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.

The effect of eliminating leg length difference on plantar foot pressure distribution in patients wearing forefoot offloading shoe.

BACKGROUND AND PURPOSE: Elevated heel construction offloads the forefoot after surgery. However, side-to-side height difference alters limb kinetics, whereas leg-length equalizing-sole at non-operated side may have beneficial effects on foot loading. The purpose of this study was to characterize leg-length equalizing sole effect on bilateral plantar pressures when using heel-lift forefoot-offloading shoe. MATERIALS AND METHODS: Twenty men were tested walking. Plantar peak pressures (PP) and pressure-time integrals (PTI) in the forefoot-offloading shoe and in contralateral running shoe were compared between two conditions: one with- and the other without leg-length equalizing sole elevation at the running shoe. RESULTS: Adding leg-length equalizing sole to the running shoe resulted in the following changes in the forefoot-offloading shoe: increased lateral midfoot PP (8.7%, p=0.03), increased lateral midfoot (11.3%, p=0.05) and lateral metatarsals PTI (10.3%, p=0.04), and decreased medial and lateral heel PTI (>5%, p=0.02). These changes were non-significant when applying a Bonferroni correction. Changes in the running shoe were: increased medial midfoot (20.5%, p=0.03) and decreased 2nd and lateral metatarsals PP (23%, p<0.01). PTI increased in medial and lateral heel (>25%, p<0.01), medial midfoot (63.2%, p<0.01) and lateral midfoot (9.2%, p=0.04) and decreased in 2nd and lateral metatarsals (>24.5%, p<0.01). CONCLUSION: Leg-length equalizing sole at contralateral running shoe in subjects wearing forefoot-offloading shoe results in lateral load shift alongside heel pressure attenuation within the forefoot-offloading shoe, which is beneficial during first month after medial forefoot surgery. Reciprocal medial load-shift in the elevated running shoe itself should yet be considered when bilateral medial forefoot pathology is present.

Walking ability of children with a hexapod external ring fixator (TSF®) and foot plate mounting at the lower leg.

Wearing an external fixator for several months can be expected to profoundly affect the ability to walk, but, in principle, full weight-bearing is possible during corrective procedures with the Taylor Spatial Frame (TSF). The present prospective cohort study was conducted to assess whether patients are able to walk with or without crutches during treatment with a TSF on the lower leg. Twenty-four patients (10 girls, 14 boys; average age 11 years, range 6-17) scheduled for fixator surgery with osteotomies in the lower leg and foot mounting were included. Dynamic foot loading during free walking was measured with plantar pressure measurements. The contact area, contact time and contact pressure on the foot plate were recorded and normalized to body weight. In the first postoperative week, all patients needed crutches and 67% showed partial weight-bearing. At the second measurement, about 6 weeks after surgery, 21% of the patients could walk without crutches and 58% were partially weight-bearing with crutches. On the day before fixator removal, 50% of the patients were fully weight-bearing without crutches and 38% were partially weight-bearing, but 12% could not bear any weight or were unable to walk. When a ring fixator is used to correct lower leg deformity and prevent equinus, there is minimal risk of complete dependence and abasia. This study shows that up to 88% of the pediatric patients are able to walk while wearing the fixator. Already a few days after surgery, two-thirds of the patients were partially weight-bearing with crutches, and only 12% needed a wheelchair and were not able to walk with the fixator.

A comparison of two implant systems in restoration of hip geometry in arthroplasty.

BACKGROUND: Restoration of hip offset and leg length during THA is often limited by available implant geometries. The recent introduction of femoral components with a modular junction at the base of the neck (two modular junction components) has expanded the options to restore femoral offset and leg length. QUESTIONS/PURPOSES: We asked (1) whether a femoral component with two modular junctions would predict by templating more frequent restoration of preoperative offset and leg length abnormalities than one with single modular junctions; and (2) how our use of these options compared with national sales data. PATIENTS AND METHODS: We retrospectively reviewed the preoperative templating data in 100 primary THAs using single modular junction implants with only a neutral version stem and 100 THAs using two modular junction implants. We compared the frequency with which the desired leg length and offset were completely restored by preoperative templating in the two groups. RESULTS: Offset and leg lengths were restored to within 1 mm in 85% of cases with two modular junction implants and 60% of cases with single modular junction implants. An anteverted or a retroverted neck was used in 25% of cases with the two modular junction stems. The national sales data revealed femoral neck components with version were used in 28% of cases. CONCLUSIONS: The use of a femoral component with two modular junctions resulted in more frequent ability to restore femoral offset and leg length than a single modular junction. The advantage of clinical flexibility should be tempered by the potential concerns of prosthetic mechanical failure (which has been reported in another implant system with two modular junctions), increased third-body wear and corrosive debris, and increased prosthetic cost. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Fixator-assisted nailing and consecutive lengthening over an intramedullary nail for the correction of tibial deformity.

