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Background: Lower limb length discrepancy (LLD) in children and adolescents, often due to congenital or acquired conditions, is treated to achieve limb equality and alignment, optimizing function and minimizing cosmetic concerns for an active adulthood. This study evaluated the Health-Related Quality of Life (HRQoL) and physical functioning of adults who underwent unilateral limb lengthening with circular external fixators (EFs) in childhood. Methods: Fifty patients treated at a median age of 14.9 years completed the Short Form 36 (SF-36) and Stanmore Limb Reconstruction Score (SLRS) questionnaires in adulthood, with a median follow-up of 8.9 years. Results: Among the 50 patients, 38 underwent a single limb lengthening (21 tibia, 12 femur, 5 both), while 12 required multiple cycles. The median residual LLD was 0.4 cm, with 12 patients (24%) having over 2 cm. Complications occurred in 67% of procedures, mainly due to prolonged healing. Physical and mental health scores were significantly lower than normative data. The mean Physical Component Summary was 52.2 ± 7.2 (p = 0.20). The mean Mental Component Summary was 43.9 ± 8.6 (p = 0.001), notably lower in congenital LLD cases. Many SLRS items (Pain, Social, Physical Function, Work, and Emotions) strongly correlated with SF-36 items. Conclusions: Adults treated with distraction osteogenesis for congenital LLD show normal physical but lower mental health scores compared to peers. Lengthening procedure characteristics did not significantly impact mental health. Routine psychological and social assessments are recommended to prevent long-term distress by providing appropriate support. [ABSTRACT FROM AUTHOR]

Background: Compound fractures of the distal tibia (with or without the middle third) represent a challenge for orthopedic and plastic surgeons because of the scarcity of available soft tissue reconstruction and the important comminution of the fractures that usually appear. Methods: The design of this study is based on the PRISMA guidelines. Databases were searched for articles published and available until the first half of 2023. Articles that presented the evolution of patients treated by combining circular external fixators with reconstructive methods were selected. Results: After searching the literature using keywords, we obtained 3355 articles, out of which 14 articles met all the inclusion criteria, with a total number of participants of 283. The bone loss varied between 0.7 and 18.2 cm, while the soft tissue defect was between 3/3 cm and 16/21 cm. The average period of fixation ranged from 4 to 22.74 months. The most used reconstruction methods were 80 free flaps and 73 pedicled flaps out of 249 interventions. Complete flap loss appeared only in 3/283 patients. Regarding the bone union, the percentage of non-union was low, and in all cases, it was achieved after reintervention. A low rate of major complications was observed. Conclusions: The orthoplastic team is the key to successfully treating the high-energy traumatism of the distal tibia (with or without a middle third). The Ilizarov external fixator can be used as a definitive limb-salvage treatment (secondary to the standard primary methods of fixation) in combination with a flap to cover the defects because it does not damage the pedicle, and it helps stabilize the soft tissues and bones around the flap to lower the complications. [ABSTRACT FROM AUTHOR]

For lengthening irregular bones, such as calcaneus, there are few reports in the literature. This study aimed to introduce the treatment strategy and preliminary outcomes for calcaneus shortening using calcaneal body lengthening. From January 2017 to January 2022, calcaneal lengthening was conducted for three patients (two males and one female) who suffered from traumatic calcaneal shortening. The Achilles tendon was lengthened in one patient. After osteotomy of the calcaneus, an Ilizarov frame was used to gradually (1 mm/day) distract the calcaneal fragment. The lengthening procedure was stopped when the calcaneal height and length were restored based on radiography. The fixator was removed after bone union. The average follow‐up length was 18 months (range, 14–24 months). X‐ray was used for radiological assessments. Patients reported satisfaction using the 100‐mm visual analog scale (VAS). Clinical outcome was evaluated following the American Orthopedic Foot and Ankle score. All data were assessed by two physicians blind to clinical assessments. The wound healed primarily in three cases. The bone got solid union without refracture and malunion. The distraction time was 30 days (range, 25–45 days). The fixation time was 113.3 days (average, 80–150 days). Calcaneal lengthening was 26 mm (range, 15–43 mm). The height and length of the calcaneus were restored nearly to the same as the opposite foot. The mean preoperative calcaneal pitch angle increased from 2.6 degrees to an average of 19.0 degrees after the surgery. The AOFAS score increased from 60.0 to 86.0. One patient experienced pin infection. The infection healed after changing the dressing. Calcaneal lengthening using an Ilizarov external fixator is a preferable technique to restore the length and height of the calcaneus and can achieve satisfactory foot function.

Abstract 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

For lengthening irregular bones, such as calcaneus, there are few reports in the literature. This study aimed to introduce the treatment strategy and preliminary outcomes for calcaneus shortening using calcaneal body lengthening. From January 2017 to January 2022, calcaneal lengthening was conducted for three patients (two males and one female) who suffered from traumatic calcaneal shortening. The Achilles tendon was lengthened in one patient. After osteotomy of the calcaneus, an Ilizarov frame was used to gradually (1 mm/day) distract the calcaneal fragment. The lengthening procedure was stopped when the calcaneal height and length were restored based on radiography. The fixator was removed after bone union. The average follow‐up length was 18 months (range, 14–24 months). X‐ray was used for radiological assessments. Patients reported satisfaction using the 100‐mm visual analog scale (VAS). Clinical outcome was evaluated following the American Orthopedic Foot and Ankle score. All data were assessed by two physicians blind to clinical assessments. The wound healed primarily in three cases. The bone got solid union without refracture and malunion. The distraction time was 30 days (range, 25–45 days). The fixation time was 113.3 days (average, 80–150 days). Calcaneal lengthening was 26 mm (range, 15–43 mm). The height and length of the calcaneus were restored nearly to the same as the opposite foot. The mean preoperative calcaneal pitch angle increased from 2.6 degrees to an average of 19.0 degrees after the surgery. The AOFAS score increased from 60.0 to 86.0. One patient experienced pin infection. The infection healed after changing the dressing. Calcaneal lengthening using an Ilizarov external fixator is a preferable technique to restore the length and height of the calcaneus and can achieve satisfactory foot function. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Circular external fixators often use fine transfixion wires as part of the construct. When a wire needs to be placed obliquely, standard methods of attaching the wire to the ring can cause tension in the surrounding soft tissues and the underlying bone. One method to avoid this issue is to use a long wire fixation bolt with conical washers above and below the ring. This technique is described in the following article.

Introduction Some progress has been made in the development of innovative implantation materials for osteoplastic surgery. However, the problem of bone defect management still remains relevant due to the continued high prevalence of injuries resulting from road accidents, catatrauma, man-made disasters and military operations. The purpose of the work was to analyze the relevant literature and to identify options for solving the problems of bone nonunion and defect management using materials developed on the principles of orthobiology and surgical technologies based on autologous repair. Materials and methods The search for sources was carried out with the ConnectedPapers analytical tool and the capabilities of the eLibrary electronic library using keywords and without restrictions on publication date. Results and discussion Recent publications contain information about the effectiveness of the combination of Masquelet technology and Ilizarov bone transport in patients with acquired and congenital defects, including in the conditions of active purulent infection. According to the literature, a promising autologous bone plastic material is the contents of the bone marrow cavity, containing osteogenic growth factors and bone morphogenetic proteins. Biomaterial is collected using the Reamer-Irrigator-Aspirator system (RIA) from the intramedullary canal of the femur or tibia. Currently, the effectiveness of bone morphogenetic proteins rhBMP-2 and rhBMP-7 in the restorative treatment of patients with bone defects and nonunion of various etiologies has actually been proven. The use of bone morphogenetic proteins has been introduced into foreign treatment protocols. Recent positive results of a combination of surgical technologies have proposed the combined use of the Ilizarov and Masquelet technologies, supplemented by PRP therapy. The basis for the expected effect from the combination of surgical technologies and orthobiological materials are the results of preclinical studies of the osteogenic potential of PRP therapy. Conclusion There are grounds for studying the clinical effect of the combined use of surgical technologies based on autologous reparative processes and materials developed on the principles of orthobiology. It is necessary and advisable to clinically implement the use of bone morphogenetic proteins rhBMP-2 and rhBMP-7 in the reconstructive treatment of patients with bone defects and nonunion of various etiologies. Multicenter clinical studies of a high level of evidence are needed to determine the effectiveness of PRP therapy in the reconstructive treatment of patients with bone nonunion and defects.

