Ulnar lengthening for children with forearm deformity from hereditary multiple exostoses: a retrospective study from a tertiary medical center.

BACKGROUND: Patients with hereditary multiple exostosis (HME) usually present with forearm deformity with or without radial head dislocation. Ulna lengthening has been proposed to address this condition. Exostosis resection plus ulna lengthening has been adopted in our hospital since 2008, and patients with this condition were retrospectively reviewed. Herein, we aimed to investigate the optimal timing and clinical outcomes of this surgical approach. METHODS: In all, thirty-five patients (40 forearms), including 22 boys and 13 girls, were enrolled in our study from July 2014 to September 2020. We divided the patients into 4 groups based on the age when they received surgery and the status of the radial head. Pronation and supination of the forearm, flexion and extension of the elbow, wrist ulnar deviation and wrist radial deviation, and radiological parameters including ulnar length (UL), ulnar variance (UV), the percentage of radial bowing (RB/RL), radio articular angle (RAA) and carpal slip (CS), were assessed and recorded. RESULTS: The mean UL was significantly improved after surgery in four Groups (P<0.05). In patients with radial head dislocation, we found significant improvement in forearm, wrist function and elbow flexion (p < 0.05). For the patients with radial head dislocation, the juniors demonstrated better improvement in % RB and RAA (p<0.05, p = 0.003 and 0.031). CONCLUSION: Exostosis resection and ulna lengthening with unilateral external fixation can effectively improve the function and radiological parameters of forearm deformity in HME children. For patients with radial head dislocation, early surgery can achieve better results. For patients not associated with radial head dislocation, we recommend regular follow-up and surgical treatment after 10 years of age.

A systematic review and meta-analysis:comparing the efficacy of the Ilizarov technique alone with lengthening over a nail for lower extremity bone defects.

PURPOSE: The task faced by surgeons becomes significantly more challenging when they encounter lower extremity bone defects due to a variety of causes requiring lengthening. The most discussed and successful approach is the Illizarov technique, or lengthening over a nail (LON):distraction osteogenesis is also widely performed with monoliteral external fixators and intramedullarylengthening nails have increasingly been used in the last decade. METHODS: The data were collected from PubMed, Cochrane Library, Embase, and the Web of Science for all available studies comparing the outcomes of Ilizarov technique alone and LON technique (from January 1, 1997, to November 30, 2023). The outcomes of interest encompassed the external fixation index (EFI) (month/cm), mean duration of follow-up (MFT) (month), length gained (LG) (cm), consolidation index (CIx) (month/cm), and bone healing index (BHI) (month/cm).Complications include pin tract infection rate (PTI), axial deviation rate (AD), occurrence of intramedullary infection (II), delayed consolidation rate (DC), as well as data categorized into three levels of problems, obstacles, and sequelae based on the severity of complications.Two reviewers independently assessed each study for quality and extracted data. The case-control or respective cohort studies were evaluated using the Newcastle-Ottawa scale (NOS) to determine their techniqueological rigor.The Cochrane Collaboration's risk assessment tool was employed to perform quality evaluations for randomized controlled trials. RESULTS: This review included thirteen studies comprising a total of 629 patients.The external fixation index (month/cm) was significantly smaller in the LON technique compared to the Ilizarov technique alone [Mean Difference(MD) = -29.59, 95% CI -39.68--19.49, P < 0.00001].In terms of the mean follow-up time(month) (MD = -0.92, 95% CI -3.49-1.65, P = 0.57), length gained (cm) (MD = -0.87, 95%CI -2.80-1.07, P = 0.38), consolidation index (month/cm) (MD = 0.66, 95% CI -3.44-4.77, P = 0.75), and bone healing index (month/cm) (MD = -3.33, 95% CI -13.07-6.41, P = 0.5), there were no significant differences observed. The LON technique exhibited a lower incidence of axial deviation [Odds Ratio(OR) = 0.06, 95%CI 0.03-0.16, P < 0.00001] and pin tract infection (OR = 0.30, 95%CI 0.18-0.50, P < 0.00001) compared to the Ilizarov technique alone.The remaining complications, such as intramedullary infection rate (OR = 0.93, 95%CI 0.42-2.06, P = 0.85) and delayed consolidation rate(OR = 0.61, 95%CI 0.20-1.86, P = 0.38), did not exhibit statistically significant differences.Our findings demonstrated that the LON technique results in lower incidences of problems (38.5%vs.58.6%) and sequelae (16.6% vs.30.9%) when compared to the Ilizarov technique alone. However, the rates of obstacles (32.4% vs.32.3%) were comparable between the two methods. CONCLUSIONS: Our findings indicate that patients treated with the LON technique experienced significantly shorter external fixation durations and a lower incidence of complications (e.g., pin tract infections and axial deviation) compared to those treated with the Ilizarov technique alone. Other outcome metrics showed no significant differences between the two techniques. However, the LON technique offers substantial benefits, including reduced external fixation times and increased comfort, which enhance patient compliance. In conclusion, the LON technique is a safe, reliable, and effective method for treating tibial and femoral defects.

