Safety range for acute limb lengthening in primary total hip arthroplasty.

PURPOSE: There is no documented maximum amount that an extremity can be safely lengthened in primary total hip arthroplasty (THA) without neurologic or soft tissue complications. We retrospectively reviewed patients who underwent primary THA with acute limb lengthening and investigated the safety range for acute limb lengthening in primary THA. METHODS: This study included 61 hips in 52 patients who underwent primary THA with acute limb lengthening (more than 2.5 cm) without femoral shortening osteotomy. The amount of lengthening was measured from pre-operative and post-operative X-ray films using computer graphics software, then the ratios of the amount of lengthening to femoral length (L/F ratio = amount of lengthening / femoral shaft length × 100) were calculated. We investigated correlation with nerve and soft tissue complications at operation in regard to this index. RESULTS: The average amount of lengthening was 3.0 cm (2.5 to 4.8). The average L/F ratio was 7.9 (6.2 to 12.9). There were seven nerve complications and two soft tissue complications in the whole series. In all nine complications, eight indicated higher L/F ratios than 8.7. Altogether, 12 hips indicated a higher L/F ratio than 8.7; 66% of them showed neurological or soft tissue problems. ROC curve analysis indicated that the optimal cutoff value of the L/F ratio was 8.7, which predicted acute lengthening-related complications with a sensitivity of 88.9% and a specificity of 92.3% (AUC = 0.88). CONCLUSION: The patients who underwent THA with acute lengthening of more than 8.7% of femoral shaft length are at high risk of complications caused by acute limb lengthening in primary THA.

Prospective comparison of subtalar arthroereisis with lateral column lengthening for painful flatfeet.

We prospectively compared subtalar arthroereisis with lateral column calcaneal lengthening for the treatment of painful flatfeet. Twenty-four feet (mean age of patients 12.8 years) were treated. Kinematic motion analysis, pedobarometry, and radiography were performed, and the Oxford Ankle-Foot Questionnaire for Children was administered for each patient before surgery and at the 1-year follow-up. We found statistically significant improvements in both groups, with no difference in their outcomes. Both groups showed significantly improved hindfoot and midfoot motion and positioning. Hindfoot range of motion was preserved. Radiography and pedobarometry also revealed significant improvements. Subtalar arthroereisis is a valid and potentially less-invasive alternative to lateral column lengthening that merits further investigation.

Resultados de alargamiento tibial con la técnica de ilizarov

Entre enero de 1992 y junio de 1997, 21 tibias en 21 pacientes se alargaron usando la técnica de ilizarov. El seguimiento fue de 5 meses a 5 años. La etiología del acortamiento en el miembro fue adquirido en 12 tibias y congénitas en 9. 20 tibias tuvieron tratamiento unifocal y una bifocal. El promedio de alargamiento fue de 6.0 cm, con un rango de 4 a 12 cm, el cual fue equivalente al 22.6 por ciento del promedio total de aumento en la longitud del segmento afectado, rango de 8.8 por ciento a 41 por ciento. El tiempo de corticalización del alargamiento fue en promedio 7 meses, con un rango de 4 a 12 meses. Las complicaciones a nivel óseo requirieron 7 cirugías adicionales, incluyendo 4 recolocaciones de clavos, 2 correcciones de deformidad angular en antecurvatum medinate recolocación del fijador y una por articotomía incompleta. 5 pacientes presentaron contractura en flexión de rodilla, 3 se movilizaron bajo anestesia y a 2 se les realizó deflexión de rodilla. Los resultados de este trabajo confirman que no hay alargamiento sin riesgo, pero existen ventajas evidentes con el método ilizarov, apoyo precoz, corrección simultánea de deformidades angulares coexistentes, lo que es difícil con otras técnicas quirúrgicas. La tasa de alargamiento y el índice de alargamiento obtenido en esta serie confirman el uso continuo de una distracción gradual previa selección del paciente.

Methods of assessing new bone formation during limb lengthening. Ultrasonography, dual energy X-ray absorptiometry and radiography compared.

We studied the quantity and rate of formation of new bone during lengthening of 17 limb segments in 10 patients using dual-energy X-ray absorptiometry (DEXA), ultrasonography and radiography. Whereas new bone was detected by both DEXA and ultrasonography within 1 to 2 weeks of distraction, it was not visible on the radiographs until 4 to 8 weeks. Limb alignment and gap measurement were accurately assessed by DEXA without the need for standard radiographs or scanograms. With ultrasound the distraction gap appeared as an echolucent window which narrowed progressively producing a hyper-reflecting line after which further consolidation could not be assessed. As measured by DEXA the density of the new bone at this stage was approximately 45% of control values and did not represent normal cortication. Whereas ultrasound could be used to identify defects in mineralisation and to determine when to dynamise the fixator system, DEXA could measure the quantity and rate of formation of bone throughout lengthening.

Current concepts in the use of bone grafts in facial fractures. Basic science considerations.

In choosing the ideal donor site for bone replacement, attention must be given to the recipient site's revascularization potential and mechanical needs. Based on histologic differences in architecture as related to these two factors, the most appropriate graft type may be harvested. Future potential exists for bone replacement by distraction osteogenesis without the need for remote site harvesting. This may provide for the most identical bone replacement.

Limb-sparing surgery in skeletally immature patients with osteosarcoma. The use of an expandable prosthesis.