Background: Ilizarov external fixation has become the treatment of choice for infected non-union of tibia. Varying degrees of bone loss and different strategies of treatment in the published reports make comparing outcomes difficult. This study hopes to bridge this gap in the literature by focussing exclusively on bone transport in patients with bone loss of 5 cm or more. Methodology: This is a prospective case series conducted at a tertiary level orthopaedic speciality hospital. Outcomes are measured by Association of the Study and Application of Method of Ilizarov (ASAMI) bony scores, ASAMI functional scores, Lengthening Index and by assessing complications encountered. Results: There were 49 patients in this study with an average of 9.57 cm bone gap. Among these, 29 patients had a bone gap of 5–10 cm and 20 patients had a bone gap of ≥ 11 cm. According to the ASAMI bony score, 42 patients had excellent or good outcomes with two fair results and five poor results. The ASAMI functional scores were 45 excellent to good outcomes, four fair and no poor results or failures. Fixed flexion deformity of the knee of more than 5°, ankle stiffness and soft tissue interposition were significantly more frequent in those with bone gap of ≥ 11 cm. Trifocal transport and bone grafting at docking significantly improved the lengthening index. Conclusion: Even massive bone defects of 11 cm or more can be reliably healed by bone transport using Ilizarov external fixation, but with a significantly higher rate of complications. Level of evidence: Level IV. [ABSTRACT FROM AUTHOR]

Background: Lower limb length discrepancy (LLD) in children and adolescents, often due to congenital or acquired conditions, is treated to achieve limb equality and alignment, optimizing function and minimizing cosmetic concerns for an active adulthood. This study evaluated the Health-Related Quality of Life (HRQoL) and physical functioning of adults who underwent unilateral limb lengthening with circular external fixators (EFs) in childhood. Methods: Fifty patients treated at a median age of 14.9 years completed the Short Form 36 (SF-36) and Stanmore Limb Reconstruction Score (SLRS) questionnaires in adulthood, with a median follow-up of 8.9 years. Results: Among the 50 patients, 38 underwent a single limb lengthening (21 tibia, 12 femur, 5 both), while 12 required multiple cycles. The median residual LLD was 0.4 cm, with 12 patients (24%) having over 2 cm. Complications occurred in 67% of procedures, mainly due to prolonged healing. Physical and mental health scores were significantly lower than normative data. The mean Physical Component Summary was 52.2 ± 7.2 (p = 0.20). The mean Mental Component Summary was 43.9 ± 8.6 (p = 0.001), notably lower in congenital LLD cases. Many SLRS items (Pain, Social, Physical Function, Work, and Emotions) strongly correlated with SF-36 items. Conclusions: Adults treated with distraction osteogenesis for congenital LLD show normal physical but lower mental health scores compared to peers. Lengthening procedure characteristics did not significantly impact mental health. Routine psychological and social assessments are recommended to prevent long-term distress by providing appropriate support.

Background: Schatzker type VI tibia fractures are usually associated with infection and surgical wound-related problems. Circular external fixation (CEF) has been shown to minimize such complications. Methods: We pose a retrospective study of patients with Schatzker type VI fractures treated with CEF. Results: Twenty-two (22) patients were included (11M/11F) with a mean age of 60.1 ± 14.9 years. According to the AO/OTA classification, two fractures (9.1%) were A2, three (13.6%) were A3, and seventeen (77.3%) were C3. Three (13.6%) of them were open. The tissue damage observed in the nineteen (86.4%) closed fractures was classified according to Tscherne (four grade I, twelve grade II, and three grade III). The mean ex-fix time was 24.1 ± 5.1 weeks. None of the patients experienced deep infections, nonunion, or malunion. The mean ROM was 111.4 ± 17.8 degrees. Although stability was achieved in all cases, 50% of them suffered osteoarthritic degeneration. Four knees required TKR at a mean of 8.77 ± 5.58 years from trauma. The mean HHS knee score was 84.2 ± 10.3 points (excellent in fifteen (68.2%) cases, good in four (18.2%), and acceptable in three (13.6%)). The mean Rasmussen radiological score was 13.3 ± 3.5 (excellent in three (13.6%) cases, good in fifteen (68.2%), and acceptable in four (18.2%)). The mean SF-12 score was 35.1 ± 10.4 points on the physical scale and 53.0 ± 10.6 points on the mental scale. Conclusions: CEF has shown itself to be a valid treatment for patients with Schatzker type VI fractures, particularly for those where the fracture is comminuted, severely displaced, open, or associated with severe soft tissue damage. [ABSTRACT FROM AUTHOR]

Introduction An aneurysmal bone cyst (ABC) is a rare, non-neoplastic, destructive, hemorrhagic, and expansile lesion accounting for 1 % of all bone tumors. ABC of the foot is very rare. Patients with foot ABC usually complain of pain and swelling of the affected area. Radiographs and MRI may be helpful in the diagnosis of ABC. No single surgical procedure has gained wide acceptance in the treatment of foot ABC. Purpose To show new effective surgical approach in the treatment of patient with ABC of the medial cuneiform bone. Material and methods We present the case of a 47-year-old woman with a 10-months history of pain and swelling in her right foot. Postoperative histopathological evaluation of resected tissues confirmed the diagnosis of ABC. An en bloc resection (total extraction of the remnant of the medial cuneiform bone) was performed and the defect was replaced with a fibular bone graft from the right leg. Allograft (Bio-Ost®) was placed along the autograft. Tibialis anterior tendon was attached to the fibular bone graft. We performed fixation of the foot and ankle using the Ilizarov original apparatus for prevention of bone graft instability and opportunity for early weight-bearing on the operated foot. Results The postoperative period was uncomplicated with complete healing of the bone defect without recurrence after 12 months of observation. AOFAS score increased significantly from 34 points preoperatively to 92 at 1-year follow-up. Discussion The optimal treatment of this lesion is still under discussion. Different treatment modalities have been described in the literature: wide resection, curettage with or without adjuvants, arterial embolization, intralesional sclerotherapy. Biological reconstruction using bone graft seems to be the best option, but fractures and nonunion are common complications of bone grafting. Conclusion The combination of Ilizarov external fixation and bone grafting provided favorable conditions for the healing of foot bone defect due to ABC without complications, allowed mobility and early weight-bearing of the patient. Recurrence was not detected radiologically. Harvesting of the fibular bone graft did not affect the position of the foot and its movements. Our surgical approach should be considered as a treatment option in similar cases.