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed. The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60). One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation. We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.

Non-invasive extendible endoprostheses for limb reconstruction in skeletally-mature patients.

We describe the application of a non-invasive extendible endoprosthetic replacement in skeletally-mature patients undergoing revision for failed joint replacement with resultant limb-length inequality after malignant or non-malignant disease. This prosthesis was developed for tumour surgery in skeletally-immature patients but has now been adapted for use in revision procedures to reconstruct the joint or facilitate an arthrodesis, replace bony defects and allow limb length to be restored gradually in the post-operative period. We record the short-term results in nine patients who have had this procedure after multiple previous reconstructive operations. In six, the initial reconstruction had been performed with either allograft or endoprosthetic replacement for neoplastic disease and in three for non-neoplastic disease. The essential components of the prosthesis are a magnetic disc, a gearbox and a drive screw which allows painless lengthening of the prosthesis using the principle of electromagnetic induction. The mean age of the patients was 37 years (18 to 68) with a mean follow-up of 34 months (12 to 62). They had previously undergone a mean of six (2 to 14) open procedures on the affected limb before revision with the non-invasive extendible endoprosthesis. The mean length gained was 56 mm (19 to 107) requiring a mean of nine (3 to 20) lengthening episodes performed in the outpatient department. There was one case of recurrent infection after revision of a previously infected implant and one fracture of the prosthesis after a fall. No amputations were performed. Planned exchange of the prosthesis was required in three patients after attainment of the maximum lengthening capacity of the implant. There was no failure of the lengthening mechanism. The Mean Musculoskeletal Tumour Society rating score was 22 of 30 available points (18 to 28). The use of a non-invasive extendible endoprosthesis in this manner provided patients with good functional results and restoration of leg-length equality, without the need for multiple open lengthening procedures.

Rehabilitation after intramedullary skeletal kinetic distractor implantation: a report of two cases and a suggested therapy program.

Adult limb lengthening occurs via distraction osteogenesis and traditionally involves use of an external fixator. Complications after placement of hardware often disrupt rehabilitative efforts and hinder patients' progress. A completely internal limb-lengthening device has been developed and increasingly used, and it may more commonly be seen by a physiatrist in consultation for postoperative rehabilitation. We present two cases of patients who underwent implantation of the intramedullary skeletal kinetic distractor and required acute inpatient rehabilitation. One patient had previously suffered a malunion deformity with a resultant limb shortening, and the second patient was born with a congenital leg-length inequality. Both patients had successful femoral intramedullary skeletal kinetic distractor implantation and were transferred for acute inpatient rehabilitation. Distraction occurred daily, based on the patient's level of physical activity in therapy, and was measured using a hand-held monitor. Both patients were successfully discharged home, without complications throughout the hospital stay. Knowledge of the theory and mechanism of action of the device is important to guide both the amount and type of therapy prescribed and to follow patient progress. We present general guidelines during the acute rehabilitation of a patient after intramedullary skeletal kinetic distractor surgery.

Recovery of function after closed femoral shortening.

This prospective, longitudinal study documents the muscle strength and baseline function of 18 patients undergoing closed femoral shortening for discrepancy in limb length. Patients were studied for two years following surgery. Function was measured by a self-reported questionnaire, timed tests of performance and measurements of muscle strength and power. After two years, the self-reported function and ability to complete timed functional tests had returned to or improved on the pre-operative values. Muscle strength remained slightly below the pre-operative value and was more marked in the quadriceps than the hamstrings. This study suggests that small decreases in muscle strength and power following closed femoral shortening do not adversely affect the patients' ability to perform everyday activities.

Correction of shortening and/or angular deformities by distraction osteogenesis using AO-tubular fixator.

Eighteen patients (20 bony segments) who had shortening and/or angular deformities were treated by distraction osteogenesis using AO-tubular external fixator. The mean angular correction was 18.9 degrees (range, 8-40 degrees). Of the group in whom shortening and angulation was corrected, the mean length gained was 4.2 cm (3-6 cm). The mean treatment time was 4.9 months (range, 2-13 months) and the mean follow-up was 12 months after removal of the fixator (range, 3-30 months). Delayed union with loosening of the fixator occurred in one patient which resulted in residual shortening of 1.5 cm. The author's technique of distraction osteogenesis using AO-tubular fixator with the new distraction rate of 1 mm/48 h (1 mm/step) could adequately correct shortening and/or angular deformities. No extra equipment was needed other than the readily-available AO-tubular fixation systems. No serious complications such as neurovascular injury were encountered.

