mismo cirujano, con técnica standard. Se indicó kinesiterapia al menos 5 veces por semana durante la fase de distracción. RESULTADOS: En todos se logró el objetivo de alargamiento planteado. No hubo complicaciones intra ni postoperatorias graves (TVP, TEP, Embolia grasa), ni fallas del sistema distractor. Un paciente desarrolló contracturas articulares de ambas rodillas por no adhesión a Kinesiterapia. Ninguno requirió aporte de injerto óseo, sin embargo en 2 pacientes de alargamiento de Fémur bilateral, se presentó deformidad en varo, que hizo necesario recambio a clavo convencional y un paciente desarrolló una parálisis transitoria del Nervio Peroneo común. CONCLUSIONES: El advenimiento de los IML significó un gran avance en el campo de la osteogénesis por distracción, sin embargo, aún se trata de un procedimiento complejo, que debe ser planificado cuidadosamente para minimizar los riesgos y complicaciones. Una selección meticulosa del paciente y la evaluación física y psicológica previa, son fundamentales para el éxito del procedimiento. Los casos bilaterales requieren de un seguimiento cercano, por el riesgo de falla del implante.

objective: We show our results, complications and lessons learned using the Intramedullary Magnetic Lengthener (IML) in a group of patients who were subjected to bone lengthening. PATIENTS AND METHODS: Between January 2017 and December 2019, 9 patients (15 segments), aged between 15 and 39 years, underwent bone lengthening with IML: 5 patients had bilateral femoral lengthening due to short stature, 1 patient had bilateral leg lengthening due to Tibia vara and mesomelic shortening and 3 had unilateral femoral lengthening for limb length discrepancy. All were operated by the same surgeon, with standard technique. Physical therapy was indicated at least 5 times per week during the distraction phase. RESULTS: In every case, the proposed lengthening amount was achieved. There were no serious intraoperative or postoperative complications (DVT, Pulmonary Embolism, Fat Embolism), nor failures of the distractor system. One patient developed knee joint contracture due to non-adherence to Physical therapy. None required bone grafting, however, in 2 patients with bilateral Femur, a varus deformity appeared, which required nail exchange with a conventional trauma nail. One case developed a transit common Peroneal Nerve palsy. CONCLUSIONS: IMLs represent a great advance in the bone lengthening realm, however, it is still a complex procedure, which must be carefully planned to minimize risks and complications. Meticulous patient selection and prior physical and psychological evaluation are essential to the success of the procedure. Bilateral cases need a closer follow up, because implant failure is a potential risk.

Tibial lengthening using a retrograde magnetically driven intramedullary lengthening device in 10 patients with preexisting ankle and hindfoot fusion.

Background and purpose - Motorized intramedullary lengthening nails (ILNs) have been developed as an alternative to external fixators for long bone lengthening. The antegrade approach represents the standard method for tibial ILN insertion. In patients with preexisting ankle and hindfoot fusion a retrograde approach provides an alternative technique that has not been evaluated so far. We report the outcome of this method in 10 patients. Patients and methods - This retrospective study included 10 patients (mean age 18 years [13-25]) with preexisting ankle and hindfoot fusion who underwent tibial lengthening with a retrograde ILN (PRECICE). The mean leg length discrepancy (LLD) was 58 mm (36-80). The underlying conditions were congenital (n = 9) and post tumor resection (n = 1). The main outcome measures were: ILN reliability, distraction achieved, distraction index (DIX), time to bone healing, consolidation index (CIX), complications, and functional results. Results - All patients achieved the goal of lengthening (mean 48 mm [26-80]). Average DIX was 0.6 mm/day (0.5-0.7) and mean CIX was 44 days/cm (26-60). Delayed consolidation occurred in 2 patients and healed after ILN dynamization or nail exchange with grafting. Toe contractures in 2 other patients were resolved with physiotherapy or tenotomy. Until last follow-up (mean 18 months [12-30]) no true complications were encountered, knee motion remained unaffected, and full osseous consolidation occurred in all patients. Interpretation - In patients with LLD and preexisting ankle and hindfoot fusion distal tibial lengthening using a retrograde ILN is a reliable alternative to the standard approach with equivalent bone healing potential and low complication rates leaving the knee unaffected.