Introduction Widespread use of intramedullary and extramedullary implants, as well as external fixation devices, has demonstrated that current surgical methods are not always successful. The study aimed to assess the efficiency of a combination of transosseous osteosynthesis with intramedullary reinforcement using elastic titanium hydroxyapatite-coated rods (HA-rods) in long bone fracture treatment. Material and methods Medical records of 40 patients aged from 18 to 55 years with closed diaphyseal tibia fractures of A1-A3 type (AO/ASIF) treated with the Ilizarov transosseous osteosynthesis method combined with intramedullary elastic HA-coated wires were analysed. Result Ilizarov fixator removal was performed on average 45.3 ± 14.7 days after surgery. Radiological signs of bone union (immature callus, patterns of periosteal and endosteal stratifications overlapping the fracture line) were visible by week 3 to 4. Discussion Соmbination of the external fixator and intramedullary elastic HA-coated wires overcomes shortcomings of both external and internal means of fixation. External osteosynthesis provides advantages of the Ilizarov method: preservation of blood supply, absence of soft tissue injury, joint function and early weightbearing. Elastic intramedullary wires do not injure a. nutricia and mechanically stimulate endosteal and periosteal bone formation. Conclusion The advantages of combined osteosynthesis provide reduction of Ilizarov apparatus fixation time, reduction in the number of wires and half-pins in the frame assembly, stimulation of bone callus formation and prevention of secondary bone fragment displacement.

OBJECTIVE: To assess the osteotomy results and application of Ilizarov to lower limb deformities. METHODOLOGY: This case series study on twenty-three patients of either sex was conducted in Akbar Medical Center Peshawar from November 2016 to April 2021. The ages of the patients were ten and above. To reduce the bias, we have excluded patients with diabetes mellitus, patients on oral anticoagulants, tobacco addicts and those on steroid or immunocompromised patients. Preoperatively, the deformity was calculated to determine how long it would take to correct, so double the time was required to consolidate the callus at the corticotomy site when it was corrected. So, some frames were removed early while others were removed late. All the data were collected with the help of a proforma and then entered into SPSS version 20 for analysis. RESULTS: There were 23 patients, nine males (39.1%) and fourteen females (60.9%). The mean age was 19.39, the minimum was 10, and the maximum was 40 years. Both sides were involved 6(26.1%) in while right 9(39.1%) was involved in and left 8(34.8%) in cases. Site of deformity was ankle in 4(17.4%), femur in 4(17.4%), knee in 8(34.8%) while tibia was involved in 7(30.4%) cases. A single osteotomy was done in 16(69.6%) cases, while a double osteotomy was done in 7(30.4%) cases due to the CORA being calculated in two places. Ten (43.5%) cases were complication-free, while there was acceptable residual deformity in 4(17.4%), pin lessening in 2(8.7%), pin tract infection in 3(13.0%), and restricted knee movement in 4(17.4%). CONCLUSION: The Ilizarov External fixator is best for deformity correction in all dimensions and directions if the patient and attendant complain otherwise.

Abstract Background Fibular Hemimelia (FH) is the most common longitudinal limb deficiency. Significant limb length discrepancy (LLD) will necessitate long treatment times and multiple settings to compensate for LLD when associated with femoral shortening. This study evaluates the outcome of simultaneous femoral and tibial lengthening using the Ilizarov frame. Methods This retrospective study included the cases of 12 children with severe limb length discrepancy caused by combined FH and ipsilateral femoral shortening from May 2015 to August 2022. The total LLD ranged from 7 to 14.5 cm. All patients underwent single-session femoral and tibial lengthening using the Ilizarov ring external fixator technique. Additional procedures were performed in the same setting, including Achilles tendon lengthening, fibular anlage excision, peroneal tendons lengthening, and iliotibial band release. Follow-up ranged from 2 to 4 years. Results The planned limb lengthening was achieved in ten cases (83%). No cases of joint subluxation or dislocation were encountered. No neurovascular injury has occurred during the treatment course. In all cases, the bone healing index was better on the femoral side than on the tibia. Poor regeneration and deformity of the tibia occurred in two cases (16.6%). Conclusion Simultaneous femoral and tibial lengthening using the Ilizarov fixator is a relatively safe procedure with the result of correction of total LLD in one session in a shorter time and less morbidity.

Background: Adolescent tibia vara [ATV] is a multiplanar malformation that can cause diminished function and permanent damage. ATV is believed to be a multifaceted developmental disease of the proximal tibia, which results in a malformation of the varus and procurvatum. In genetically vulnerable individuals, this disorder may also be partially attributed to mechanical strain.The Aim of the work: This pooled analysis goal is to evaluate and compile the data about the efficacy and complications of the most popular surgical lines of treatment of tibia vara in adolescents: osteotomy, Ilizarov, and hemiepiphysiodesis.Methods: Considering the search strategy, a literature study was conducted from 2010 to 2020 in the Web of Science, PubMed, Scopus, and Cochrane datasets. Studies were selected if it included. This systematic review had 15 published papers with a total sample size of 357 limbs.Results: Temporal hemiepiphysiodesis is used effectively to treat mild/moderate ATV in patients with sufficient growth. Temporal hemiepiphysiodesis has been linked to an elevated failure and recurrence rate of approximately 28.4%. In managing ATV, a modified Rab osteotomy with minimal fixation using two or three screws yields encouraging outcomes. However, the post-operative time of healing is affected by BMI. Thus, it's not the best choice for obese patients with ATV. For correcting mild to moderate ATV, medial opening wedge high tibial osteotomy—with or without a bone graft—is an appropriate approach.Conclusion: The best surgical technique for adolescent tibia vara depends on the patient's circumstances. Osteotomy is generally preferred over hemiepiphysiodesis due to its lower recurrence rate. The use of simple circular frame fixation with proximal tibial osteotomy is the ideal option for treating neglected ATV, mainly when the patient is obese and has severe deformities.

Background: Fibular Hemimelia (FH) is the most common longitudinal limb deficiency. Significant limb length discrepancy (LLD) will necessitate long treatment times and multiple settings to compensate for LLD when associated with femoral shortening. This study evaluates the outcome of simultaneous femoral and tibial lengthening using the Ilizarov frame. Methods: This retrospective study included the cases of 12 children with severe limb length discrepancy caused by combined FH and ipsilateral femoral shortening from May 2015 to August 2022. The total LLD ranged from 7 to 14.5 cm. All patients underwent single-session femoral and tibial lengthening using the Ilizarov ring external fixator technique. Additional procedures were performed in the same setting, including Achilles tendon lengthening, fibular anlage excision, peroneal tendons lengthening, and iliotibial band release. Follow-up ranged from 2 to 4 years. Results: The planned limb lengthening was achieved in ten cases (83%). No cases of joint subluxation or dislocation were encountered. No neurovascular injury has occurred during the treatment course. In all cases, the bone healing index was better on the femoral side than on the tibia. Poor regeneration and deformity of the tibia occurred in two cases (16.6%). Conclusion: Simultaneous femoral and tibial lengthening using the Ilizarov fixator is a relatively safe procedure with the result of correction of total LLD in one session in a shorter time and less morbidity. [ABSTRACT FROM AUTHOR]

