Evolution of orthopaedic diseases through four thousand three hundred years: from ancient Egypt with virtual examinations of mummies to the twenty-first century.

PURPOSE: This study conducts a comprehensive comparative analysis of bone pathologies between ancient Egypt and today. We aim to elucidate the prevalence, types, and potential aetiological factors influencing skeletal disorders in these two distinct temporal and cultural contexts. METHODS: The research employs a multidisciplinary approach, integrating osteological, paleopathological, and historical data to understand bone pathologies in mummies and the actual world. Applying radiographs and CT scans as noninvasive techniques has shed new light on past diseases such as fractures, dysplasia, osteoarthritis, surgery, and tuberculosis. Virtual inspection has almost replaced classical autopsy and is essential, especially when dealing with museum specimens. RESULTS: Findings indicate no significant disparities in the prevalence and types of bone pathologies through 4300 years of evolution. Moreover, this study sheds light on the impact of sociocultural factors on bone health. Examination of ancient Egypt's burial practices and associated cultural beliefs provides insights into potential behavioral and ritualistic influences on bone pathologies and the prevalence of specific pathologies in the past and present. CONCLUSION: This comparative analysis illuminates the dynamic of bone pathologies, highlighting the interplay of biological, cultural, and environmental factors. By synthesizing archeological and clinical data, this research contributes to a more nuanced understanding of skeletal health's complexities in ancient and modern societies, offering valuable insights for anthropological and clinical disciplines.

Neglected war injuries: Reconstruction versus amputation.

INTRODUCTION: War injuries are remarkably different situations with profound severity and significant contamination compared to civilian injuries. Delayed definitive management makes the situation much more complicated. This study aimed to report the outcomes of limb reconstruction of neglected war injuries with a previous decision of amputation. PATIENTS AND METHODS: From 2010 to 2021, 1104 patients with war-related fractures from conflict-zone countries were referred to our center including 589 open tibial fractures. Of these tibial fractures, amputation had already been decided in 54 cases, and the patients were looking for a trial of reconstruction and avoiding amputation. These cases were included in the current study. The treatment approach was a single-stage procedure with bone and soft tissue reconstruction. RESULTS: This study included 54 male patients with a mean age of 26.3 years. Infection was the predominant feature in 43 cases (79.6 %). CT angiography revealed a one-vessel limb in 17 patients. Peripheral nerve injuries affected 15 patients. The mean time from injury to presentation was 8.5 weeks. The bone gap (2-13 cm) was evident in 44 cases. In four cases, the contralateral limb was amputated below the knee. There were associated injuries in nine cases. Rotational flap coverage was done in the same setting for 19 legs. Gastrocnemius flap was done in two cases. The mean follow-up duration was 45.1 months. The treatment methods included bifocal management (33 cases), trifocal management (17 cases), fibular transfer (two cases), and a mono-focal approach in two cases. All fractures healed successfully. The mean external fixation period was 7.6 months. Recurrence of infection occurred in three patients. A non-displaced refracture developed in one case. Five cases had a residual angular deformity. Eventually, the ASAMI bone and functional results were good in all cases. CONCLUSIONS: Neglected war injuries constitute a complex problem where amputation may be indicated. Our approach includes one-stage limb reconstruction with the corticotomy-first technique, conservative debridement of the docking site, concomitant osteoplastic procedure, and gradual distraction to tackle all the aspects of the problem. The good results obtained in the presented series make it a valid approach to avoid amputation in neglected war injuries.

High tibial osteotomy for acute correction and subsequent gradual tensioning of the posterolateral knee ligament complex in treating genu varum combined with a lateral thrust using the Ilizarov technique in adults: surgical technique and early results.

