Results of cosmetic lower limb lengthening by the lengthening over nail technique.

We conducted a retrospective study by reviewing our results following cosmetic lengthening using the lengthening over nail technique in terms of the importance of the patient selection process, bone and soft tissue complications, and functional and subjective clinical outcomes. The study data were obtained from medical records and radiographs. A total of 32 patients, 24 males and 8 females, with constitutional short stature underwent the lengthening over nail technique for cosmetic purposes between 2000 and 2013. Lengthening was performed in the femora of 15 patients and in the tibiae of 17 patients. All patients who were accepted for cosmetic lengthening underwent a careful selection process that included a psychiatric evaluation. The mean follow-up time was 73 months (range, 12 to 163 months). Thirty-four complications were reported. Cosmetic lengthening is not without complications. Patient selection is of paramount importance. This technique is recommended for cosmetic lengthening because it is minimally-invasive and it has documented reproducible results.

Median nerve excursion in response to wrist movement after endoscopic and open carpal tunnel release.

PURPOSE: To compare the perioperative kinematic effects of endoscopic versus open carpal tunnel release on longitudinal excursion (gliding) and volar displacement (bowstringing) of the median nerve at the wrist region in patients with idiopathic primary carpal tunnel syndrome. METHODS: Sixteen hands of 13 patients were randomly assigned into 2 groups (group 1, endoscopic; group 2, open carpal tunnel release). For the measurement of gliding and bowstringing of the median nerve, a metallic marker was used. Before and after the division of the transverse carpal ligament, longitudinal excursion and volar displacement of the median nerve were calculated based on fluoroscopic imaging for each wrist. Movement was analyzed for the measurement of the marker locations. RESULTS: The mean prerelease median nerve excursion during wrist range of motion was 20 mm (range, 10-28) in group 1 and 21 mm (range, 16-31 mm) in group 2. The mean postrelease median nerve excursion during wrist range of motion was 20 mm (range, 13-29) in group 1 and 18 mm (range, 8-26 mm) in group 2. There was no statistically significant difference in pre- and postrelease longitudinal excursion changes between the groups (p = .916 and p = .674, respectively). The mean prerelease volar displacement of the median nerve during wrist range of motion was 3 mm in group 1 and 4 mm in group 2; the postrelease mean values were 2 mm and 5 mm, respectively. There was no statistically significant difference between the groups with regard to pre- and postrelease volar displacement changes of the median nerve (p = .372 and p = .103, respectively). CONCLUSIONS: This study demonstrated that the endoscopic release and open carpal tunnel release produce similar perioperative effects on longitudinal and volar movements of the median nerve.

[Knee arthrodesis using a unilateral external fixator for the treatment of infectious sequelae]. / Enfeksiyon sekeli tedavisinde unilateral eksternal fiksatör ile diz artrodezi.

OBJECTIVES: We evaluated the results of arthrodesis using a monolateral external fixator for the treatment of septic sequelae of the knee joint. METHODS: Eleven patients (4 males, 7 females; mean age 60 years; range 29 to 75 years) underwent arthrodesis using a monolateral external fixator. Indications for arthrodesis were infected total knee prosthesis (n=6), septic arthritis sequelae (n=4), and infected distal femoral tumor prosthesis (n=1). Eight patients had active infection; of these, seven patients initially underwent complete clinical and laboratory eradication of infection with debridement, application of antibiotic-impregnated cement spacer (n=6), and parenteral antibiotics. Resection guides of total knee arthroplasty were used to create wide bleeding femoral and tibial bone surfaces. Biplanar or uniplanar monolateral external fixation was applied for a mean of eight months (range 5 to 12 months). The mean follow-up was 28 months (range 7 to 69 months). Complications were evaluated according to the Paley's classification. RESULTS: Fusion was achieved in all the patients. There were no recurrent infections. No remarkable shortening developed following the procedure. All the patients could walk without walking aids, except for one patient who further required lengthening for marked shortening due to previous wide tumor resection. Shortening was 3 cm in one patient with infected total knee prosthesis, while it ranged from 1 cm to 2 cm (mean 1.4 cm) in the remaining patients. Pin tract infections were seen in five patients, all of which were successfully treated with oral antibiotics and local wound care. CONCLUSION: Knee arthrodesis using a monolateral external fixator is associated with a high fusion rate and a low complication rate, and provides a more comfortable treatment option compared to a circular external fixator.

External fixation reconstruction of the residual problems of benign bone tumours.