Percutaneous versus open epiphysiodesis.

OBJECTIVE: Epiphysiodesis is used for the treatment of leg-length discrepancy in skeletally immature patients. Phemister described an open technique that requires surgical dissection with potential morbidity. Recently, minimally invasive approaches that utilize intraoperative fluoroscopy have been introduced. The aim of this study is to compare our experience using the open and the minimally invasive percutaneous techniques. METHODS: A prospective follow-up of 87 consecutive patients undergoing epiphysiodesis for correction of post traumatic leg-length discrepancy using either the open or the percutaneous technique at the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia between January 1993 and December 2000. RESULTS: Out of the 87 patients, 52 were carried out using the open technique and 35 were utilized by this percutaneous technique. There was no statistically significant difference between the 2 groups in terms of demographic date, operative time, perioperative complications or time required to achieve the growth arrest. However, there was a significant difference in the hospital stay and postoperative need for physiotherapy. The percutaneous group had a shorter hospitalization (average 2.5 days) compared to the open technique group (average 4 days). CONCLUSION: Our experience is similar to what is reported in the literature and confirms that the percutaneous technique has an advantage over the open technique with shorter hospitalization and less duration of physiotherapy.

Leg lengthening by the Ilizarov technique for patients with sequelae of poliomyelitis.

Limb length discrepancy is common in patients with sequelae of poliomyelitis. However, treatment of this problem is difficult and complicated. From 1988 to 1993, 71 patients with sequelae of poliomyelitis were treated with leg lengthening by modifications of the Ilizarov technique. Their median age at surgery was 26.4 years (range, 11.6-38.1 yr). Patients were divided into four groups according to the method of treatment, with femoral lengthening in 18 patients, combined femoral and tibial lengthening in 6, tibial lengthening in 35, and tibial lengthening along and intramedullary locking nail in 12. At follow-up of 2 to 6.7 years, the combined femoral/tibial group had the greatest gain in length. Treatment time in the Ilizarov device was shortest in the tibial lengthening with locking nail group. The lengthening index, which was defined as days in the Ilizarov device required for each centimeter of lengthening (days/cm), was lowest in the tibial lengthening with locking nail group, followed by the combined femoral/tibial lengthening group. Complications such as soft tissue contracture, callus fracture and residual deformities were most common in the combined femoral/tibial lengthening group and the femoral lengthening group. Complications were least common in the tibial lengthening with locking nail group. The satisfaction rate was highest in the tibial lengthening with locking nail group. We found that in leg lengthening for patients with sequelae of poliomyelitis, callus maturation was slow, and patients tended to develop contractures despite physiotherapy, bracing or joint fixation. Concomitant and secondary surgery were frequently required to treat associated problems or residual deformities. Lengthening along an intramedullary locking nail can significantly shorten the treatment time with relatively few complications.

Alargamiento óseo con el fijador del Dr. Espinosa. Experiencia de 5 años en el Instituto Nacional de Pediatría / Bone lenghtening by Espinosa external fixator. Experience of 5 years of National Institute of Pediatrics

Objetivo: Determinar el porcentaje del alargamiento óseo en pacientes con discrepancia de miembros pélvicos, con respecto al miembro contralateral, al terminar el tratamiento con el fijador del Dr. Espinosa. Estudio retrospectivo, descriptivo, longitudinal y observacional. Departamento de Ortopedia Pediátrica del Instituto Nacional de pediatría, del primero de julio de 1995 al 24 de febrero de 1996. Se seleccionaron los expedientes clínicos y radiológicos de los pacientes elongados por discrepancia de miembros inferiores con el fijadro de Epinosa, en el lapso citado, que fueron intervenidos quirúrgicamente en el Instituto. En dichos pacientes se investigó: edad, discrepancia con respecto al miembro contralateral, lapso transcurrido, consolidación obtenida y complicaciones. Doce pacientes cumplieron con los criterios de selección del estudio. Su edad promedio fue de once años y medio, con una desviación estándar (ñ DE) de dos años 7 meses, La discrepancia observada fue de 7.07 (ñ 2.33) cm. Los pacientes estuvieron 9 meses y medio (ñ 2 meses) en tratamiento y se obtuvo el 96.4 por ciento (ñ 4.6) del alargamiento deseado. En 7 casos no hubo complicaciones. Se presentó pie equino en 3 pacientes; en otro caso pseudoartrosis y mala alineación en otro. Los pacientes en los que permaneció más tiempo el fijador, estaban en una percentila menor de talla. Sin embargo, en todos los pacientes se logró una adecuada consolidación

Dismetría de los miembros inferiores como causa de lumbalgia / Lower limb unequality as a cause of low back pain