OBJECTIVE: To report the early results of using the Ilizarov technique in performing medial wedge opening high tibial osteotomy (MWOHTO) combined with gradual tensioning of the posterolateral corner in adult patients presenting with genu varum (GV) and lateral thrust. METHODS: A prospective case series study included 12 adult patients with a mean age of 25.2 ± 8.1 years who presented with GV deformity associated with lateral thrust. They were evaluated clinically using the "hospital for special surgery" (HSS) knee scoring system. Radiological evaluation was performed using long film from hip to knee to ankle (HKA) radiographs; the overall mechanical alignment was measured as the HKA angle, the upper tibial deformity was measured as the medial proximal tibial angle (MPTA), and the joint line convergence angle (JLCA) was measured. Surgical technique included using Ilizarov for MWOHTO below the level of the tibial tubercle, acute correction of the GV deformity, fibular osteotomy, and gradual distalization of the proximal fibula. RESULTS: After a mean follow-up of 26.3 ± 6.4 months, all osteotomies were united. All patients achieved fibular osteotomy site bony union except two with a fibrous union. The HSS score showed improvement from a mean preoperative score of 88.7 ± 7.6 to a postoperative 97.3 ± 3.9 (P < 0.05). The overall mechanical lower limb alignment improved significantly from a mean preoperative HKA of 164.5 ± 3.2 to a postoperative 178.9 ± 1.6 (P < 0.05). The MPTA improved significantly from 74.6 ± 4.1 to 88.9 ± 2.3, as well as the JLCA from 12.17 ± 1.9 to 2.3 ± 1.7 (P < 0.05). Grade 1 pin tract infection was developed in four patients and was treated conservatively. In two patients, mild pain over the fibular osteotomy site was relieved over time. The lateral thrust reoccurred at the last follow-up evaluation in the two poliomyelitis patients. CONCLUSION: MWOHTO, concomitant with tensioning the knee lateral soft tissue structure at the same setting through applying an Ilizarov apparatus, showed promising functional and radiological outcomes.

Lateral column lengthening (LCL) using a rectangular shape graft for managing symptomatic flexible flatfoot showed acceptable early functional and radiological outcomes.

PURPOSE: We aimed to report the results of performing lateral column lengthening (LCL) using a rectangular-shaped graft to correct the flat foot deformity. METHODS: A total of 28 feet of 19 patients (10 males, 9 females) having an average age of 10 ± 3.2 years who were unresponsive to conservative management underwent flat foot deformity correction through LCL procedure supplemented with rectangular-shaped graft harvested from the fibula. Functional assessment was performed according to the American Orthopedic Foot and Ankle Society (AOFAS) scale. The radiographic assessment consisted of four parameters, Meary's angle in both anteroposterior (AP) and lateral (Lat.) views, calcaneal inclination angle (CIA), and calcaneocuboid angle (CCA). RESULTS: After an average of 30.2 ± 8.1 months, the AOFAS improved significantly from 46.7 ± 10.2 preoperatively to 86.7 ± 9.5 at the last follow up (P < 0.05). All the osteotomies showed healing at an average of 10.3 ± 2.7 weeks. All the radiological parameters showed significant improvement at the last follow up compared to the preoperative measurements, CIA from 6.3 ± 2.8-19.3 ± 3.5, Lat. Meary's angle from 19.3 ± 4.9-5.8 ± 2.5, AP Meary's Angle from 19.3 ± 5.8-6.1 ± 3.1, and CCA from 23.9 ± 8.2-6.8 ± 4.5, (P < 0.05). No pain at the site of the fibular osteotomy was reported in any of the patients. CONCLUSION: Lateral column lengthening using a rectangular graft effectively restores bony alignment with good radiological and clinical results, high patient satisfaction, and acceptable complications.

Neglected infected floating knee injury: evaluation of closed reduction techniques.

PURPOSE: Floating knee injury is uncommon yet challenging problem. The situation is more complicated by presence of infection, open comminuted fractures, and late presentation. The aim of this study was to evaluate the closed reduction techniques by circular external fixation in a single stage to treat patients having infected neglected floating knee injuries. METHODS: This retrospective study included 19 patients with a mean age of 34.4 years. The average duration from trauma to surgery was 51.1 days. All patients had at least one infected open fracture. According to Fraser's classification, ten injuries were type I, one case was type IIa, four were type IIb, and four were type IIc. Patients were treated by closed reduction techniques using the Ilizarov principles. Orthoplastic procedures were done in four cases in the same surgical setting. RESULTS: Closed reduction and union were achieved in all cases with control of infection in 17 cases. The follow-up period averaged 41 months. The mean knee flexion was 97.4°. The complications included 5° extension lag (two cases), malunion (three cases), refracture (two cases), and DVT (four cases). The bone results were excellent (12 cases), good (5 cases), and poor (2 cases). The functional results were excellent (two cases), good (seven cases), acceptable (seven cases), and poor (three cases). CONCLUSIONS: Closed reduction techniques using a circular frame provided a valid treatment option for infected neglected floating knee injuries in one stage without bone grafting. However, the high rate of complications and the diminished knee range of motion should be considered.