The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov's contribution that allows deformity correction and reconstruction of bone defects. We present a retrospective study of 20 patients who suffered from a variety of benign tumours for which external fixators (EF) were used to treat deformity, bone loss, and limb-length discrepancy. A total of 26 bony segments in twenty patients (10 males, 10 females; mean age 17 years; range 7-58 years) were treated with EF for residual problems from the tumour itself (primary treatment) in 8 patients and for complications related to the primary surgery (secondary treatment) in 12 patients. Histological diagnoses were Ollier's disease (n = 4), Fibrous Dysplasia (n = 5), Congenital multiple exostosis (n = 5), giant cell tumour (n = 2) and one case for chondromyxoid fibroma, desmoid fibroma, chondroma and unicameral bone cyst. Various types of external fixators used to treat these problems. These were Ilizarov, unilateral fixator, multiaxial correction frame (Biomet, Parsippany, NJ), Taylor spatial frame (Memphis, TN) and smart correction multiaxial frame. The mean follow-up time was 69.5 months (range 35-108 months). The mean external fixation time was 159.5 days (range 27-300 days). The mean external fixation index was 67.4 days/cm (12-610) in 26 limbs who underwent distraction osteogenesis. The mean length of distraction was 4.9 cm (range 0.2-14 cm). At final follow-up, all patients had returned to normal activities. Complications were in the form of knee arthrodesis in one patient, pin tract infection in six and residual shortening in eight patients. The use of EF and the principles of distraction osteogenesis, in the management of problems associated with benign bone tumours and related surgery yields successful results especially in young patients. With this approach, the risk for recurrence of shortening and deformity may be minimized with overcorrection or over-lengthening as dictated by preoperative planning.

Treatment of infected nonunion of the juxta-articular region of the distal tibia.

OBJECTIVE: The purpose of this study was to summarize our clinical results with distraction osteogenesis for the treatment of infected tibial nonunion around the ankle joint. METHODS: Between 1994 and 2009, 13 patients with a mean age of 50 years (range: 27-79 years) underwent tibial reconstruction for the treatment of infected nonunion of the distal tibia, with a mean bone loss of 4.8 cm (range: 1-7 cm). Lengthening over an intramedullary nail as a second procedure was used in 2 patients, bifocal compression and distraction technique in 5 cases, compression with Ilizarov external fixator in 5 cases, and Taylor Spatial Frame (TSF, Smith Nephew, Memphis, TN, USA) in 1 case. At final follow-up, functional and radiographic results were evaluated according to Paley's bone and functional healing criteria. RESULTS: Mean duration of follow-up was 36 months. Mean external fixation time was 198 days, and mean external fixation index was 29 days/cm. According to Paley's bone healing criteria, there were 10 excellent, 2 good, and 1 poor result(s); additionally, according to Paley's functional healing criteria, there were 5 excellent, 6 good, and 2 fair results. There were 11 problems, 5 obstacles, and 1 sequel according to Paley's classification of complications. There was 1 persisting nonunion, which underwent revision with a retrograde intramedullary nail. CONCLUSION: External fixator and/or combined treatment are effective and reliable methods to treat infected nonunion of the distal tibia. Every patient should be evaluated according to their infection level and bony defects for reconstruction.

Thoracolumbar flexion-distraction injuries combined with vertebral body fractures.

Surgery was performed on 25 patients with combination injuries (flexion-distraction injury plus vertebral body fracture): 8 patients with anterior-column failure (compression) and 17 patients with anterior-column plus middle-column failure (burst). Patients with compression received posterior instrumentation and underwent fusion; patients with burst received posterior instrumentation and later underwent anterior decompression and fusion. Eleven patients in the burst group had a neurologic deficit. Single dural tears were discovered in 7 patients during the posterior-instrumentation procedure. By the end of the follow-up period (mean, 34.4 months; range, 18-76 months), neither implant failure nor loss of correction had occurred. Combined mechanisms may go unrecognized and thereby result in increased morbidity and inappropriate treatment. Proper evaluation of the posterior elements is of utmost importance for the diagnosis of flexion-distraction injuries with vertebral body fractures. After diagnosis, treatment should be started with a posterior procedure.

[Surgical management of intraarticular calcaneus fractures]. / Intraartiküler kalkaneus kiriklarinin cerrahi tedavisi.

OBJECTIVES: We evaluated the midterm results of surgical treatment for intraarticular calcaneal fractures. METHODS: This study included 19 feet of 14 patients with intraarticular fractures of the calcaneus. Twelve patients were males and two were females (mean age 28.3 years; range 17 to 54 years). The fractures were bilateral in five patients. In one patient the contralateral foot was treated conservatively. Anteroposterior, lateral, and tangential radiographs and computed tomography (CT) scans were obtained in all patients preoperatively. According to the Sanders CT classification, there were 10 type II, five type III, and four type IV fractures. An extensile lateral incision was performed in all patients but one to provide an anatomic reduction with the use of Sherman plates, screws, and staples. The patients were followed-up by radiographs and CT. The results were evaluated using the Maryland Foot Score. The mean follow-up was 32.7 months (range 24 to 43 months). RESULTS: Radiographs and CT scans obtained in the early postoperative period showed that a complete anatomic reduction was achieved in 13 feet. According to the Maryland Foot Score, the results were excellent in five, good in eight, fair in four, and poor in two feet. None of the patients required a subsequent operation due to surgery-associated causes. CONCLUSION: The success of surgical treatment of intraarticular calcaneal fractures depends only on the achievement of an anatomic reduction and on maintaining it with a stable osteosynthesis using appropriate strength hardware.

Functional results of lower extremity lengthening by motorized intramedullary nails.

