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

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

Relevant advances in bone lengthening research: a bibliometric analysis of the 100 most-cited articles published from 2001 to 2017.

This study aimed to assess the scientific production of bone lengthening research by identifying the most-cited papers. All articles including the term 'bone lengthening' published between 2001 and 2017 were retrieved through the Web of Science database. The 100 most-cited articles on bone lengthening included a total of 4244 citations, with 414 (9.7%) citations in 2017. There was an average of 249.6 citations per year. The articles predominantly addressed biomechanics and bone formation (38). Different surgical techniques, including intramedullary nail (14), Ilizarov (nine), intramedullary skeletal kinetic distractor (ISKD) (six), Taylor spatial frame (6), the PRECICE device (three), and lengthening and submuscular locking plate (three), were the second most-studied topic. Most studies were therapeutic (58), whereas 30 studies were experimental investigations using animal models. Among the clinical studies, case series were predominant (level of evidence IV) (57). This study presents the first bibliometric analysis of the most relevant articles on bone lengthening. The list is relatively comprehensive in terms of identifying the top issues in this field. However, the most influential clinical studies have a poor level of evidence, although a slight tendency toward a better level of evidence has been observed in more recent years.

A Brief History of Limb Lengthening.

In the last 35 years, orthopaedic surgeons have witnessed 3 major advances in the technique of limb lengthening: "distraction osteogenesis" facilitated by Gavriil Ilizarov method and infinitely-adaptable circular fixator with fine-wire bone fragment fixation; the introduction of the "6-strut" computer program-assisted circular fixators to effect complex deformity correction simultaneously; and the development of motorized intramedullary lengthening nails. However, the principles and associated complications of these techniques are on the basis of observations by Codivilla, Putti, and Abbott from as much as 110 years ago. This review notes the contribution of these pioneers in limb lengthening, and the contribution of Thor Heyerdahl principles of tolerance and diversity to the dissemination of Ilizarov principles to the Western world.

Alargamiento de extremidades: actualización y revisión del tema / Limb lengthening: review and update

El alargamiento de extremidades trata las discrepancias de longitud de extremidades superiores e inferiores. Lograr un adecuado tratamiento temprano evita secuelas irreversibles como la artrosis. El estudio de las discrepancias se realiza con una telerradiografía estandarizada, la cual entrega la información de cuál es el segmento óseo comprometido y cuál es el largo total a corregir. Menos de 15mm de discrepancia se ha demostrado que no tiene influencia sobre la mecánica de la marcha ni de las articulaciones. Más de 15mm produce una alteración en las cargas articulares, rangos de movimiento articular, compensaciones musculares, compensaciones de columna (escoliosis compensatoria), entre otras, que producen secuelas a largo plazo. Los métodos de tratamiento existentes son conservadores y quirúrgicos. Dentro de estos últimos están los fijadores externos e internos. Los fijadores externos tienen una alta frecuencia de infecciones superficiales a través de las agujas, sin embargo, son versátiles y capaces de corregir prácticamente cualquier deformidad. Los fijadores internos (por ejemplo, clavos intramedulares) no pueden corregir grandes deformidades, así como tampoco realizar grandes alargamientos, sin embargo, su frecuencia de complicaciones es mucho menor y son mucho mejor tolerados por el paciente. Estos métodos de tratamiento logran resultados muy precisos. Tienen un margen de error de 3,5 mm de longitud, lo cual no tiene consecuencias mecánicas para una extremidad. La tasa de satisfacción es de alrededor del 90 por ciento y logran un alivio del dolor significativo...

Limb lengthening can be used to correct upper and lower limb length discrepancies. To obtain an appropriate treatment early in life prevents irreversible consequences, such as arthritis. The limb length discrepancies study is performed with a standardised leg length X-ray. This X-ray shows the compromised bone segment and what the total limb length discrepancy is. A limb length discrepancy of less than 15mm has no influence on factors such as, gait mechanics, joint range of motion, or long term joint degeneration. Over 1.5cm, several consequences appear such as: joint overload, decreased joint range of motion, muscle compensations and compensatory spine malalignment. Existing treatment includes non-surgical and surgical methods. Among the latter are internal and external fixations. External fixations have a high frequency of superficial infections, but are highly versatile, being able to correct virtually any deformity. The internal fixation (e.g. intramedullary nails) cannot correct large deformities, or make big lengthenings, but its complication rate is much lower and is much better tolerated by the patient. These treatment methods achieve very accurate results. They have an error of 3.5mm in length, which has no mechanical consequences to an extremity. The satisfaction rate is high, with around 90 percent achieving a significant pain relief...

The Ilizarov paradigm: thirty years with the Ilizarov method, current concerns and future research.