The treatment of defects of the long bones remains one of the biggest challenges in trauma and orthopedic surgery. The treatment path is usually very wearing for the patient, the patient's environment and the treating physician. The clinical or regional circumstances, the defect etiology and the patient´s condition and mental status define the treatment path chosen by the treating surgeon. Depending on the patient´s demands, the bony reconstruction has to be taken into consideration at a defect size of 2–3 cm, especially in the lower limbs. Below this defect size, acute shortening or bone grafting is usually preferred. A thorough assessment of the patient´s condition including comorbidities in a multidisciplinary manner and her or his personal demands must be taken into consideration. Several techniques are available to restore continuity of the long bone. In general, these techniques can be divided into repair techniques and reconstructive techniques. The aim of the repair techniques is anatomical restoration of the bone with differentiation of the cortex and marrow. Currently, classic, hybrid or all-internal distraction devices are technical options. However, they are all based on distraction osteogenesis. Reconstructive techniques restore long-bone continuity by replacing the defect zone with autologous bone, e.g., with a vascularized bone graft or with the technique described by Masquelet. Allografts for defect reconstruction in long bones might also be described as possible options. Due to limited access to allografts in many countries and the authors' opinion that allografts result in poorer outcomes, this review focuses on autologous techniques and gives an internationally aligned overview of the current concepts in repair or reconstruction techniques of segmental long-bone defects. [ABSTRACT FROM AUTHOR]

The use of external fixators (EFs) for lower limb lengthening is common for treating lower limb length discrepancy (LLD) in children. The concern at present revolves around extended treatment times, with some suggesting a healing index (HI) > 45 days/cm as a major complication. The aim of this study is to assess the factors affecting bone healing and treatment duration in children who undergo limb lengthening for LLD using circular EFs. A total of 240 lengthening procedures on 178 children affected by congenital or acquired LLDs (mean age at surgery 13.8 ± 2.8 years) were retrospectively evaluated. Complications according to Lascombes' classification and treatment duration factors were analyzed. Mean HI was 57 ± 25 days/cm for the femur and 55 ± 24 days/cm for the tibia, with an HI > 45 days/cm in 64% of the procedures. A total of 189 procedures (79%) reported complications; 85 had an HI > 45 days/cm as the sole complication. While reducing the frame time is crucial, revising the classifications is necessary to avoid the overestimation of complications. [ABSTRACT FROM AUTHOR]

Abstract 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

IntroductionLimb 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.MethodsWe 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.ResultsLimb 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.DiscussionLimb 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.

Circular external fixators often use fine transfixion wires as part of the construct. When a wire needs to be placed obliquely, standard methods of attaching the wire to the ring can cause tension in the surrounding soft tissues and the underlying bone. One method to avoid this issue is to use a long wire fixation bolt with conical washers above and below the ring. This technique is described in the following article. [ABSTRACT FROM AUTHOR]

Background and aims: Gavril Ilizarov pioneered the use of fine wire circular ring fixators within Soviet Russia in the early 1950's and advocated a wire tension within the range of 980 N–1275 N. Ilizarov used a technique known as “Russian tensioning” whereby a wire is subtended around the fixation bolt in order to produce wire tension across the frame. The use of a mechanical tensioning device was conceived to elongate the wire and impart tension on the wire.This biomechanical study compares these two techniques at achieving adequate tension and aims to quantify how initial wire tension is affected by the addition of a second, orthogonal wire. Methods: In this in vitro series of experiments, a stabilised, testing rig utilised an initial wire passed across a 160mm stainless-steel ring. A Russian tensioning method and mechanical tensioning device was used. A calibrated tensiometer was used to record spoke deflection which was then converted to Newtons of tension. Results: When Russian tensioning, adequate tension was only achieved at 90° of bolt rotation. Notably the first wire tensioned did not achieve a suitable tension until the 2nd wire was added across all angles of bolt rotation.Only at 110 and 130KgF was initial wire tension adequate. Following the addition of an orthogonal wire at both of these settings wire tension was maintained within the acceptable range. Conclusion: Both methods of tensioning are an effective method of tensioning in Ilizarov constructs. A ''ring deflection phenomenon'' may cause an initial loss of tension but the addition of an orthogonal wire ensures adequate wire tension, provided there is 90° of bolt rotation with Russian tensioning or at least 110 KgF with a mechanical tensioner.

Historically, mangled extremities were generally treated with a primary amputation. Advancements in surgical repair and reconstruction have increased the possibility of salvage in the limbs damaged by high-energy trauma, with a reasonably functional outcome. The Mangled Extremity Severity Score is a useful guide for evaluating and managing a crushed limb. However, most literature does not support the practicality of any particular scoring system to discriminate between the limbs requiring amputation and those likely to be salvaged successfully. In young patients, without significant comorbidities and borderline injury scores, an earnest attempt at limb salvage should be made. The case report highlights how shared and timely decision-making coupled with the innovative use of the Ilizarov apparatus, in a seemingly distraught situation, led to successful salvage and restoration of function. [ABSTRACT FROM AUTHOR]

Historically, mangled extremities were generally treated with a primary amputation. Advancements in surgical repair and reconstruction have increased the possibility of salvage in the limbs damaged by high-energy trauma, with a reasonably functional outcome. The Mangled Extremity Severity Score is a useful guide for evaluating and managing a crushed limb. However, most literature does not support the practicality of any particular scoring system to discriminate between the limbs requiring amputation and those likely to be salvaged successfully. In young patients, without significant comorbidities and borderline injury scores, an earnest attempt at limb salvage should be made. The case report highlights how shared and timely decision-making coupled with the innovative use of the Ilizarov apparatus, in a seemingly distraught situation, led to successful salvage and restoration of function.

Introduction Based on the assessment of the problems and effectiveness in the use of the induced membrane and bone transport techniques, a new technological solution was proposed. It combines the methods of Masquelet and Ilizarov for restorative treatment of patients with bone defects and nonunion. Materials and methods The combination of the technologies was successfully applied for filling bone defects in the conditions of active purulent infection and its remission in 24 patients. Patients of the first group (n = 17) had bone defects in the conditions of the osteomyelitic process remission. In the second group of patients (n = 7), the osteomyelitic process was active. The combined technology of bone grafting included segment reconstruction in two stages. At the first stage of treatment, a sanitizing treatment of soft and bone tissues in the area of the defect and nonunion was performed followed by spacer implantation and transosseous fixation of bone fragments with the Ilizarov apparatus. During the second operating session, the spacer was removed, and after osteotomy (corticotomy), the fragment(s) were transported according to Ilizarov. Empirical antibiotic therapy against a wide range of pathogens was started after the verification of the microbial tests of the biomaterial and the determination of sensitivity to antibiotics, the correction of antibiotic therapy was carried out. Results The postoperative wounds in the area of the implanted spacers healed by primary intention in the first group. In two patients of the second group (29 %), purulent fistulas were formed by the time the spacers were removed, and the wounds healed by secondary intention. The duration of distraction in the first group was 45.4 ± 9.8 days. Bone transport in the patients of the second group continued 52.8 ± 5.3 days. The duration of fixation of the segments with the device was 195.1 ± 9.9 days in the first group and 181.8 ± 11.4 days in the second group. Discussion At the initial stage of the combination of the Masquelet technique and non-free Ilizarov bone grafting, the risks of the activity of a purulent process remain if the debridement of the infection nidus is not radical, implanted spacers with a prophylactic dose of antibiotics are massive, and the antibiotic therapy is empirical. The formation of an induced membrane with bactericidal activity at the second stage of surgical treatment, the creation of favorable conditions for bone transport, adequate sanitation of the purulent focus, and targeted antibiotic therapy ensure a stable suppression of the activity of the purulent process. Conclusions Surgical rehabilitation of patients with segmental infected defects results in bone defect filling with distraction regenerates undergoing complete organotypic restructuring, which eliminates the likelihood of deformities or fractures at the level of newly formed bone areas and reduces the risk of recurrence of the osteomyelitis process.