OBJECTIVE: The aim of this study was to evaluate the outcome of patients undergoing limb lengthening using motorized intramedullary nails. METHODS: This study included eleven femora and 4 tibiae from 14 patients (9 male, 5 female; mean age: 26.9 years; range: 14 to 51 years) who underwent limb lengthening using motorized intramedullary femoral nails (Fitbone(®) TAA). Average preoperative limb shortening was 4.9 (range: 2.5 to 7.5) cm. Distraction was initiated on the seventh postoperative day. Serial radiographs and Paley's bone and functional outcome scoring systems were used to evaluate the results. RESULTS: Mean follow-up period was 33.5 (range: 7 to 88) months. Mean distraction index value was 1.2 (range: 0.7 to 2.1) days/mm and mean bone-healing index value was 43.7 (range: 13.8 to 144) days/cm. The average lengthening achieved was 51.7 (range: 25 to 75) mm. The distraction mechanism of the nail did not function properly in two patients, restricted transient knee motion was observed in four patients, and delayed consolidation was observed in four patients. Other complications included valgus deformities and superficial infections surrounding the antenna of the intramedullary nail, as well as femur fractures at the proximal end of the nail. Bone scores were excellent in 11 segments and were good in one segment. Functional scores were excellent for all 12 patients. CONCLUSION: While usual complications related to the external fixators, such as pin-track infections and mobilization difficulties were not encountered, the development of additional complications such as dysfunction of the distraction mechanism should be monitored with the use of motorized intramedullary nails in limb lengthening.

Fixator-assisted acute femoral deformity correction and consecutive lengthening over an intramedullary nail.

BACKGROUND: External fixators are being used frequently in standard limb-lengthening and deformity-correction procedures. Lengthening over an intramedullary nail has been a successful technique, and fixator-assisted intramedullary nailing has provided satisfactory results for the correction of selected deformities. We report a combined technique for the treatment of femoral deformities associated with shortening. METHODS: Between 1997 and 2005, twenty-eight femora in twenty-five patients with a median age of twenty-seven years underwent reconstruction with an intramedullary nail and a unilateral fixator. The mean amount of shortening was 6.33 cm, and the mean preoperative mechanical axis deviation was 33.86 mm. Deformity correction was performed acutely and secured by the intramedullary nail, which was locked distally, and the same external fixator that was used for the deformity correction was utilized for lengthening. At the end of the distraction period, proximal locking screws were placed in the intramedullary nail and the external fixator was removed. At the time of follow-up, deformity correction and bone healing were assessed clinically and radiographically, complications were noted, and the functional results were assessed. RESULTS: The mean duration of follow-up was forty months. The mean duration of the external fixation was 83.29 days, and the mean external fixation index was 14.98 days/cm. The mean amount of lengthening was 6.02 cm. The mean amount of mechanical axis deviation at the end of the treatment was 11.29 mm. The mean bone healing index was 36.66 days/cm. A knee flexion contracture developed in one patient and resolved after intensive rehabilitation. One patient underwent two revisions because of Schanz screw displacement secondary to cortical fracture, and four patients with minor pin-track infections were treated successfully with local wound care and oral antibiotics. CONCLUSIONS: While femoral lengthening and deformity correction can be obtained with classic methods for application of an external fixator, the long period of external fixation, patient discomfort, and plastic deformation of the regenerated bone after removal of the fixator are major disadvantages. Two techniques, fixator-assisted nailing and lengthening over an intramedullary nail, were combined in this series. The duration of the external fixation was reduced compared with that required for classic treatment with an external fixator and patient comfort was increased. In addition, the intramedullary nail prevented fracture and deformation of the regenerated bone.

Correction of complex foot deformities using the Ilizarov external fixator.

There are many drawbacks to using conventional approaches to the treatment of complex foot deformities, like the increased risk of neurovascular injury, soft-tissue injury, and the shortening of the foot. An alternative approach that can eliminate these problems is the Ilizarov method. In the current study, a total of 23 deformed feet in 22 patients were treated using the Ilizarov method. The etiologic factors were burn contracture, poliomyelitis, neglected and relapsed clubfoot, trauma, gun shot injury, meningitis, and leg-length discrepancy (LLD). The average age of the patients was 18.2 (5-50) years. The mean duration of fixator application was 5.1 (2-14) months. We performed corrections without an osteotomy in nine feet and with an osteotomy in 14 feet. Additional bony corrective procedures included three tibial and one femoral osteotomies for lengthening and deformity correction, and one tibiotalar arthrodesis in five separate extremities. At the time of fixator removal, a plantigrade foot was achieved in 21 of the 23 feet by pressure mat analysis. Compared to preoperative status, gait was subjectively improved in all patients. Follow-up time from surgery averaged 25 months (13-38). Pin-tract problems were observed in all cases. Other complications were toe contractures in two feet, metatarsophalangeal subluxation from flexor tendon contractures in one foot, incomplete osteotomy in one foot, residual deformity in two feet, and recurrence of deformity in one foot. Our results indicate that the Ilizarov method is an effective alternative means of correcting complex foot deformities, especially in feet that previously have undergone surgery.