Refracture after Ilizarov fixation of infected ununited tibial fractures-an analysis of eight hundred and twelve cases.

INTRODUCTION: Refracture of the tibia after union is a challenging problem for the patients and the surgeons. The purpose of the current study is to present our experience in conservative management of such patients with refracture of infected ununited tibia after successful treatment by Ilizarov external fixator and bone transport. MATERIAL AND METHODS: We reviewed the files of 812 patients with infected ununited tibia who were treated by debridement, corticotomy, and bone transport using Ilizarov methods in our institute between 1997 and 2017. Inclusion criteria were patients with refracture after union and removal of the Ilizarov apparatus. Twenty-two patients with 23 refracture tibia were included in the study. All the 23 tibias were treated conservatively by above knee cast that was converted to Sarmiento below knee cast after early callus formation, except in the case of upper tibial fracture that continued in above knee cast till union. Afterwards, a protective splint was used for additional two months. RESULTS: There were 19 males (86.4%) and three females (13.6%), the mean age of the patients was 38.39 years, the mean time of Ilizarov external fixator application was 10.86 months (range, 6-17), and the mean time of refracture after fixator removal was 2.33 months. Union was achieved in 19 tibias (82.6%), with a mean time of 7.2 months (range, 4-12). Complications included five cases of skin irritation that was treated by large windows in the cast and changing the casts more frequently, three cases developed DVT (deep venous thrombosis), and axial deviation occured in four tibias (17.3%). CONCLUSION: Conservative treatment of refractured tibia after removal of Ilizarov external fixator following treatment of infected non-union tibia by above knee cast is effective in achieving union. However, complications as skin irritation, DVT (deep venous thrombosis), and axial deviation can be anticipated.

Limb reconstruction in a resource-limited environment.

INTRODUCTION: Limb salvage and reconstruction are often challenging and even more so in the limited resource setting. The purpose of this narrative review is to explore the strategies for addressing the unique obstacles and opportunities of limb reconstructive surgery in resource-limited environments globally. METHODS: We review (1) the global burden and dimension of the problem, (2) the relevance of orthopedic forums and communication, (3) free and open-access software for deformity analysis and correction, (4) bidirectional learning opportunities, and the value of fellowships and mentoring between resource-rich and resource-limited countries, and (5) how societies like SICOT can help to tackle the problem. Finally, case examples are presented to demonstrate the choice of surgical implants, their availability in regions with limited resources, and how the universal principles of limb reconstruction can be applied, irrespective of resource availability. RESULTS: Limb reconstruction can often be life-changing surgery with the goals of limb salvage, improved function, and ambulation. The contradiction of relatively few severe limb deformities in high-income countries (HICs) with abundant resources and the considerable burden of limb deformities in resource-limited countries is striking. Free, open access to education and software planning tools are of paramount importance to achieve this goal of limb reconstruction. Bidirectional learning, i.e., knowledge exchange between individual surgeons and societies with limited and abundant resources, can be reached via fellowships and mentoring. The presented cases highlight (1) fixator-assisted wound closure obliviating the need for plastic surgery, (2) open bone transport, and (3) hinged Ilizarov frames for correction of severe deformities. These cases underline that optimal clinical outcome can be achieved with low-cost and readily available implants when the principles of limb reconstruction are skillfully applied. DISCUSSION: Limb lengthening and reconstruction are based on universally applicable principles. These have to be applied regardless of the planning tool or surgical implant availability to achieve the goals of limb salvage and improved quality of life.

Paediatric infected femoral nonunion; mid-term results of a rare problem with a single-stage treatment and up to eleven and half years follow-up.