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. [ABSTRACT FROM AUTHOR]

Objectives: Complications are common in the treatment of lower extremity congenital or acquired deformities by Ilizarov method. The results to be obtained vary in specific patient groups. In this study, deformities who developed before the age of 16 were compared with those developed after this age regardless of the type of aetiology, in terms of results obtained, treatment durations and complications encountered. Methods: 53 bone deformities with an average of 9.5 (7.5-18) years of follow-up treated by the same surgeon were divided into 2 groups according to the age of deformity onset. Demographics and deformity characteristics of patients were defined, treatment times, bone healing indexes, consolidation/correction rates, problems encountered and results obtained were compared retrospectively. The results were compared with ASAMI functional and bone scoring. Complications were rated according to Paley and relative risk increases between groups were calculated. Results: 26 of the patients were men and 22 were women. The average age was 26.47 (7-57). The mean deformity was 23.98° (7-60) and the mean shortness in 39 patients was 38.65 (10-110)mm. Mechanical axis deviation was corrected in 83% of patients. The Lengthening index was 54.13days/cm in the development group and 63.69 days/cm in adults. Consolidation/correction rate was 2.54 in developmental age and 2.4 (p=0.698) in adults. The risk increased by 1.02 times in terms of problems encountered, 2 for obstacles, 3 times in complications and 1.34 times in total difficulties per case, according to Paley. The duration of stay in the fixator was higher in developmental group (p=0.023). ASAMİ functional (p=0.000148) and anatomical (p=0.000242) scores were better in the adult group. Conclusion: Congenital or acquired deformities in the lower extremity can be treated with satisfactory results by Ilizarov method. The development of deformity at an early age makes treatment difficult. Although the bone healing index is lower in this group of patients, which usually has a higher amount of shortness, the treatment is usually longer than that of adult deformities; complications are more frequent and serious. Functional and anatomical results are more unsuccessful. [ABSTRACT FROM AUTHOR]

Background: The limb reconstruction system (LRS), rail road fixator, and Ilizarov fixator are used to treat open fractures with bone loss and infective non-union of long bones. It benefits the fracture site by permitting distraction, compression, and further enhancing micromotion at the level of fracture site which plays an important part in healing. The LRS is a straightforward, unidirectional arrangement that provides exceptional strength and rigidity. The limb rebuilding procedure has proven to be an effective treatment option in instances of fracture infective non-union of long bones. Aims and Objectives: This study is to evaluate and to observe the use of limb reconstruction devices (such as the Ilizarov fixator and the rail road fixator) in the treatment of open fractures with bone loss and infective non-union of long bones. Materials and Methods: Twenty patients (15 males and five females) with fracture non-union of long bones were involved in this study after taking permission from ethic committee and consents from all 20 individuals. These patients then underwent thorough debridement and resection of non-viable bone ends with the application of limb reconstruction devices which were then followed by bone transport to fill the bone gap. This was done by means of Ilizarov in 13 patients and by rail road fixator in the remaining seven patients. The average time of union and complications were evaluated. Results: Mean duration of fracture union was 7.9 months. While one patient had failure resulting in non-union, other 19 patients achieved union by limb reconstruction devices. Majority of the cases had no complications. Mean period of hospital stay for Ilizarov was 68.13 days and for rail road fixator 53.17 days. After applying independent “t-test,” no statistically significant differences were observed in fracture union duration between Ilizarov and rail road fixator, since the calculated P value was observed to be >0.05. Mean union of Ilizarov and rail road fixator application was found to be 7.6 months and 8.2 months, respectively. Conclusion: Limb reconstruction devices in our present study can be utilized as an effective way to tackle infective non-union of long bones and open fracture with bone loss for achieving better stabilization. Both Ilizarov and rail road fixator perform a crucial role in causing early mobilization of the patient and also in fracture union by distraction osteogenesis.

Objectives: The Ilizarov mini-fixator, an external fixator developed for digits, has a structure different from that of general unilateral external fixators. The purpose of this study was to provide information for clinical external fixator selection by clarifying the biomechanical properties of the Ilizarov mini-fixator. Methods: Three types of loads were applied to the fracture fixation model using a carbon fiber cylinder as the bone model: axial pressure, 4-point bending, and torsion. Ilizarov mini-fixators with six 1.5 mm pins (6-pin group), four 1.5 mm pins (4-pin group), and four 2.0 mm-threaded-pins (2 mm-pin group) and a group using a 1.5-mm plate (plate group) were set, and the stiffness was compared between these four groups. Results: Compared to the 6-pin group, which is the basic configuration of the Ilizarov mini-fixator, the 4-pin group had lower stiffness against axial load and bending, and there was no significant difference in stiffness against torsion. The 2 mm-pin group had high stiffness against axial load and bending and low stiffness against torsion. The plate group exhibited high stiffness against axial pressure and low stiffness against bending and torsion. Conclusions: The Ilizarov mini-fixator is a reasonable option for fixing small phalanges. However, other options should be considered for the fixation of larger bones with higher loads. In particular, a configuration with fewer pins such as the 4-pin model may have insufficient strength during early postoperative exercise, even for fixing the phalanges.

Objective To evaluate the outcomes of Ilizarov ankle arthrodesis in the treatment of end‐stage varus ankle osteoarthritis (OA). Methods This was a retrospective study of 63 patients with varus ankle OA who underwent Ilizarov ankle arthrodesis between June 2013 and December 2018. There were 24 males and 39 females with an average age of 56.57 ± 4.45 years (range, 47–64 years). Thirty‐six cases were affected on the left side, and 27 were affected on the right side. The patients' mean body mass index (BMI) was 25.18 ± 2.93 kg/m2. According to the modified Takakura staging criteria, there were 18 cases of stage 3b (28.57%) and 45 cases of stage 4 (71.43%). Nine patients were primary (14.29%), 48 were traumatic (76.19%), and six were caused by rheumatoid OA (9.52%). Functional assessments were performed according to the American Orthopedic Foot and Ankle Society (AOFAS) ankle‐hindfoot score, Ankle Osteoarthritis Scale (AOS), and visual analogue scale (VAS). The tibial anterior surface angle (TAS), coronal plane tibial‐talar angle (CPT), talar tilt angle (TT), deformity angle (DA), and tibial lateral surface angle (TLS) were assessed on X‐ray films. Results The average operation time was 147.84 ± 13.67 min (range, 135–168 min). The average follow‐up time was 34.24 ± 8.72 months (range, 24–61 months). Bony fusion was achieved in all ankles, and the fusion time was 12.43 ± 1.99 weeks on average. The average AOFAS score at the final follow‐up increased from 42.14 ± 8.66 to 80.90 ± 6.80. The average VAS score and AOS pain and disability scores at the final follow‐up decreased from 7.29 ± 1.27 to 2.24 ± 0.94, from 67.94 ± 7.68 to 27.92 ± 5.82, and from 71.64 ± 9.37 to 41.32 ± 8.99, respectively. The average TAS, CPT, and TLS at the final follow‐up increased from 77.76° ± 4.44° to 89.81° ± 1.25°, from 69.04° ± 3.73° to 90.43° ± 1.80°, and from 82.14° ± 3.77° to 88.67° ± 2.50°, respectively. The average TT and DA at the final follow‐up decreased from 8.76° ± 4.30° to 2.05° ± 1.28° and from 20.95° ± 3.73° to 1.57° ± 0.93°, respectively. Three patients developed superficial pin tract infections, all settled with local dressing and antibiotic treatment. Two patients were found to have subtalar arthritis and underwent conservative treatment. Conclusion Ankle arthrodesis using the Ilizarov technique is efficient in treating end‐stage varus ankle OA.