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.

Prophylactic Intramedullary Rodding After Femoral Lengthening in Patients With Achondroplasia and Hypochondroplasia.

BACKGROUND: Femoral fracture after femoral lengthening in patients with achondroplasia and hypochondroplasia is a frequent complication, occurring in up to 30%. The purpose of this study is to demonstrate the effectiveness of prophylactic intramedullary rodding in preventing this complication. METHODS: Multicenter retrospective study involving 86 femoral lengthening procedures in 43 patients with achondroplasia or hypochondroplasia. Forty-two femora (21 patients) were prophylactically managed with intramedullary Rush rodding after external fixation removal (11 females and 10 males, mean age 14.6 years) compared with 44 femora (22 patients) without prophylactic intramedullary rodding (13 females and 9 males, mean age 15.2 years). The mean amount of lengthening in the rodding group was 13.3 cm (52.6%) with an External Fixation Index of 25.8 days/cm; in patients without rodding was 14.3 cm (61.5%) and 24.5 days/cm, respectively. RESULTS: Seven cases (15.9%) without rodding developed fractures. Four of them required surgical correction due to displacement or shortening. Only 1 patient (2.4%) had fracture of the femur after prophylactic rodding, and surgery was not required. The incidence of femur fracture was significantly lower in the prophylactic rodding group compared with the nonrodding group (2.4% vs. 15.9%, respectively; P =0.034). There were no cases of infection or avascular necrosis. CONCLUSIONS: Prophylactic intramedullary rodding is a safe and effective method for preventing femoral fractures after femoral lengthening in patients with achondroplasia or hypochondroplasia. LEVEL OF EVIDENCE: Level III-a retrospective comparative study.

Characterizing the Magnitude and Risk Factors of Functional and Anatomic Limb Lengthening in Patients Undergoing Revision Total Knee Arthroplasty.

BACKGROUND: In revision total knee arthroplasty (TKA), there is little information on the magnitude of potential limb lengthening, risk factors for lengthening, or its impact on patient-reported outcome measures. We aimed to quantify limb length alteration during revision TKA and assess risk factors for lengthening. METHODS: We identified 150 patients over a 3-year period who underwent revision TKA and had preoperative and postoperative EOS hip-to-ankle standing radiographs. The average patient age was 64 years, 51% were women; 68% had a preoperative varus deformity and 21% had a preoperative valgus deformity. Outcomes assessed included change in functional and anatomic limb length, risk factors for lengthening, and clinical outcome scores, including the Knee Osteoarthritis Outcome Score Joint Replacement, and the Veterans RAND 12-item Physical and Mental Scores. RESULTS: There were 124 patients (83%) who had functional limb lengthening, and 108 patients (72%) had anatomic limb lengthening. Patients had an average functional limb lengthening of 7 mm (range, -22 to 35) and an average anatomic limb lengthening of 5 mm (range, -16 to 31). Patients undergoing revision for instability experienced significantly greater anatomic lengthening (7.6 versus 4.6, P = .047). Patients who had ≥ 10° of deformity were more likely to be functionally lengthened (91 versus 79%) and had significantly greater average functional lengthening (12 versus 6 mm; P = .003). There was no significant change in clinical outcome scores at 6 weeks and 1 year for patients lengthened ≥ 5 or 10 mm compared to those not lengthened as substantially. CONCLUSIONS: There is major potential for functional and anatomic limb lengthening following revision TKA, with greater preoperative deformity and revision for instability being risk factors for lengthening.