PURPOSE: Nonunion of femur fractures is a devastating disabling complication which is rare in children. The purpose of this study was to report the outcomes of treating infected femur nonunions in children by the Ilizarov fixator in one stage. PATIENTS AND METHODS: The study included 13 patients with unilateral infected nonunion of the femur with an average age of 9.1 years. The nonunion duration averaged 10.69 months. Ten cases were draining nonunions, and three patients had quiescent sinuses. Associated problems include shortening in all cases (mean 3.5 cm), joint stiffness (9 cases), and angular deformity (7 cases). The quiescent cases were treated by bloodless monofocal compression-distraction. Four draining cases were treated by debridement and compression with relengthening through nonunion site. The remaining six cases were treated by bifocal technique. RESULTS: The mean follow-up duration was 60.15 months. External fixation period averaged 5.3 months. Successful union was achieved in all patients. Recurrences of infection occurred in two cases including one with refracture and another one with late pathological fracture. Other complications included pin tract infections, one delayed union, two residual angular deformities, and 6 cm residual shortening in one patient. ASAMI bone results were excellent (8 patients), good (3 patients), fair (one patient), and poor (one patient). The functional results were excellent (9 cases), good (3cases), and fair (one case). CONCLUSIONS: The Ilizarov method provided a viable treatment option for treating paediatric infected femur nonunions in single stage of management with infection control in most cases and satisfactory outcomes.

Infected tibial nonunion in children: Is radical debridement mandatory?

Nonunion is a devastating complication of tibial fractures with a debilitating effect. Several studies reporting tibial nonunions in adults are available; however, the reports on infected nonunions in children are scarce. The purpose of this study was to evaluate the results of treating paediatric infected tibial nonunion using Ilizarov fixator without radical resection. MATERIALS AND METHODS: The study included 36 cases with infected nonunion of the tibia with 31 males and 5 females, and an average age of 11.4 years. The mean number of previous operations was 3.5. The duration before presentation averaged 10.4 months. At presentation, 24 cases were draining nonunions, while 12 patients had quiescent sinuses. Preoperative shortening was evident in 31 patients ranging from 1 to12 cm. Six cases had equinus foot deformity. Stiffness of the ankle and/or knee was present in 11 cases. Angular deformity of more than 10° was evident in 13 nonunions. The monofocal compression-distraction was used for 10 cases managed by bloodless technique, and four draining cases managed by limited debridement and compression distraction. Limited debridement and bone transport was used in the remaining cases including proximal chondrodiastasis (two cases), proximal tibial corticotomy (17 cases), and partial osteotomy (three cases). RESULTS: The mean follow-up duration was 51.9 months. The external fixation period averaged 5.3 months. Delayed union occurred in three cases treated by repeating compression-distraction. Eventually, union was achieved in all cases. Two cases suffered refracture. Four cases had residual angular deformity of about 5-7°. Infection recurred in one case. ASAMI bone results were excellent in 29 patients, good in three patients, fair in two patients, and poor in two patients. The ASAMI functional results were excellent in 27 cases, good in 5 cases, fair in two cases, and poor in two cases. CONCLUSION: The Ilizarov method provides a viable treatment method for treating paediatric infected nonunions in a single stage of management. Limited debridement was enough to control infection and achieved good results without radical resection.

Clinical outcomes with the corticotomy-first technique associated with the Ilizarov method for the management of the septic long bones non-union.

PURPOSE: Corticotomy is an integral part of the Ilizarov method on management of infected nonunited fractures that are challenging orthopaedic surgeons. However, the presence of active draining sinuses may contaminate the operative field with the potential of developing corticotomy site infection. The authors present a surgical technique aiming at minimizing or avoiding the risk of surgical site infection (SSI) in the corticotomy zone. PATIENTS AND METHODS: A total of 144 cases of draining infected nonunions were treated by Ilizarov fixator using the corticotomy-first technique. The study included humeral (18 cases), femoral (52 cases), and tibial (74 cases) nonunions. The mean age was 44.48 years with 87 males and 57 females. The mean duration of nonunion was 28.69 months. After debridement, the combined shortening and nonunion gap averaged 5.98 (range 3-10) cm. Evaluation of bone and functional results was done according to Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. RESULTS: The follow-up period averaged 51.05 (range 36-72) months. None of the cases developed corticotomy site or distraction gap infection. Union was successfully achieved in 141 cases (97.92%). Nonunion persisted in three cases (2.08%) in the distal tibia. Infection was eventually controlled in 138 cases (95.83%). Bone grafting was not needed in any case. CONCLUSIONS: The Ilizarov fixator with the corticotomy-first technique was effective in the management of draining infected non-united fractures of long bones while avoiding the SSI in the corticotomy site in all cases.