Thumb lengthening using a three-dimensional half-ring distraction frame.

The purpose of this study was to evaluate the use of a three-dimensional half-ring distraction frame for thumb phalangeal lengthening. From February 2009 to March 2015, 23 patients (23 thumbs) with thumb loss were treated with a half-ring distraction frame. Active movements of the metacarpophalangeal (MCP) joint were measured with a goniometer. These measurements were compared with the opposite hand. Differences were considered statistically significant at p<0.05. Clinical outcome was assessed based on the modified Mayo score. Bone union and good alignment were achieved in all patients. The mean distraction time was 44 days (range, 35-62 days). The mean time to union was 20 days (range, 49-86 days). The mean palmar and radial abduction of the thumb was 60° (range, 53°-65°) and 63° (range, 58°-70°), respectively; on the uninjured side, these measurements were 62° (range, 56°-65°) and 64° (range, 60°-73°), respectively (p>0.05). The mean extension-flexion arc of the MCP joint was 46° (range, 40°-50°); the measurement on the uninjured side was 48° (40°-54°) (p>0.05). The mean follow-up period was 51 months (4.25 years) (range, 48-65 months). The mean modified Mayo Score was 138 (range, 113-145). There were 19 excellent, 3 good, and 1 fair results. The half-ring distraction frame is a viable alternative for thumb lengthening as it provides stable, three-dimensional fixation, resulting in good hand function.

Health-related quality of life in early-onset-scoliosis patients treated with growth-friendly implants is influenced by etiology, complication rate and ambulatory ability.

BACKGROUND: Progressive Early-Onset Scoliosis (EOS) in children may lead to surgical interventions with growth-friendly implants, which require repeated lengthening procedures in order to allow adequate growth. Quality of life was studied using the validated German version of the EOS-Questionnaire (EOSQ-24-G) in surgically treated EOS children with different lengthening modalities. METHODS: EOSQ-24-G and the KINDLR questionnaire were given to families with EOS children who had been treated by either vertical expandable prosthetic titanium rib implants and repetitive lengthening surgeries every 6 months or children who had received a magnetically expansion controlled implant, which was externally lengthened every 3 months. Results were compared according to differences between the two tests, and with possible influencing factors such as surgical method, severity of scoliosis, relative improvement of curvature, etiology, weight, age, travelling distance, complications, ambulatory ability and others. RESULTS: 56 children with an average curve angle of 69° corrected to 33° (52%; average age 5.6 yrs) answered the EOSQ-24-G and the KINDLR after an average follow-up of 3.9 years. Health-related quality of life (HRQoL) was not affected by the initial scoliosis correction, the number of surgeries or the implant type. However, there was a negative correlation with non-ambulatory status, complications during treatment and for children with a neuromuscular scoliosis. CONCLUSION: Using the validated EOSQ-24-G, no statistically significant differences were found between the group of children receiving repetitive surgeries and children with external lengthening procedures without surgery. However, results were influenced by the etiology, complication rate or ambulatory ability. LEVEL OF EVIDENCE/CLINICAL RELEVANCE: Therapeutic Level IV.

Extreme bone lengthening by bone transport with a unifocal tibial corticotomy: a case report.

BACKGROUND: Bone transport is used for the treatment of extensive limb bone defects. The application of ring or unilateral external fixators combined with single or double corticotomy are well documented; however, there are few cases adopting a single corticotomy to repair bone defects > 24 cm. CASE PRESENTATION: The present case study describes an 18-year-old male, who was involved in a traffic accident and was diagnosed with open fracture of the right tibia. The patient received emergency surgery in a local hospital and was transferred to The Second People's Hospital of Yunnan for further treatment 3 months later. The patient was diagnosed with fracture nonunion and infection following admission. Complete debridement was performed three times to control the infection. The infection was resolved after 26 days and the 24.5 cm massive tibia defect remained the biggest challenge. The bone transport technique involving a unilateral external fixator and single corticotomy was employed to treat the bone defect. Docking site union was achieved and bone consolidation was complete 40 months after corticotomy. The external fixator was subsequently removed. The bone healing index was 1.6 months/cm. The Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) revealed a good functional and bone repair result. Similarly, Knee Society Score (KSS) yielded good result and the The Lower Extremity Functional Scale (LEFS) was 65. A total of 45 months after injury, the patient was able to walk painlessly without ambulatory assistive devices and resumed daily activities successfully. Eighteen months after the bone and soft tissue wound have healed, the SF-36 score was 86, and the LEFS was 70. CONCLUSION: To the best of the authors' knowledge, the present study described the longest bone defect repair performed using bone transport with single level corticotomy.