Se estudian 500 pacientes que presentan lumbalgia crónica de más de cuatro meses de evolución de los cuales pacientes 298 fueron hombres (59.6 por ciento) y 202 mujeres (40.4 por ciento); la edad varió de 15 a 75 años como promedio 30 años; se excluyeron a los que a su ingreso presentaban radiculopatía. Talla 1.60 m. El rango de normalidad de la dismetría varió de 4-24 mm. Se encontró en 394 pacientes (79 por ciento) y la izquierda 106 pacientes (21 por ciento). En todos los pacientes se les realizó proyecciones radiológicas anteroposterior y lateral de columna lumbosacra de pie y descalzo en placas de 14 x 17 pulg. y una escanometría para efectuar la medición de la dismetría. Radiológicamente en todos predominaba el basculamiento pélvico y una escoliosis no mayor a los ocho grados. A todos los pacientes con dismetría mayor de 4 mm, se les indicó tratamiento conservador a base de analgésicos, antinflamatorios, medidas higienico-dietéticas, y la corrección de la dismetría por medio de una talonera que equilibrara el acortamiento, (menos 4mm) y posteriormente con aplicación de ejercicios para la reeducación muscular, se integraron a sus actividades cotidianas, el seguimiento de los pacientes es de seis a 18 meses de evolución, siendo cada vez más satisfactoria la misma. Unicamente el 5 por ciento de los pacientes evolucionaron mal cuando se agregó otra patología extra-articular

Custom shoe therapy. Current concepts, designs, and special considerations.

Custom orthopedic shoes represent the ultimate combination of function and aesthetics. Incorporating biomechanics and craftsmanship, shoes can redistribute weight, restrict joint motion, facilitate ambulation, and decrease the probability of neuropathic ulceration. Despite these advantages, many podiatrists know little about shoe therapy and consequently underuse it. This article describes the various types of therapeutic shoe modalities available and presents a systematic method of their application. Some of the latest developments in technology and health care reform also are revealed.

Tratamiento de la discrepancia de las extremidades inferiores con clavo Colchero y distractor de Wagner. Técnica SSEIDO / Treatment of lower limbs inequality by lengthening of the short limb with Colchero intramedullary rod and external Wagner distractor. SSEIDO Technique

Se presenta un estudio prospectivo con una nueva técnica de alargamiento de fémur y tibia, la cual consiste en la combinación de clavo Colchero y distracción de Wagner, corticotomía y tenotomías percutáneas en aductores, recto anterior, sartorio y fascia lata en fémur y sobre el tendón de Aquiles en tibia con una distracción progresiva y controlada a razón de 1 mm por día; al término del alargamiento se estabiliza el clavo Colchero y se inicia una rehabilitación enérgica con apoyo total de la extremidad alargada. Se muestra la evolución de la técnica hasta la actual. Se trataron 20 pacientes obteniéndose alargamientos de 3.8 a 12.4 cm, con promedio de 6.3 cm. Siete tibias y trece fémures. A los primeros 10 pacientes se les colocó injerto óseo; pero en los siguientes no se les colocó éste, obteniendo hueso neoformado y consolidación en promedio a las 12.7 semanas. Sólo en un enfermo no se obtuvo consolidación, requiriendo aplicación del injerto óseo. Se concluye que el fresado medular no afecta la formación del hueso neoformado, y que el periostio es el único elemento indispensable para la neoformación en la distracción progresiva y controlada (1 mm en 24 h). Al retirar el distractor de Wagner y estabilizar el clavo Colchero se evita tener un dispositivo externo por largo tiempo, molesto para el paciente y poco estético, asegurándose la marcha con el apoyo de la extremidad alargada en forma inmediata y su consolidación.

CT scanography for limb length determination.

The authors present an alternative to classic techniques used to measure limb length discrepancy radiographically. CT scanography seems to have advantages over currently-used Bell-Thompson roentgenography in that it uses less radiation and is of no increase in cost.

The influence on the spine of leg-length discrepancy after femoral fracture.

We investigated the spines of 15 patients who had significant leg-length inequality as a result of femoral shaft fractures sustained after skeletal maturity but below the age of 21 years. The patients were examined at least 10 years after fracture. The spines were studied clinically and radiographically before and after correction of leg-length inequality with a shoe-raise. Lateral spinal flexion was measured from radiographs. The lumbar scoliosis associated with the leg-length inequality was compensatory: after equalisation of leg-length the overall curve and the axial rotation were corrected completely. There was also an equal range of lateral flexion to either side after correction. Minor malalignments of the whole spine remained despite correction of the compensatory scoliosis, and within the lumbar spine correction of the scoliosis had not occurred equally at all levels. No patients complained of significant discomfort and neither structural abnormalities nor degenerative changes were seen on the radiographs.