Expanding the phenome and variome of skeletal dysplasia.

PURPOSE: To describe our experience with a large cohort (411 patients from 288 families) of various forms of skeletal dysplasia who were molecularly characterized. METHODS: Detailed phenotyping and next-generation sequencing (panel and exome). RESULTS: Our analysis revealed 224 pathogenic/likely pathogenic variants (54 (24%) of which are novel) in 123 genes with established or tentative links to skeletal dysplasia. In addition, we propose 5 genes as candidate disease genes with suggestive biological links (WNT3A, SUCO, RIN1, DIP2C, and PAN2). Phenotypically, we note that our cohort spans 36 established phenotypic categories by the International Skeletal Dysplasia Nosology, as well as 18 novel skeletal dysplasia phenotypes that could not be classified under these categories, e.g., the novel C3orf17-related skeletal dysplasia. We also describe novel phenotypic aspects of well-known disease genes, e.g., PGAP3-related Toriello-Carey syndrome-like phenotype. We note a strong founder effect for many genes in our cohort, which allowed us to calculate a minimum disease burden for the autosomal recessive forms of skeletal dysplasia in our population (7.16E-04), which is much higher than the global average. CONCLUSION: By expanding the phenotypic, allelic, and locus heterogeneity of skeletal dysplasia in humans, we hope our study will improve the diagnostic rate of patients with these conditions.

Gradual fibular transfer by ilizarov external fixator in post-traumatic and post-infection large tibial bone defects.

INTRODUCTION: Several reconstructive procedures have been used in management of large tibial bone defects including bone graft, bone transport (distraction osteogenesis) using various external fixators, and vascularized bone graft. Each of these procedures has its limitations and complications. The study describes gradual medial fibular transfer using Ilizarov external fixators in management of patients with large tibial defect, either following infection or trauma. PATIENTS AND METHODS: Between May 2011 and June 2013, 14 patients were prospectively included in the current study. The inclusion criteria were large tibial defect due to trauma or infection with severe soft tissue compromise, and small or poor tibial bone remnants making bone lengthening difficult. Exclusion criteria were patients with vascular or nerve injuries. The average age of the patients was 31.64 (± 6.5) years. Medial fibular transfer was done for all patients using Ilizarov at a rate of 0.5 mm twice daily. Iliac bone graft was used in all patients after the transfer. RESULTS: The average segmental bone defect of the tibia was (13.2 ± 2.6), ranging between 8 and 18.6 cm. Union was achieved in all patients with average fixator time was 32.42 (± 4.32) weeks. Average follow-up after removal of the fixator was 40.5 (± 6.9) months. CONCLUSION: Gradual fibular transfer by Ilizarov external fixator is a reliable technique in management of post-traumatic and post-infection large tibial bone defects with good clinical outcome, and with few complications.

Humeral lengthening and deformity correction.