Aims: The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. Methods: We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture. Results: There were 244 frames (230 patients) included in the analyses, of which 90 were Ilizarov type frames and 154 were hexapods. There were 149 frames which underwent single-stage reloading and 95 frames which underwent a two-stage reloading protocol. Mechanical failure occurred after frame removal in 13 frames (5%), which suffered refracture. There were no cases of change in alignment. There was no difference between refracture patients who underwent single-stage or two-stage reloading protocols (p = 0.772). In all, 14 patients had failure prevented through identification with the reloading protocol. Conclusion: Our reloading protocol is a simple and effective way to confirm the timing of frame removal and minimize the rate of mechanical failure. Similar failure rates occurred between patients undergoing single-stage and two-stage reloading protocols. If the surgeon is confident with clinical and radiological assessment, it may be possible to progress directly to stage two and decrease frame time and patient morbidity. Cite this article: Bone Jt Open 2022;3(5):359–366.

(1) Background: Neglected hip dislocation is an uncommon condition, especially in developed countries because dislocations are considered trauma emergencies and thus are treated early. They are usually treated with methods used in commonly occurring dislocations. The aim of this study is to detail a two-stage strategy for neglected hip dislocations in adults applied in a complicated case. (2) Case presentation: We present a complicated case of neglected hip dislocation in a patient with an associated neurological condition. Two-stage open reduction was performed combined with arthrodiastasis and Ilizarov external fixators. After complications requiring a third intervention, the joint was stabilized, and the patient has presented no more episodes to date. (3) Conclusions: Arthrodiastasis has been used to treat these conditions. Comparing it with the other methods described in the literature, it seems to be a good therapeutic strategy, especially in elderly patients. Because of the limited number of studies, we cannot establish the most efficient therapeutic method, but we believe that the described strategy can be useful for patients with this condition.

INTRODUCTION: Tibial bicondylar fractures are difficult fractures to treat and are usually associated with complications. MATERIALS AND METHODS: Thirty-five patients with Schatzker type V and VI fractures were managed from June 2016 to July 2018 with Ilizarov technique. The mean age of the patients was 46.5 ± 8.9 years, with 28 male and seven female patients. Sixteen patients had Schatzker type V fracture and the remaining had type VI. The functional outcome was assessed by using Modified functional evaluation system by Karlstrom - Olerud and the radiological outcome by Rasmussen's Radiological Score (RRS). RESULTS: All patients achieved radiological union at a mean duration of 16 weeks for type 5 and 17 weeks for type 6 however, full weight-bearing was allowed at a mean of 18 weeks (14 - 22 weeks). Functional results were excellent in 24 cases, good in 10 and poor in one. Most patients achieved functional range of motion at the knee joint (average flexion 1280) except one, who had a flexion of less than 1100. One patient with a delayed union united after bone marrow injection. Other complications included pin tract infections in 9 cases, axial malalignment of less than 100 in 4 cases and a prominent screw in one. CONCLUSION: Percutaneous restoration of articular anatomy and a ring external fixation with or without minimal internal fixation is an excellent method of treatment in this group of fractures caused by high energy trauma and with a usual association of severe comminution and a poor soft tissue envelope.

Abstract Background Open pilon fractures combined with sizeable segmental bone defects are rare, difficult to treat, and often result in the loss of ankle joint function. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures and sizeable segmental bone defects treated by limited ORIF combined with an Ilizarov external fixator. Methods We conducted a retrospective analysis of open pilon fractures with sizeable segmental bone defects treated by limited ORIF combined with the Ilizarov external fixator strategy between July 2014 and August 2019. All patients were included for assessments of fracture healing and infection rates. Ankle functional outcomes were assessed in all patients according to the Paley criteria and American Orthopedic Foot and Ankle Society Score (AOFAS) at least 24 months post-injury. Results All patients were followed up for a mean of 41.09 months. The mean bone defect size was 5.64 ± 1.21 cm. The average EFI and BTI were 1.56 ± 0.28 months/cm and 11.12 ± 0.74 days/cm, respectively. According to the Paley evaluation system, the success rate of ankle joint reconstruction was 64% (7/11). The mean score based on the AOFAS functional assessment was 77.73 ± 8.87. Five patients showed posttraumatic arthritis, one of whom required ankle arthrodesis. Three patients developed pin site infections, and one patient developed a deep infection after bone grafting. Conclusion The strategy of limited ORIF combined with an Ilizarov external fixator can restore ankle function in most patients with complex open tibial pilon fractures. Ankle stiffness, pin tract infection, and traumatic arthritis were the most common complications associated with this therapy.

PurposeThe rail fixator can improve the treatment outcome and provide good stability in patients with femoral bone transport. The purpose of this study is to investigate the clinical outcomes of bone transport using the Ilizarov technique by rail fixator in the treatment of femoral nonunion or bone defects caused by infection.MethodsClinical feature and treatment outcomes of 32 consecutive adult patients with femoral nonunion or bone defect caused by infection from January 2012 to January 2019 at a minimum of 2 years of follow-ups were retrospectively analyzed. Data were collected on participants' demographic details. All difficulties related to bone transport were documented according to Paley's classification. The clinical outcomes were evaluated using ASAMI criteria at the last clinical visit.ResultsAll 32 patients with an average follow-up of 33.5 months. There were 17 problems, 21 obstacles, and 8 complications, and the complication rate per patient was 1.4. The main complications were pin-site infection (53.1%), axial deviation (21.9%), joint stiffness (18.8%), the delayed union of the docking site (18.8%), soft tissue incarceration(15.6%), delayed consolidation(6.3%), malunion(6.3%), and refracture (3.1%). All the patients achieved bone union, and no recurrence of infection was observed. The excellent and good rates of ASAMI bone and functional results were 87.5% and 81.3%, respectively.ConclusionBone transport using the Ilizarov technique is an effective method for the treatment of femoral nonunion or bone defect caused by infection, and rail fixators have obtained satisfactory results in terms of bone and functional results.

Background: The management of infected metaphyseal nonunion of the tibia is devastating, especially when associated with significant bone loss, poor soft tissues, draining sinuses, axial deformity, knee or ankle joint stiffness, limb discrepancy, and multiresisted pathogens. A systematic review, performed recently by the primary investigators but not yet published, yielded the lack of studies in the field and the huge heterogeneity of the presented results. We found several bias and controversies such as no clear definition of the exact part of the tibia where the nonunion was located, the pathogen causing the fracture-related infection, the number of previous interventions and time to presentation, and the exact type of treatment methods including the use of muscle flaps or bone grafting. Time to final union as a functional score is another important but missing data. Objective: The proposed study is designed to evaluate a sufficient number of patients with infected metaphyseal tibial nonunions using various general health, functional, and bone scores. Methods: This prospective clinical trial study, with a minimum follow-up period of 36 months, focuses on the effectiveness of the Ilizarov method after radical nonunion debridement and targeted antibiotic therapy in patients with infected metaphyseal tibial nonunions. The primary outcomes would be the definite healing of nonunion and infection-free results. Secondary outcomes would be limb alignment and discrepancy, alteration in the patient’s quality of life, and functional results. A power analysis calculated a minimum of 11 patients to obtain statistical power, but we aim to include at least 25 patients. Limb discrepancy, clinical validation of infection eradication and fracture healing, radiographic validation, and patient-reported outcome measures will be highlighted and correlated. Statistical analysis of the results will offer data missing from the literature so far. Measurements are scheduled at specific times for each patient: preoperatively, 3 and 6 months postoperatively, 1 month after Ilizarov frame removal, and once per semester afterward until the end of the follow-up period (minimum 36 months). Laboratory evaluation will be assessed once per month. Any complication will be reported and treated when it occurs. Results: The trial has already started. It was funded in June 2020. As of May 2022, 19 participants have been recruited and no major complications have been noticed yet. Data analysis will be performed after data collection ends, and results will be published afterward. Conclusions: An infected metaphyseal tibial nonunion is a rare condition with limited treatment options and many controversies. There is no consensus in the literature about the best treatment strategy, and this lack of evidence should be fulfilled. [ABSTRACT FROM AUTHOR]