Repeated intramedullary stabilization following failed telescopic nail lengthening - An appropriate treatment strategy.

Externally magnetic-controlled intramedullary telescopic nails for bone lengthening have recently gained popularity due to many advantages when compared to more traditional lengthening methods. Patients requiring lengthening often present with a clinical history of previous multiple surgeries increasing the risk for complications of further procedures. However, studies regarding the treatment of complications following implantation of these devices remain scarce in literature. Therefore, we report our experience with revision surgery after lengthening with a telescopic intramedullary lengthening nail. In 6 out of 20 cases (30%) of lower limb lengthening for leg length discrepancy revision surgery was necessary. Two revisions were necessary due to nail breakage while the other 4 cases required a secondary procedure for non-union. In all cases, revision surgery included standard intramedullary locking nailing with additional autologous bone grafting. The median interval between index and revision surgery was 11.5 months (range 2-15 months). Satisfying clinical results, the intended extend of lengthening and bony consolidation was observed in all 6 patients. We conclude that revision surgery using an intramedullary locking nail with autologous bone grafting after failed telescopic nail-based lengthening represents an useful salvage procedure in these cases.

Lower limb lengthening over an intramedullary nail: a long-term follow-up study of 28 cases.

BACKGROUND: Limb lengthening using an external fixator requires a long period of external fixation and may be associated with several complications such as axial deformity, fracture of the regenerated bone, and joint stiffness. With the goal of reducing the time of external fixation as well as some of these complications, we performed femoral or tibial lengthening over an intramedullary nail, according to Paley's technique, in 28 patients, followed up after a mean period of 8 years. MATERIALS AND METHODS: Twenty-eight patients treated for lower limb discrepancy by limb lengthening over an intramedullary nail were reviewed from 5 to 11 years after healing of regenerated bone. There were 20 femurs and 8 tibiae, with average age at surgery of 14.2 years and average length inequality of 6.1 cm for femurs and 5.3 cm for tibiae. RESULTS: The mean lengthening was 5.8 cm for femurs and 4.8 cm for tibiae. The mean period of radiographic consolidation of the regenerated bone was 6 months for femoral lengthening and 4.5 months for tibial lengthening. At follow-up, we observed 8 excellent results, 15 good results, 4 fair results, and 1 poor result, based on Paley's evaluation criteria. The main complications were one deep infection, one nonunion of the distracted segment, one breakage of the distal fiche of the external fixator, and one breakage of both distal locking screws of the intramedullary nail. DISCUSSION: We believe that limb lengthening over an intramedullary nail still represents a good method to treat limb length discrepancy because it reduces the time of external fixation, prevents axial deformities and fractures of regenerated bone, and allows early rehabilitation. The new intramedullary lengthening nails, which theoretically are the ideal device for treating limb length inequality, are still very expensive and need longer follow-up for definitive evaluation. LEVEL OF EVIDENCE: 4.

Lengthening With Monolateral External Fixation Versus Magnetically Motorized Intramedullary Nail in Congenital Femoral Deficiency.