Preliminary Results of Calcaneal Lengthening Osteotomy Combined With Extra-articular Subtalar Arthrodesis for Severe Pes Planovalgus Deformity in Children With Cerebral Palsy: A New Surgical Technique.

OBJECTIVE: Pes planovalgus is the most common foot deformity seen in patients with cerebral palsy (CP). There are several different treatment modalities to treat this condition. Single or double calcaneal osteotomies, extra-articular arthrodesis, calcaneo-cuboido-cuneiform osteotomy, intraarticular arthrodesis, and arthroereisis are some of these modalities. Currently, there is insufficient information to determine the most effective treatment approach for pes planovalgus in children with CP. The aim of this study is to show the short to mid-term results of the new technique which combines calcaneus lengthening osteotomy, extra-articular subtalar arthrodesis, and soft tissue reconstruction that aims to decrease recurrence and complication rates of pes planovalgus surgery for patients with ambulatory CP. METHODS: Patients with CP who were treated with calcaneal lengthening surgery and extra-articular subtalar arthrodesis between 2018 and 2021 were investigated retrospectively. All patients were ambulatory and Gross Motor Function Classification System I-II-III. Functional levels of the patients were assessed with the American Orthopaedic Foot and Ankle Society, Ankle-Hindfoot Score, and the Foot and Ankle Ability Score (Foot and Ankle Ability Measure) in preoperative and postoperative periods. On anteroposterior x-rays, talus-first metatarsal, talocalcaneal, talonavicular coverage angle and on lateral x-rays talus-first metatarsal, talocalcaneal, calcaneal inclination angle and talar tilt angle were evaluated. RESULTS: The mean follow-up was 46 (range: 36 to 60) months. The mean American Orthopaedic Foot and Ankle Society increased from 41 (20 to 79) to 74 (38 to 93; P < 0.001). The mean Foot and Ankle Ability Measure increased significantly from 35 (7 to 73) to 54 (29 to 96; P <0.001). Clinical results were "satisfactory" for 32 feet, while they were "unsatisfactory" for 2 feet. Significant deformity correction was observed in all radiologic parameters. CONCLUSION: Our technique is found to be efficient for patients with Gross Motor Function Classification System I-II-III CP with pes planovalgus deformity. In short to mid-term follow-up, the technique achieved successful clinical and radiologic results with low complication rates. Superiority of this technique compared with the traditional ones can only be shown with randomized prospective studies. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

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.

Is posterior vertebral arthrodesis at the end of the electromagnetic rod lengthening program necessary for all patients? Comparative analysis of sixty six patients who underwent definitive spinal arthrodesis and twenty four patients with in situ lengthening rods.