Limb-sparing surgery has a definite role in the treatment of osteosarcoma in children. Increased survival, however, raises problems of limb-length discrepancy and prosthetic longevity. The concept of an expandable adjustable prosthesis addresses the problem of leg-length discrepancy. The problem of prosthesis longevity will require further long-term evaluation of current designs and methods of fixation, as well as the development of a permanent prosthesis or biologic replacement. At skeletal maturity, the expandable prosthesis may either be maintained or substituted with another implant or biological alternative if warranted by the clinical situation.

IIB osteosarcoma. Current management, local control, and survival statistics--The Netherlands.

Guarded optimism is justified in light of the results of treatment of IIB osteosarcoma in the Netherlands. This is due to improvements in diagnostic imaging techniques, staging, adjuvant chemotherapy, and surgical treatment. Five-year survival rates have increased from 25% to 80%. En bloc resection is currently possible. This makes reconstructive procedure justified, both from an oncologic and orthopedic view. Many questions are still unanswered, concerning evaluation of tumor necrosis because of chemotherapy, optimal adjuvant therapy, functional evaluation of different types of reconstruction, and psychological development of the patient. An international gathering of data on the overall treatment of IIB osteosarcoma is advocated to find answers on the above-mentioned questions. A noninvasive adjustable-lengthening prosthesis is mentioned as a Dutch solution to leg-length discrepancy. This prosthesis can be used after limb-saving surgery in young children.

Neoadjuvant chemotherapy for nonmetastatic osteosarcoma of the extremities.

Between September 1986 and December 1988, 125 patients with osteosarcoma of the extremities entered the second neoadjuvant study at the authors' institution. Patients received preoperatively two cycles of methotrexate (MTX) intravenously, followed by cisplatinum (CDP) intraarterially, plus adriamycin (ADM) intravenously. After surgery, the patients classified as "good responders" (more than 90% tumor necrosis) received ADM, MTX, and CDP, while the "poor responders" (less than 90% tumor necrosis) had a longer chemotherapy that included ifosfamide and etoposide (VP-16) in addition to MTX, ADM, and CDP. Limb salvage was possible in 85% of patients, 8% had an amputation, and 7% had a rotationplasty. The surgical margins were adequate (radical or wide) in 88% of cases and inadequate (marginal or intralesional) in 12%. At an average follow-up period of 28 months (range, 13 to 41), 109 patients (87%) remained continuously disease free, 15 (12%) relapsed with pulmonary metastases, and one patient (0.8%) had a local recurrence. Compared with the first neoadjuvant study at the authors' institution that used only MTX and CDP preoperatively, the percentage of limb salvages, "good responders," and continuously disease-free survival at two years was significantly higher in the second Rizzoli neoadjuvant study (85%, 74%, and 87% versus 77%, 52%, and 59%). Systemic toxicity because of chemotherapy was superimposable. A retrospective analysis of the real dose intensity for each patient demonstrated a correlation between the intensity of chemotherapy and prognosis.

Osteomyelitis. The Ilizarov perspective.

It is evident that Professor Ilizarov has devised some remarkable strategies for dealing with chronic osteomyelitis. In summary, his methods include: Extensive debridement and intercalary bone transport. Oblique osteotomy through multiloculated cavitary osteomyelitis in intact bone. Elimination of large cavities by gradual displacement of one cortical wall. The role that these techniques will play in the future of osteomyelitis surgery remains to be determined by careful clinical and experimental research.

Contributing factors for osteogenesis in children's limb lengthening.

A progressive bone lengthening procedure according to the Wagner and Ilizarov technique and our own protocol was performed on 24 children (32 bones). Wagner's (transverse midshaft osteotomy, intraoperative lengthening of 1 cm and postoperative distraction of 1 mm/day) led to a marked reduction in osteogenic capacities. Patients operated on according to the Ilizarov technique had osteogenic reactions in the medullary cavity and on the posterior aspect of bone segments. Our own method, which included bone decortication, 5-7 days of neutral fixation without distraction, led to massive bone production in the medullary canal and around the bone segments. Rigid osseous bridging was present as early as 3 months after surgery. Neither the type of external fixator nor the location or shape of osteotomy had any specific influence on this massive bone reaction. Osteogenesis in limb lengthening is thus closely related to surgical management.

[Surgical treatment of congenital brachymetacarpus by dynamic elongation osteosynthesis. Report of a clinical case]. / Traitement chirurgical de la brachymétacarpie congénitale par ostéosynthèse dynamique d'élongation. Rapport sur un cas clinique.

Dynamic elongation osteosynthesis is a new technique studied and applied by us in the treatment of congenital brachymetacarpal deformity. The anatomical, functional and aesthetic results of this operation in a young woman were excellent. We used a microtractor according to Ilizarov's in order to achieve methodology 22 mm of lengthening of the fourth metacarpal bone of the left hand. All soft tissue structures were elongated such as arteries, veins, nerves, intrinsic muscles, flexor and extensor tendons without any adverse effects. We therefore recommend this technique for the treatment of this congenital disease.

Distractional hemi-epiphysiolysis of the wrist. Presentation of a case and the surgical method used.

It is the purpose of this study to illustrate the possibility of correcting angular deformities of the wrist during growth by means of asymmetrical epiphyseal distraction (distractional hemi-epiphysiolysis), using the Monticelli-Spinelli external fixator. The authors present and discuss some problems related to this method due to the rarity of its clinical application to the upper limb, and to the wrist in particular.