BACKGROUND: Limb lengthening for congenital femoral deficiency (CFD) with or without fibular hemimelia can be performed with both external and internal devices. The purpose of this study is to compare clinical outcomes of femoral lengthening utilizing monolateral external fixation versus a magnetically motorized intramedullary nail in patients with CFD with or without fibular hemimelia. METHODS: This retrospective review included 62 patients with femoral lengthening, 32 patients had monolateral external fixation (group A), 30 patients had internal lengthening nail (group B). Mean age in years was 9.4±3.8 and 15.4±4.9 for groups A and B, respectively. Mean follow-up in years was 4.47±2.7 and 1.86±0.7 years for groups A and B, respectively. RESULTS: Mean lengthening achieved was 5.6±1.7 and 4.8±1.4 cm for group A and group B, respectively (P=0.052). Mean distraction index was 0.7±0.2 mm/d for group A and 0.7±0.2 mm/d for the group B (P=0.99). Mean consolidation index for group A was 29.3±12.7 and 34.8±11.2 d/cm for group B (P=0.08). Mean arc of motion before surgery and at final follow-up were similar between groups (P=0.35). Group A had significantly less range of motion at the end of distraction (P=0.0007) and at consolidation (P<0.0001). Both groups had similar rates of obstacles and complications. A significant difference between groups was found in the total problems (P<0.001) specifically with pin site/superficial infection (P<0.0001). CONCLUSIONS: The intramedullary nail had superior range of motion during the lengthening phase and at consolidation and an overall lower problem complication rate, while maintaining similar distraction and healing indices to monolateral external fixation. Internal lengthening nails represent a significant advance in technology for CFD lengthening. LEVEL OF EVIDENCE: Level IV-therapeutic.

Can polyaryletherketone cage be used to achieve union and maintain correction in anterior calcaneal lengthening osteotomy for treatment of flexible flatfoot?

A structural graft is often used to maintain correction and achieve union after anterior calcaneal lengthening osteotomy for treatment of flexible flatfoot. Autograft, the current gold standard, is limited in availability and configuration and is associated with donor site morbidity in as much as 48%, whereas the alternative allograft carries risks of disease transmission and collapse. Polyaryletherketone cage, with a healing rate similar to that of autograft, high stability, and no donor-site morbidity, has been used in spine surgery. However, its use has not been documented in foot and ankle surgery. We reviewed 15 patients with painful flatfeet after failure of conservative treatment who were treated by anterior calcaneal lengthening osteotomy using polyaryletherketone cage instead of bone graft. Minimum follow-up was 1 year (average, 1.27 years; range, 1-1.5 years). The male-female ratio was 1:1.5 (six males, nine females). Mean age at time of surgery was 10.8 ± 1.7 years (range, 8-13.5 years). Minimum follow-up was 1 year (average, 1.27 years; range, 1-1.5 years). Nine patients had a unilateral procedure and three had a simultaneous bilateral procedure, for a total of 15 operated feet (seven right and eight left). The paired t-test result was statistically significant in comparison of radiographic measurements at presurgery and postsurgery with P value <0.001. All cases showed full union clinically and radiographically at last follow-ups and no complications occurred. Our data suggest that polyaryletherketone cage may be used as a structural graft option for anterior calcaneal lengthening osteotomy.

Limb lengthening and deformity correction in children with abnormal bone.

Flexible intramedullary nailing (FIN) provides multiple advantages in limb lengthening and progressive deformity correction in combination with external fixation. The article presents brief literature review and authors' experience in limb lengthening of abnormal bone (Ollier's disease, fibrous dysplasia, osteogenesis imperfecta). Titanium and, especially, hydroxyapatite-coated bent elastic nails in combination with external fixator are appropriate in limb lengthening of abnormal bone in children. FIN left in situ after lengthening procedure and external frame removal should be applied for long-term reinforcement of lengthened bone in patients with abnormal bone (metabolic bone disorders, skeletal dysplasias with compromised bone tissue development). The FIN respects bone biology, which is mandatory for good bone consolidation. Osteoactive properties of intramedullary elastic implants are favorable for bone formation and as well as for stable position of nails without risks of migration in long-term follow-up.

The role of external fixation in paediatric limb lengthening and deformity correction.