PURPOSE: Magnetically controlled growing rods (MCGR) should be removed or changed at most two years after their implantation in the treatment of patients with early-onset scoliosis (EOS) (Safety notice July 2021). However, in the face of patients at high risk of intraoperative complications and relying on the principle of auto-fusion of the spine, some surgeons would prefer a more wait-and-see attitude. The aim of this study was to report on patients who did not undergo final fusion at the end of the lengthening program with MCGR and to compare them with those who did. METHODS: This was a multicenter study with ten centres. We collected all graduate patients with EOS who had received MCGR between 2011 and 2022. RESULTS: A total of 66 patients had final fusion at the end of the lengthening program and 24 patients kept MCGRs in situ. The mean total follow-up time was 66 months (range, 25.3-109), and the mean follow-up time after final lengthening was 24.9 months (range, 3-67.7). Regarding the main curve and thoracic height, there was no significant difference in the percentage of correction over the whole follow-up between the two groups (p = 0.099, p = 0.176) although there was a significant difference between the end of lengthening and the last follow-up (p < 0.001). After completion of the lengthening program, 18 patients who had final fusion developed 24 of the 26 recorded complications (92.3%). CONCLUSION: Contrary to the manufacturer's published safety notice, not all patients systematically benefited from the removal of the MCGRs. Although arthrodesis significantly improved the scoliotic deformity, no significant difference was found in terms of radiographic outcome between patients who underwent spinal fusion and those who kept the MCGRs in situ.

Fibular hemimelia: reconstruction of difficult cases with tibial lengthening and ankle arthrodesis.

PURPOSE: Management of fibular hemimelia includes either prosthetic care with or without a suitable amputation or tibial lengthening. Many studies have documented the success of both procedures. Most parents of these children refuse an amputation or have no access to good prosthetic care. The author presents a limb-salvage procedure with tibial lengthening and ankle stabilization. METHODS: Twelve children of fibular hemimelia with 14 extremities had been subjected to limb lengthening after lateral leg release. To correct the valgus procurvatum, double oblique diaphyseal osteotomy (DODO) of the tibia was performed in 11 extremities. The age of the patients ranged from two to 15 years with the median of five years. All were male. The proposed procedure included three stages of loosening, lengthening, and stabilization with ankle arthrodesis at a later stage. RESULTS: All patients returned for follow-up for the first four years and had been walking on their sensate feet. With DODO followed by fixator/traction could straighten and lengthen the tibia simultaneously and correct the valgus procurvatum. Ankle stabilization provided stability and a plantigrade foot. A follow-up of six to 30 years with a median of ten years has been reported. CONCLUSION: A new procedure of loosening, lengthening, and stabilization of the leg with ankle arthrodesis has been proposed. A follow-up of 30 years with a median of ten years of the said procedure has been reported. The procedure provides a long-lasting plantigrade and painless foot that has sensation and proprioception. An amputation at any level has not been recommended.

Clinical compatibility of magnetic resonance imaging with magnetic intramedullary nails: a feasibility study.

INTRODUCTION: The use of magnetic resonance imaging (MRI) with a magnetic intramedullary lengthening nail in place is contraindicated per the manufacturer due to the concern of implant activation and migration. A prior in vitro study did not confirm these complications only noting that a 3.0 T MRI weakened the internal magnet. Therefore, a retrospective analysis of patients who underwent an MRI with a magnetic nail in place was performed to determine if any adverse effects occurred in the clinical setting. MATERIALS AND METHODS: A retrospective review of all patients who underwent an MRI with a magnetic lengthening nail in place was performed. The time spent being imaged in the MRI, number of times the patient entered the MRI suite, and the images obtained were recorded. Radiographs were performed before and after the MRI to determine if any hardware complications occurred. The patients were monitored for any adverse symptoms while they were in the suite. RESULTS: A total of 12 patients with 13 nails were identified. Two patients underwent imaging with a 3.0 T MRI while the remaining 10 underwent imaging with a 1.5 T MRI. Each patient entered the MRI suite 2.1 times and spent an average of 84.7 min being imaged in the MRI (range 21-494). No patients noted any adverse symptoms related to the nail while in the suite and no hardware complications were identified. CONCLUSION: MRI appears to be safe with a magnetic nail in place and did not result in any complications. Given the manufacturer's recommendations, informed consent should be obtained prior to an MRI being performed and a 3.0 T MRI should be avoided when possible if further activation of the nail is required.