Introduction: Few studies have reported the treatment and rehabilitation of combined fractures of the femur, tibia, and ankle in the same lower limb., Case Report: A 69-year-old man presented to our hospital with a fall injury due to high-energy trauma after falling from a 5 m ladder while painting and landing on both feet. Examination revealed right femoral supracondylar; left tibial plateau; right calcaneal; left ankle crush; first and third lumbar vertebrae burst; sacral; C7, Th1, and Th9 compression; and bilateral acetabular fractures. External fixation of both femurs and tibias was performed on the day of injury. After the patient's general condition had stabilized, a two-stage operation was performed on the 8th day after injury for osteosynthesis of the left tibial plateau and right calcaneus fractures and ilizarov fixation of the left ankle crush fractures. In addition, the right femoral supracondylar fracture underwent osteosynthesis on day 15 after the injury, while the burst fractures of the first and third lumbar vertebrae underwent posterior fixation on day 24. The sacral fracture; C7, Th1, and Th9 compression fractures; and acetabular fractures were treated conservatively with a brace and no weight-bearing until the ilizarov apparatus was removed and gait training started. The ilizarov apparatus was removed 90 days after application.Mild passive and active assist rehabilitation on both toes and knees was started the day after the injury. Wheelchair transfer training was started 51 days after the injury. On day 60, trunk stability and swaying were eliminated and strength training in the sitting position was started. On day 107, the patient transferred without assistance (supervised). On day 121, weight-bearing and short-term standing training (right lower limb only) was started. On day 141, weight-bearing on both lower limbs was started. On day 148, the patient walked approximately 100 m using a walking aid. On day 176, the patient walked twice on parallel bars and 4 m with Lofstrand coupling while wearing a patellar-tendon-bearing orthosis. At 212 weeks, the patient walked long distances and use the Lofstrand for 100 m. The patient could also change direction smoothly., Conclusion: This study reports the treatment and rehabilitation of an elderly patient with bilateral compound fractures of the lower leg. The patient underwent long-term rehabilitation on the floor using the ilizarov method; however, with appropriate rehabilitation, he recovered to the point where he could walk., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Introduction: Treatment of diabetic foot ulcer is complex and expensive, and frequently results in amputation. Transverse Tibia Transport is a new strategy for diabetic foot ulcers, which is based on the techniques of distraction histogenesis., Presentation of Case: We present a 32-year-old male with longstanding insulin-dependent diabetes mellitus and many medical comorbidities with a non-healing heel ulcer of greater than 1 year. Following diagnosis of his diabetic foot ulcer complicated by osteomyelitis, he underwent a series of vascular and local wound interventions unsuccessfully. Transverse tibia transport was successful in healing the ulcer after 4 months. No complications were observed during follow up., Discussion: Distraction histogenesis mechanically stimulates regeneration of soft tissues such as muscles, tendons, and blood vessels by sustained tension. Inducing vascular regeneration at a targeted site has broad potential value for treating various disorders such as atrophic union and osteomyelitis., Conclusion: For patients with refractory diabetic foot ulcers, transverse tibia transport may be considered as a treatment option., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introducción: Las secuelas postraumáticas en los miembros son un cuadro de muy difícil abordaje por la gravedad de las lesiones, la falta de protocolos de tratamiento y especialmente por la elección de la mejor alternativa. El objetivo de este estudio fue analizar el resultado del tratamiento reconstructivo con un puntaje prequirúrgico diseñado para tal fin y evaluar su predictibilidad de resultado. Materiales y Métodos: Se realizó un análisis retrospectivo de tipo cohorte de los resultados del tratamiento con fijación externa en 32 pacientes con secuela traumática de la pierna en los últimos siete años que fueron estadificados con un puntaje preoperatorio elaborado para tal fin y comparado con el resultado obtenido con la tabla de resultados de la ASAMI con dos años de seguimiento mínimo. Resultados: Se obtuvo una relación directa entre la estadificación prequirúrgica y el resultado final. Dicha relación se ve reflejada en el alto porcentaje de excelentes resultados en pacientes de bajo riesgo (50%) y una tasa del 60% de malos resultados en pacientes de alto riesgo. Conclusiones: La evidencia actual es contradictoria y se discute cuál es la mejor opción de tratamiento. Los pacientes considerados de alto riesgo tienen un alto porcentaje de malos resultados y tal vez no se beneficien con la cirugía reconstructiva.

We report the case of an 18-year-old male with congenital absence of quadriceps and hypoplasia of the patella who presented with a significant leg length discrepancy (LLD) and knee flexion contracture. Surgical management was aimed toward lengthening the limb, stabilizing the joint, and correcting the knee flexion contracture. Correction of a significant congenital LLD and knee flexion contracture poses challenges due to long-standing altered biomechanics. These are rare conditions for which no accepted surgical algorithms exist. It is essential to anticipate the biomechanical consequences of limb lengthening and flexion contracture correction that might arise and plan comprehensive interventions accordingly.

Objective To assess the feasibility and results of tibial cortex transverse distraction (TCTD) followed by open correction with internal fixation (OCIF) for foot and ankle deformity with concurrent ulcers. Methods A retrospective analysis was conducted. Between 2010 and 2019, a two‐stage management of TCTD followed by OCIF was performed in 13 patients (13 feet). There were five males and eight females with a mean age of 33.8 ± 14.6 years. Ten patients had a right‐side lesion, and three patients had a left‐side lesion. The etiology of deformity included seven cases of congenital neurological disease, one case of Charcot–Marie–Tooth disease, one case of trauma sequelae, and three cases of myelomeningocele. Duration of disease, size of ulcers, surgical procedures, healing time, external fixation time, and complications of these patients were recorded. The Texas wound classification and National Pressure Ulcer Advisory Panel (NPUAP) classification were used for assessing the ulcers. The modified Dimeglio score of deformity and American Orthopeadic Foot and Ankle Society (AOFAS) ankle‐hindfoot score were applied to evaluate the status before treatment and the results at final follow‐up. Results The TCTD and wound debridement were performed in all patients, and an additional Ilizarov correction technique was added in two patients. All ulcers were healed in 3 months after first‐stage treatment. The median patient self‐report time of ulcer healing was 2.0 weeks (IQR, 1.8–3.3). The median external fixation time was 138.0 days (IQR, 134.5–141.5) days. After second‐stage operative correction, the patients were followed‐up for an average of 28.0 ± 2.9 months. At the final follow‐up, the modified Dimeglio score of deformity was decreased from 6.7 ± 2.1 to 1 (IQR, 0.0–1.0), and the mean AOFAS score was improved from 42.9 ± 19.1 to 82.6 ± 7.7. Before the treatment, there were eight patients with severe deformity, four patients with moderate deformity, and one patient with mild deformity. Postoperatively, seven patients were classified as mild deformity and six patients had a postural foot. The results of AOFAS ankle‐hindfoot score were defined as excellent in three patients, as good in five, and as fair in five. Complications include one case of mild displacement of the osteotomized cortex and one case of pin‐tract infection. No delayed union, nonunion, relapse of ulcers, or deformity were observed. Conclusions The two‐stage management of TCTD followed by OCIF could be considered as an alternative treatment for foot and ankle deformities combined with chronic ulcers.