INTRODUCTION: Ilizarov principles and hybrid fixation have improved the results of humeral lengthening. We reviewed the literature on humeral lengthening using different fixators with regard to indications, operative technique, results and complications. We also retrospectively reviewed 56 segments in 46 patients treated with humeral lengthening and deformity correction using Ilizarov external fixation. The etiology was achondroplasia (10 patients), epiphyseal injury (8 cases), infection (11 cases) and Erb's palsy (17 cases). The average age at surgery was 14 years (range 8-20 years). The patients were assessed clinically and radiographically and DASH score was available for 36 segments. Follow-up ranged from 1-11 years. The magnitude of lengthening achieved ranged from 5-15.5 cm with an average of 9 cm. The average healing index was 29.5 cm (range 26-37 days). The percentage of area of lengthening to the original length ranged from 25 to 100% with an average of 55%. The average DASH (available for 36 segments only) score ranged from 15-40 preoperatively to 7-16 (P = 0.04) at last follow-up. Functionally, all the patients returned to their preoperative jobs and daily activities including sports. COMPLICATIONS: Complications included pin track infection in 46 segments, radial nerve palsy which recovered completely in 2 patients, fracture of the regenerate in 7 cases and premature consolidation of the regenerate in one case. CONCLUSION: Humeral lengthening, whether unilateral or bilateral, is a valid method that improves the outcome following arm shortening and deformity correction, including angulation and rotation. Extensive lengthening up to 100% of the original length could be achieved without increasing the risk of complications. LEVEL OF EVIDENCE: IV, retrospective cohort.

Hinged distraction of the hip joint in the treatment of Perthes disease: evaluation at skeletal maturity.

The aim of this work is to determine the effect of this type of treatment on the shape of the femoral head, the range of motion (ROM), radiological changes in the femoral head, and the prognosis of Perthes disease at skeletal maturity. From 1998 to 2007, 53 patients with Perthes disease were treated with a combination of soft tissue release and joint distraction with a hinged monolateral external fixator in 32 patients and by Ilizarov external fixator in 21 patients. Nineteen of our 53 patients attained skeletal maturity and were evaluated in our study. This study included 15 boys and four girls, mean age at surgery 9.3 years (range 7.2-13.1), and mean age at the last follow-up 17.4 years (range 14.9-21.3). The duration of symptoms varied from a period of 6 to 60 months before the operation. Radiographs taken during the fragmentation stage of the disease were classified by the lateral pillar classification of Herring; 19 of our patients attained skeletal maturity and were evaluated. Clinical assessment included the Harris hip score, hip ROM, and limb length discrepancy. Radiographic assessment included sharp transverse acetabular inclination, the uncoverage percentage, the epiphyseal index before surgery (modified Eyre-Brook), at frame removal, and at the last follow-up, the epiphyseal quotient (of Sjovall), and the Stulberg classification. The mean follow-up was 7.2 years (range 4.1-11.3). The mean Harris hip score was 87.1/100 (range 49.2-94.8). An improvement in hip (ROM) of 83.3% of the normal range was restored. There was a marked improvement in the degree of pain and limp postoperatively. The hip ROM was slightly limited in most patients, and seven patients had limb shortening of between 1 and 3 cm. The mean sharp transverse acetabular inclination of the affected side was 44° (range 35-51) compared with 37° for the unaffected side (P=0.042). The mean uncoverage percentage was 36% (range 24-45) compared with 21% for the unaffected side (P=0.027). The mean epiphyseal index was 0.74 (range 0.36-0.94) before surgery, 0.78 (range 0.49-0.89) at frame removal (P=0.017), and 0.80 (range 0.54-0.91) at the last follow-up (P=0.701). The epiphyseal quotient was 0.74 (range 0.51-0.94) and the Stulberg classifications were type II in eight patients, type III in seven patients, type IV in three patients, and type V in one patient. Arthrodiastasis of the hip joint with soft tissue release may represent a good contribution toward the treatment of Legg-Calvé-Perthes disease. This method of treatment has many advantages such as easy technique, minimal rate of complications, a short hospitalization period, correction of shortening because it adds to the length of the limb, and a higher rate of acceptable results than would be expected compared with other methods. It also improves the ROM, reduces superior and lateral subluxation, and provides better radiographic sphericity of the femoral head. In addition, it does not distort the anatomy of the pelvis or the proximal femur; it can be used with equal success in older children who are typically expected to have a poor prognosis. Distraction treatment is not limited by hip stiffness, degree of femoral head deformity, or subluxation, and can be used when other methods of treatment are contraindicated.

Arthrodiastasis of the hip.