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.

Evaluation of simultaneous bilateral femoral distraction osteogenesis with antegrade intramedullary lengthening nails in achondroplasia with rhizomelic short stature: a retrospective study of 15 patients with a minimum follow-up of 2 years.

BACKGROUND AND PURPOSE: Bilateral femoral distraction osteogenesis in patients with achondroplasia is insufficiently reported. We aimed to perform the first study that exclusively analyzed simultaneous bilateral femoral distraction osteogenesis with motorized intramedullary lengthening nails via an antegrade approach in patients with achondroplasia focused on reliability, accuracy, precision, and the evolving complications. PATIENTS AND METHODS: In this retrospective singlecenter study we analyzed patients with achondroplasia who underwent simultaneous bilateral femoral lengthening with antegrade intramedullary lengthening nails between October 2014 and April 2019. 15 patients (30 femoral segments) of median age 14 years (interquartile range [IQR] 12-15) were available for analysis. The median follow-up was 29 months (IQR 27-37) after nail implantation. RESULTS: The median distraction length per segment was 49 mm (IQR 47-51) with a median distraction index of 1.0 mm/day (IQR 0.9-1.0), and a median consolidation index of 20 days/cm (IQR 17-23). Reliability of the lengthening nails was 97% and their calculated accuracy and precision were 96% and 95%, respectively. The most common complication was temporary restriction of knee range of motion during distraction in 10 of 30 of the lengthened segments. 1 patient was treated with 2 unplanned additional surgeries due to premature consolidation. CONCLUSION: The method is reliable and accurate with few complications.

A modified lateral column lengthening for the treatment of flexible flatfoot: From clinical applications to finite element analysis.

BACKGROUND: Finite element (FE) analysis and clinical follow-up were used to evaluate the efficacy of a modified lateral column lengthening (H-LCL) for treating flexible flatfoot. METHODS: By applying inclusion and exclusion criteria, we selected patients who underwent H-LCL surgery at our institution from January 2019 to January 2023. We compared the Visual Analog Scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, Pain Interference (PI), and Physical Function (PF) scores in Patient-Reported Outcomes Measurement Information System (PROMIS) between preoperative and final follow-up assessments of patients, as well as FE submodels. Furthermore, evaluate the H-LCL's biomechanical characteristics and clinical outcome before and after surgery. RESULTS: A total of 66 patients met the criteria. The average surgery time was 69.47 ± 13.22 min, and the follow-up duration was 15.18 ± 6.40 months. In the last follow-up, VAS and PI decreased compared to before surgery, while AOFAS and PF increased compared to before surgery. Meary's angle (dorsoplantar image and lateral image), calcaneal valgus angle, and talonavicular coverage angle decreased compared to before surgery, while the pitch angle increased compared to before surgery. In FE analysis, postoperative tension on the plantar fascia (PF), spring ligament (SL), and posterior tibial tendon (PTT) decreased compared to before surgery, pressure on the talonavicular joint and subtalar joints also decreased compared to before surgery, and there was no significant change in pressure on the calcaneocuboid joint. CONCLUSION: H-LCL in correcting flexible flatfoot resulted in a significant improvement of clinical outcome scores and led to good radiological correction of flatfoot deformities. It can reduce the soft tissue and interosseous pressure in maintaining the foot arch.

Metatarsal lengthening by distraction osteogenesis for brachymetatarsia in paediatric patients: is it safe and effective?