The use of external fixators (EFs) for lower limb lengthening is common for treating lower limb length discrepancy (LLD) in children. The concern at present revolves around extended treatment times, with some suggesting a healing index (HI) > 45 days/cm as a major complication. The aim of this study is to assess the factors affecting bone healing and treatment duration in children who undergo limb lengthening for LLD using circular EFs. A total of 240 lengthening procedures on 178 children affected by congenital or acquired LLDs (mean age at surgery 13.8 ± 2.8 years) were retrospectively evaluated. Complications according to Lascombes’ classification and treatment duration factors were analyzed. Mean HI was 57 ± 25 days/cm for the femur and 55 ± 24 days/cm for the tibia, with an HI > 45 days/cm in 64% of the procedures. A total of 189 procedures (79%) reported complications; 85 had an HI > 45 days/cm as the sole complication. While reducing the frame time is crucial, revising the classifications is necessary to avoid the overestimation of complications.

Background: The limb reconstruction system (LRS), rail road fixator, and Ilizarov fixator are used to treat open fractures with bone loss and infective non-union of long bones. It benefits the fracture site by permitting distraction, compression, and further enhancing micromotion at the level of fracture site which plays an important part in healing. The LRS is a straightforward, unidirectional arrangement that provides exceptional strength and rigidity. The limb rebuilding procedure has proven to be an effective treatment option in instances of fracture infective non-union of long bones. Aims and Objectives: This study is to evaluate and to observe the use of limb reconstruction devices (such as the Ilizarov fixator and the rail road fixator) in the treatment of open fractures with bone loss and infective non-union of long bones. Materials and Methods: Twenty patients (15 males and five females) with fracture non-union of long bones were involved in this study after taking permission from ethic committee and consents from all 20 individuals. These patients then underwent thorough debridement and resection of non-viable bone ends with the application of limb reconstruction devices which were then followed by bone transport to fill the bone gap. This was done by means of Ilizarov in 13 patients and by rail road fixator in the remaining seven patients. The average time of union and complications were evaluated. Results: Mean duration of fracture union was 7.9 months. While one patient had failure resulting in non-union, other 19 patients achieved union by limb reconstruction devices. Majority of the cases had no complications. Mean period of hospital stay for Ilizarov was 68.13 days and for rail road fixator 53.17 days. After applying independent "t-test," no statistically significant differences were observed in fracture union duration between Ilizarov and rail road fixator, since the calculated P value was observed to be >0.05. Mean union of Ilizarov and rail road fixator application was found to be 7.6 months and 8.2 months, respectively. Conclusion: Limb reconstruction devices in our present study can be utilized as an effective way to tackle infective non-union of long bones and open fracture with bone loss for achieving better stabilization. Both Ilizarov and rail road fixator perform a crucial role in causing early mobilization of the patient and also in fracture union by distraction osteogenesis. [ABSTRACT FROM AUTHOR]

Gold standard surgical treatment remains controversial for pilon fractures. This retrospective study aimed to analyze the mid-term results of tibial pilon fractures that were treated with the Ilizarov external fixator and Minimally Invasive Plate Osteosynthesis (MIPO). The study population consists of 50 patients with a minimum of one-year follow-up. Patients were divided into two groups bases on the treatment method (Group 1, Ilizarov, n=25; Group 2, MIPO, n=25). The American Orthopaedic Foot and Ankle Society (AOFAS) score, the Foot and Ankle Disability Index (FADI), and Visual Analogue Scale (VAS) score were used in the evaluation of functional outcomes. Ankle and subtalar joint range of motion (ROM) were evaluated at the last evaluation. The association between reduction quality and the development of ankle OA was analyzed as well. There was no significant difference between the two groups regarding AOFAS, FADI, VAS scores, and ankle ROM at the last follow-up (P>0.05). Also, union time and complication rates were similar between the two groups (P>0.05 ). Both MIPO and the Ilizarov techniques are effective and safe methods with low complication rates in the treatment of pilon fractures. [ABSTRACT FROM AUTHOR]

Context: Hexapod circular external fixators allow bone manipulation in all planes to correct complex deformities. However, the patient must perform the strut adjustments consistently and correctly, often multiple times daily for weeks or months, to achieve intended corrections. This presents a potential source of variability, error, and anxiety to the patient. A computer-programmed, robotic automated motorized strut adjustment technology (Maxframe Autostrut™ Multi-Axial Correction System, Orthospin Ltd., Yoqneam, Israel) has been developed which automatically adjusts the struts without patient or clinician involvement. Aims: The aims of this study were as follows: first, to determine whether the motors performed the programmed initial and residual schedules and, second, to identify technology-specific problems and their management. Settings and Design: This was a retrospective observational study of a consecutive series of the first 16 patients who had the motorized hexapod frame applied. Subjects and Methods: A chart review was performed to record demographic information, indications and goals for hexapod frame care, whether the care goals were achieved, and whether unexpected and/or adverse events occurred (such as technical difficulties and medical complications) and the management of those issues. Statistical Analysis Used: Not applicable. Results: All patients achieved the index and residual adjustments as programmed. Conclusions: The Autostrut™ system appears reliable and safe. It executes programmed index and residual adjustments as well as strut change scenarios as directed. The system recognizes unexpected mechanical or programming issues and ensures patient safety by halting progress and alerting the patient. Future versions of the technology may benefit from added features such as remote reprogramming or current strut position monitoring. [ABSTRACT FROM AUTHOR]

Introduction: Nonunion of long bone fractures is a common condition encountered by an orthopedic surgeon in daily practice. For effective treatment of nonunion, internal fixation with or without bone grafting can be done but, an infected non union can prove to be a tough challenge. The aim of our study is to assess the surgical and functional outcomes of infected nonunion of femur and tibia treated with debridement, corticotomy and Ilizarov ring fixator. Materials and Method: This was a multi-centric prospective study of twenty patients in a time span of three years from May 2017 till April 2020. Observations and Results: Patients were assessed using clinical and functional results as per Association for the Study and Application of Methods of Ilizarov (ASAMI) Scoring System. Conclusion: The Ilizarov method remains one of the most successful and versatile means of achieving bone-healing in infected nonunion of long bones of lower limbs with benefits of correcting deformities, bone defects and limb length discrepancy. [ABSTRACT FROM AUTHOR]

Background: Femoral lengthening is generally considered a cumbersome procedure due to the long fixator duration and complexity of the surgery. Lengthening over nail and lengthening over plate (LOP) have solved most of the problems but are associated with the risk of deep infection and plate prominence, respectively. We report a series of 14 cases with the use of a slotted plate to minimize both the problems. Materials and Methods: The study includes 14 patients, 8 females and 6 males, including four children. The average age of patients was 17.8 years, ranging from 7 years to 30 years. Femoral lengthening was performed with Ilizarov external fixator and slotted plate. Results: The target length ranged from 3 cm to 7 cm with an average of 4.6 cm. External fixator duration achieved ranged from 42 days to 92 days with a mean external fixator duration of 61.5 days. The mean external fixator index was 13.3 days/cm. We had no incidence of plate prominence or deep infection. We had four cases of knee stiffness, of which one needed surgery. All the patients had good quality regenerate and consolidation. Conclusion: The use of a slotted plate for LOP in femoral lengthening is a useful technique to minimize the incidence of plate prominence associated with LOP. [ABSTRACT FROM AUTHOR]