BACKGROUND: Hip distraction in Legg-Calvé-Perthes disease unloads the joint, which negates the harmful effect of the stresses on the articular surface, which may promote the sound healing of the areas of necrosis. METHODS: Nonarticulated arthrodiastasis without soft tissue release using an Ilizarov external fixator was applied to 29 patients with Legg-Calvé-Perthes disease (older than 8 y at onset and lateral pillar type C or B). RESULTS: Follow-up period ranged from 2.5 to 11 years with an average of 7.5 years. Twenty-seven cases (93%) had improvement of the range of motion postoperatively. Preoperatively, all patients had constant pain, whereas at last follow-up 26 (86%) patients had no pain and 3 had an improvement. Stulberg classification was applied to 21 cases who reached skeletal maturity at last follow-up: 9 cases were type II, 7 cases were type III, 4 cases were type IV, and 1 case was type V. CONCLUSIONS: Nonarticulated hip distraction without soft tissue release seems to be a valid treatment option in cases with Legg-Calvé-Perthes disease where poor results are expected from conventional treatment.

Articulated distraction.

Articular hip distraction can be applied either by using a monolateral articulated distractor or a circular fixator. The fixator should be aligned such that its axis is aligned with the transverse axis of the hip joint. Following distraction, the range of motion is maintained with regular physiotherapy. It is a useful salvage procedure in older children with hip stiffness, when other methods of containment are not applicable.

Managing flexion knee deformity using a circular frame.

UNLABELLED: Knee flexion deformity can cause marked physical disability. Acute correction, whether nonoperative or operative, may lead to serious complications. We treated 50 patients (71 knees) between 1994 and 2002 with the Ilizarov external fixator. The deformity was gradually corrected using Ilizarov principles. Of the 50 patients, 29 were affected unilaterally and 21 bilaterally. In 15 patients, there were associated deformities. In no patient did we surgically release soft tissues; in two patients with arthrodesed or congenitally fused knees, we performed osteotomy before distraction. All patients were assessed clinically and radiographically. We assessed knee flexion angle, range of motion, stability, presence of pain, and healing index. After a minimum followup of 1 year (mean 3.7 years; range, 1-8 years), 18 of 20 of the preoperatively nonambulatory patients having bilateral surgery could walk at last followup. Complications included pin tract infection in all patients, knee subluxation in three patients, and fracture related to treatment in seven patients. We believe gradual correction using a circular frame an effective method to treat flexion knee contractures. In patients with bilateral deformities, improvement in functional activity may be expected in most patients. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Unilateral humeral lengthening in children and adolescents.

This study evaluates our early experience with unilateral humeral lengthening in children and adolescents. From 1995 till 2001, 16 cases with unilateral humeral shortening ranging from 5.5 to 15 cm were referred to our center. The cause was Erb's palsy in eight cases, epiphyseal injury in five cases and infection in three cases. The average age at operation was 13 years (range 8.5-17 years). Hybrid fixation using wires and half pins were applied to all cases to minimize the risk of operative neurovascular complications. Osteotomy was performed in the middle third of the humerus through a posterior approach. After a latent period of 5-7 days lengthening started at a rate of 0.33 mm every 8 h. At an average follow up of 3 years and 2 months (range 1 year and 4 months to 5 years and 6 months) there were 10 excellent and six good results. The average healing index was 28 days/cm. Complications included pin tract infection in all cases; radial nerve palsy in one patient whose humerus overlengthened by 2 cm but improved completely after compression; fracture of the regenerate in two cases.

Treatment of tibial hemimelia without amputation: preliminary report.

Treatment of tibial hemimelia, traditionally, is by amputation. This is not acceptable in our community. Hence we treated our cases without amputation. We treated two cases of type Ia and four cases of type II tibial hemimelia. The age at operation ranged from 3.5 to 13 years For type Ia cases, we applied the Ilizarov external fixator to the femur, fibula and foot to centralize the fibula between the femoral condyles and talus using gradual distraction. The second step was the Brown procedure. Then the fixator was reapplied to correct the deformities. For type II, synostosis of the tibia and fibula was performed followed by differential lengthening. Then we overlengthened the femur. After follow-up for 2-5.5 years, all patients showed improved function and were satisfied. The tibial lengthening ranged from 6 to 8.5 cm, and femoral lengthening ranged from 5 to 7 cm.