PURPOSE: The primary aim is to assess the efficacy of the surgical callus distraction technique of the metatarsus in paediatric patients. Secondary objectives are to assess complications and treatment duration. We have also described the details of our surgical technique. MATERIALS AND METHODS: A case series review of paediatric patients who had metatarsal lengthening at our unit between 2014 and 2022. Patient demographics, duration of time in frame, complications and metatarsal length achieved were recorded. The AOFAS Midfoot and the MOXFQ were taken pre-operatively and at final follow-up. RESULTS: Sixteen metatarsals in 8 patients (14 feet) underwent lengthening between 2014 and 2022 using the MiniRail OrthoFix 100 (Orthofix Medical Inc, Lewisville, TX, USA). The mean age was 13.3 (12-17) years. The average duration between surgery and implant removal was 5.2 months. According to Paley's classification, there was one obstacle encountered in a patient who required a revision of their osteotomy and one problem in another patient who had an infected metatarsophalangeal joint stabilising k-wire treated with oral antibiotics. The Mean AOFAS Midfoot score improved from 53.10 to 86.40 (p < 0.0001) and the Mean MOXFQ improved from 32.5000 to 12.1250 (p < 0.05); these were statistically significant. CONCLUSION: Gradual metatarsal lengthening using the MiniRail external fixator is a safe and effective method to treat brachymetatarsia in paediatric patients. This preliminary report describes and supports metatarsal lengthening in appropriate patients. Holistic care in terms of a pre-operative assessment, psychological support and preparation for the extended rehabilitation period are vital.

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.

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.

Outcomes of Limb Lengthening With Computer-assisted Hexapod External Fixators in the Treatment of Fibular Hemimelia.

BACKGROUND: Fibular hemimelia (FH) represents the most common deficiency of the long bones and is associated with multiple deformities. Reconstructive treatment with external fixators in FH restores normal lower extremity alignment and length with plantigrade feet for a balanced and effective gait. The aim of this study is to evaluate the outcomes of lower limb lengthening and simultaneous tri-plane deformity correction with a computer-assisted hexagonal external fixator in children with FH. METHODS: A retrospective review was performed for FH cases treated with a computer-assisted hexagonal external fixator in a tertiary referral center. Leg length discrepancy (LLD), interphyseal angles, tibiocalcaneal distances, healing index (HI), and callus shapes were analyzed for radiologic evaluation, and the Pediatric Quality of Life Inventory (PedsQL) was used for functional assessment. Limbs with HI <50 days/cm, PedsQL >75, and without regenerate fractures were considered successful lengthenings. RESULTS: Twenty-four limbs of 23 patients were included. The limbs were lengthened for a mean of 7.24 cm (range, 4.7 to 15.6). The initial LLD of 5.6 cm (range, 0.5 to 19 cm) increased to 1.7 cm (range, 0.1 to 6 cm), and the mean interphyseal angle was 12.7 degree (range, 1.5 to 54.2 degree), tibiocalcaneal distance was 0.85 cm (range, 0.1 to 1.7) at final follow-up. The most common regenerated bone morphology was cylindrical, as seen in 11 limbs (45.8%). The average PedsQL score was 83.5 (range, 69.5 to 96.7). Sixteen limbs (66.7%) had successful lengthening at their first, and 4 limbs (80%) had successful lengthening at their second surgeries. Seven limbs had complications requiring surgical intervention (29.1%), with 3 (12.5%) regenerate fractures after external fixators removal. CONCLUSIONS: Limb reconstruction with computer-assisted hexapod fixators is a successful and reliable option for the treatment of LLD in FH, and patients demonstrate good functional outcomes. Surgeons should be aware of potential complications and should utilize prophylactic measures when necessary. LEVELS OF EVIDENCE: Level III, retrospective comparative study.

Botulinum toxin type A for lower limb lengthening and deformity correction: A systematic review and meta-analysis.