Limb deformity and shortening remains a common presenting complaint in paediatric orthopaedics. The ability to restore length, alignment with consistent bone formation allows standardised treatment in these difficult conditions. The use of an external fixator produces a stable construct which allows manipulation of the bone segments, with a controlled rate and rhythm. Deformity analysis permits the surgeon to plan osteotomy levels and frame application to produce accurate correction. Complications, especially in congenital conditions remain an issue and modification of the treatment is required to try and reduce their incidence. New types of fixators, the latest being hexapod frames, have increased the versatility in deformity correction. The aim of this paper is to review the use of external fixators in elective paediatric orthopaedics and highlight the latest changes in technique and application for the limb reconstruction surgeon.

Low-intensity pulsed ultrasound enhances callus consolidation in distraction osteogenesis of the tibia by the technique of lengthening over the nail procedure.

BACKGROUND: Low-intensity pulsed ultrasound (LIPUS) has been widely accepted in promoting the fracture healing process. However, there have been limited clinical trials focused on the efficacy of LIPUS during distraction osteogenesis (DO) by the technique of lengthening over the nail procedure. The purpose of the current study was to evaluate the efficacy of LIPUS during DO. METHODS: We retrospectively evaluated 30 patients (60 segments) who underwent simultaneous bilateral tibial lengthening over the nail. The patients were grouped into the LIPUS group and the control group based on LIPUS stimulation. The two patient groups were compared for demographic data (sex, age at operation, preoperative height, BMI, and smoking history), qualitative assessments of the callus (callus shape and type), external fixation index, and four cortical healing indexes. RESULTS: Fifteen patients (30 segments) were classified as the LIPUS group, and another 15 patients (30 segments) were classified as the control group. No significant differences were found in the assessed demographic data between the groups. LIPUS stimulated a more cylindrical, more homogenous, and denser type of callus formation at the end of the distraction phase. The two groups exhibited equivalent outcomes in terms of external fixation index (p = 0.579). However, significant differences were found in healing indexes of the anterior and medial cortices (p <  0.001 and p = 0.002, respectively). The healing indexes of those cortices in the LIPUS group (mean of 36.6 days/cm and 32.5 days/cm, respectively) reflected their significantly faster healing compared to the control group (mean HI of 57.5 days/cm and 44.2 days/cm, respectively). There were no LIPUS-related complications. CONCLUSIONS: LIPUS is a noninvasive and effective adjuvant therapy to enhance callus maturation during DO. It enhances callus consolidation and may have a positive effect on the appropriate callus shape and type.

Double-level fixator-assisted nailing (DL-FAN).

AIMS: Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator. PATIENTS AND METHODS: A total of 23 patients underwent this surgery, involving 27 segments (23 femora and four tibiae), over a period of ten years. The most common indication was polio in ten segments and rickets in eight; 20 nails were inserted retrograde and seven antegrade. A total of 15 lengthenings were performed in 11 femora and four tibiae, and 12 double-level corrections of deformity without lengthening were performed in the femur. The mean follow-up was 4.9 years (1.1 to 11.4). Four patients with polio had tibial lengthening with arthrodesis of the ankle. We compared the length of time in a fixator and the external fixation index (EFI) with a control group of 27 patients (27 segments) who had double-level procedures with external fixation. The groups were matched for the gain in length, age, and level of difficulty score. RESULTS: The mean gain in length was statistically similar in the two groups: 3.9 cm (1.5 to 9.0) in the study group and 4.2 cm (3.4 to 5.0) in the control group (p = 0.350). The mean time in a fixator was significantly less in the study group compared with the control group: 8.6 weeks (2.0 to 22.8) versus 30.2 weeks (25.0 to 35.4; p < 0.001). The mean EFI was significantly lower in the study group compared with the control group: 17.7 days/cm (10.6 to 35.6) versus 73.4 days/cm (44.5 to 102.3; p < 0.001). The ASAMI (Association for the Study and Application of the Method of Ilizarov) bone score was excellent in 22, good in four, and fair in one. The ASAMI functional score was excellent in 20 and good in seven. There were no infections, superficial or deep. CONCLUSION: Double-level osteotomies or two procedures using a custom-made straight nail and external fixation can be used to correct deformities or to treat nonunion or malunion and may be combined with arthrodesis of the ankle with lengthening. It is a reasonably safe procedure that allows accurate and cost-effective treatment with a relatively short time in a fixator.