The Ilizarov method of bone lengthening, reconstruction and osteosynthesis has developed immensely since its introduction by G.A. Ilizarov in the Soviet Union in the 1960s and in the Western countries in the early 1980s. It has become an integral part of the arsenal used by the orthopaedic community worldwide. The evolutionary development of the method and its current role has considerably improved the quality of life for millions of people around the whole world. Despite the great versatility of its possible applications for bone injuries and diseases, the Ilizarov method could not and cannot be the alternative to a range of other methods that are applied for some specific bone conditions, but rather is a method of choice. Its combination with the current methods of internal fixation or the means of internal fixation that use the biological principles that were laid down by G.A. Ilizarov have demonstrated the importance of tension stress, blood supply, functional loading, and fragment control during bone treatment. The objective of this study was to present an overview of the current state and concerns in the application of the Ilizarov method and define the prospective research trends aimed at regeneration stimulation, better control of treatment, infection barriers and patient comfort.

Elongaciones óseas con clavos endomedulares / Bone lengthening by intramedullary nailing

Se presenta una revisión histórica de las elongaciones óseas con clavo endomedular y un estudio clínico preliminar sobre 10 casos de alargamiento femoral mediante 'callotasis modificada' empleando un clavo intramedular F-D y un aparato de fijación externa de reconstrucción de miembros. El tiempo de fijación externa medio fue de 13 días/cm, para un alargamiento medio conseguido de 5,4 cm. No se observaron desviaciones axiales del regenerado óseo, en ningún caso fue necesario el aporte de injerto óseo, ni hubo fracturas ni tampoco casos de infecciones (AU)

[A new surgical method: lengthening of jaw bone by means of distraction technique]. / Ny kirurgisk metod: förlängning av käkben med distraktionsteknik.

Callus distraction, or distraction osteogenesis as the method also is called, is a new surgical technique which makes it possible to create new bone by bone elongation. The method was originally used in orthopedic surgery to extend long bones but has subsequently proved useful for extending the mandible as well as other bones in the facial skeleton. By callus distraction, it is now possible to treat severe jaw anomalies and also to treat bone defects in the jaws without bone transplantation. This article describes the biological background to the method and the basic principles that must be observed for successful results. The treatment of four patients illustrates the method.

[Pioneers in the lengthening of the extremities]. / Pioniere der Extremitätenverlängerung.

Successful lengthening of the extremities was first published at the beginning of the twentieth century. Those reports in which methods such as the distraction of fragments, callus or epiphysis were mentioned for the first time are reviewed. Lengthening of the extremities by epiphyseal distraction was first mentioned by Bernhard v. Langenbeck in 1869 in an animal experiment. The publications of Codivilla, who introduced lengthening by fragment distraction, Kirschner, Bier and others are cited and analyzed critically. Thus, the historical development of the lengthening of the extremities is reported from 1869 to the middle of the twentieth century.

[Bone lengthening. History of the development and field of applications]. / Knogleforlaengelse. Udviklingshistorien og anvendelsesmulighederne.

Leg lengthening has been performed since early in this century. The first successful lengthening was reported in 1905. Leg lengthening evolved from forced lengthening of the bone during anaesthesia, through use of cortical bone grafts, plate and screws to callus distraction (callotasis). Development of external fixators and evolution of biological concepts of bone regeneration has been important. In 1951 Ilizarov developed his apparatus. Ilizarov pioneered the biology of bone and soft-tissue regeneration. He performs a percutaneous subperiosteal corticotomy and waits five to seven days prior to distraction with a rate of 0.25 mm of length four times each day. The method has increased the opportunities in reconstructive bone surgery. The technique is difficult with many problems and obstacles which can be overcome.

Callus distraction: a new method? A historical review of limb lengthening.

The technique of callus distraction can be traced back to the work of Codivilla at the beginning of the century. Subsequent to Codivilla, various crude methods of limb lengthening were used but resulted in high complication rates. Not until the work of Putti and Abbott in the 1920s and their painstaking operative technique did the results become verifiable. During the 1930s, various modifications were introduced and the apparatus was simplified. However, because of an increasing tendency to apply this technique to unsuitable cases, it fell into disrepute. After World War II, Anderson, Allan, and Ilizarov developed better equipment, allowing for a better understanding of the biologic principles of callus distraction. In the 1980s, this method was adopted for treatment of major bone defects and shortening of limbs.

[History of lengthening and equalization of lower extremities]. / Historia wydluzania i egalizacji konczyn dolnych.

Chronological history of development of methods for elongation and equalization of lower extremities is presented. An elongation by distraction of an osteotomized shaft and shortening by resection of a shaft fragment is discussed. An epiphyseal stimulation and arrest and non-aggressive method of epiphyseal distraction are shown. The author's intention was to present the development of this field of orthopedics and to prevent researching ideas known in the past.

[Leg lengthening using callotasis. I. History of lengthening of extremities and surgical technics]. / Prolongace bérce kalotaxí. I. cást: Historie prodluzování koncetin a operacní technika.

In the first part of the article divided into two sections the authors describe the history of approaches to limb length discrepancy and they compare several methods and discuss their advantages and disadvantages. The surgical method proper used at the clinic is described incl. preoperative preparation and deliberations as used at the clinic up to the procedure used for removing the fixator after completion of the lengthening of long bones. The operation proper is described in detail from application of the apparatus to performance of osteotomy. The lengthening process is also described.