BACKGROUND: Botulinum toxin type A (BTX-A) is the most popular therapeutic agent for muscle relaxation and pain control. Lately, BTX-A injection received great interest as a part of multimodal pain management for lower limb lengthening and deformity correction. This systematic review aimed to determine the role of BTX-A injection in pain management for during lower limb lengthening and/or deformity correction. METHODS: We searched Medline, Embase, and CENTRAL. We included randomized controlled trials (RCTs) that compared the BTX-A injection to placebo for individuals undergoing lower limb lengthening and/or deformity correction. We sought to evaluate the following outcomes: pain on visual analogue scale (VAS), range of motion parameters, average opioid consumption, and adverse events. The standardized mean difference (SMD) was used to represent continuous outcomes while risk ratio (RR) was used to represent dichotomous outcomes. RESULTS: A total of 4 RCTs that enrolled 257 participants (337 limbs) deemed eligible. Adjuvant BTX-A injection showed a significant reduction in post-operative pain compared to placebo (SMD = -0.28, 95% CI -0.53 to -0.04). No difference was found between BTX-A injection and placebo in terms of range of motion parameters, average opioid consumption, or adverse events after surgical limb lengthening and/or deformity correction (RR = 0.77, 95% CI -0.58 to 1.03). CONCLUSIONS: Adjuvant BTX-A injection conferred a discernible reduction in post-operative pain during surgical limb lengthening and/or deformity without increasing the risk of adverse events. PROSPERO REGISTRATION NUMBER: CRD42021271580.

Long-term effects of retrograde approach on the knee after motorized femoral limb lengthening.

BACKGROUND AND PURPOSE: The retrograde femoral approach is an established technique for implantation of nails for leg lengthening and correction and in cases of distal femoral fractures. The purpose of this study was to determine the 10-year outcome of this technique by analyzing the clinical long-term effects and radiological status of the knee after leg lengthening via a retrograde femoral approach. PATIENTS AND METHODS: This retrospective single-center study included 13 patients (median age at surgery 17 [range 15-20] years) who underwent unilateral, retrograde, femoral lengthening with a motorized nail. Outcome measurements were graded variables of the SF-36, ISKD score, and Lysholm score. MRI of both knees was performed in all patients. MRI was evaluated for the presence of degenerative changes and compared with the healthy contralateral knee. Cartilage condition was graded according to the International Cartilage Repair Society (ICRS) scoring system. RESULTS: All patients were pain-free and had a full range of motion 10 (range 10.0-12.2) years after surgery. All postoperative knees showed fibrosis of Hoffa's fat pad and moderate to severe cartilage defects (ICRS Grade 2-4) of the trochlear groove (nail entry site). 6 out of 13 operated knees exhibited retropatellar cartilage defects. CONCLUSION: Our study showed that patients were pain-free, but cartilage defects at the entry point and arthrofibrosis at Hoffa's fat pad were observed without causing clinical impairment.

Complications and risk factors of intramedullary bone lengthening nails: a retrospective multicenter cohort study of 314 FITBONE and PRECICE nails.

BACKGROUND AND PURPOSE: Intramedullary bone-lengthening nails have become increasingly popular. The 2 most used and successful nails are the FITBONE and the PRECICE nails. Uniform reporting is lacking on complications of intramedullary bone-lengthening nails. The purpose was therefore to assess and categorize the complications of lower limb bone-lengthening nails and investigate risk factors. PATIENTS AND METHODS: We performed a retrospective review of patients operated on with intramedullary lengthening nails at 2 hospitals. We included only lower limb lengthening with FITBONE and PRECICE nails. Recorded patient data was patient demographics, nail information, and any complication. Complications were graded according to severity and origin classification. Complication risk factors were assessed with modified Poisson regression. RESULTS: 314 segments in 257 patients were included. The FITBONE nail was predominantly used (75%), and most of the lengthenings were performed in the femur (80%). 53% of the patients had complications. 269 complications were identified in 175 segments (144 patients). Device-related complications were most frequent (0.3 complications/segment), followed by joint complications (0.2 complications/segment). An increased relative risk was found for complications in the tibia compared with the femur and for age groups above 30 years compared with the 10-19 years group. CONCLUSION: Complications with intramedullary bone lengthening nails were more frequent than has previously been reported, with 53% of patients sustaining a complication. Future studies need to document the complications meticulously so that the true risk can be established.