Search

Purpose: The study aimed to evaluate preliminary clinical and radiographic results of patients with Cierny-Mader type IV chronic femoral osteomyelitis and augmented with a non-vascularized fibular autograft as a salvage procedure because of the poorly regenerated new bone after bone transport over an intramedullary nail (BTON)., Methods: Patients diagnosed with CM type IV chronic femoral bone infection and treated with BTON procedure between 2003 and 2020 were retrospectively reviewed. Seven patients were included in the study whose distraction gap was poorly regenerated and then augmented with a non-vascularized fibular autograft. A three-stage treatment was administered. First, the infection was eradicated. Second, BTON was performed. Third, the poorly regenerated distraction gap was augmented with a fibular autograft before removing the external fixator (EF). Clinical and radiological results were evaluated based on the criteria described by Paley-Maar and Li classification., Results: The mean patient age was 52 years. The mean treatment time was 24.8 months, with a mean femoral lengthening of 12.6 cm. The mean EF and bone healing indexes were 0.57 months/cm and 0.8 months/cm, respectively. The mean length of the fibular graft was 13 cm. The bone healing of new bones was achieved in all patients with good quality after grafting. Functional scores were excellent in four patients. No patients experienced any sequelae., Conclusions: Non-vascularized fibular autograft augmentation may be an effective salvage procedure for poorly regenerated new bone after BTON to manage chronic femoral bone infection., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

We aimed to retrospectively investigate and compare patients who underwent bilateral simultaneous and consecutive lengthening surgery of the femur and tibia in terms of the effect on physeal growth. We hypothesize that compared with the sequential lengthening technique, simultaneous lengthening of the bilateral femur and tibia affects physeal growth to a greater extent. Twenty-six patients with achondroplasia who operated in our clinic between 1995 and 2015 for limb lengthening were included in the study. Fourteen patients with bilateral lengthening of the femur and tibia at the same time were named as simultaneous bilateral lengthening (SBL). Twelve patients with bilateral lengthening of the femur and then bilateral tibia lengthening in other sections or vice versa, at a different time was named consecutive bilateral lengthening (CBL). All patients were followed until at least 18 years old. The physeal arrest was measured with predicted final length at the first visit (investigated with the multiplier method), the total amount of lengthening, and final clinical, and radiological length. Mean limb lengthening was 145 mm (48.5%) and 151 mm (46.6%) for simultaneous and consecutive groups respectively. For lower extremity length, the first group reached 527.6 mm while the expected was 447.3 mm. Considering 151 mm lengthening, the mean growth disturbance for the SBL group was 70.7 mm and for the CBL group was 47.5 mm. For total height comparing between two groups, disturbance for height was 80.5 mm and 65.4 mm, respectively. Although there was no statistical difference, simultaneous bilateral femoral and tibial lengthening has more physiological physeal disturbance effects than consecutive lengthening in patients with achondroplasia., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

This study aims to present our results for limb salvage in Gustilo IIIC open fractures of the femur and tibia. 92 patients with Gustilo IIIC fractures operated in our clinic between January 2000 and March 2016 were retrospectively evaluated. Demographic data, ischemia time, method of arterial repair, means of primary and secondary fixation, time to amputation, complications, and final VAS scores were recorded. The difference between the primary amputation rates of tibia and femur fractures was not statisti- cally significant (18% vs 21%, p>0.05). The difference between the secondary amputation rates of tibia and femur fractures was not significant (16% vs 27%, p>0.05). All secondary amputations were done within the first month during the initial hospital stay. Overall limb salvage rate was 69% for Gustilo IIIC fractures of the femur and 58% for Gustilo IIIC fractures of the tibia. The overall limb salvage rate was not significantly different between the two groups (p>0.05). At the final follow-up, patients in the limb salvage group had average VAS scores of 4.3 (femur) and 4.7 (tibia). The decision between amputation versus limb salvage remains a difficult decision that should be jointly made by the treating physicians and the patient.

Objectives: This study investigated the effect of the femur, tibia, and humeral lengthening rate in patients with achondroplasia and regenerated bone quality., Methods: The records of the patients with achondroplasia who underwent limb lengthening surgery for both upper and lower extremities between 2002 and 2019 were retrospectively reviewed. Bone formation regeneration was evaluated in each segment at anteroposterior and lateral radiographs and the callus quality was determined at the first month of the consolidation period according to Li's classification system., Results: This study included 42 (28 females and 14 males), 38 (26 females and 12 males), and 17 (11 females and 6 males) patients with bilateral femoral, bilateral tibial, and bilateral humeral lengthening. The mean lengthening rate was 0.920 ± 0.23 (range, 0.53-1.67), 0.813 ± 0.17 (range, 0.51-1.26), and 1.02 ± 0.26 (range, 0.58-150) mm/day in the femoral, tibial, humeral groups, respectively. In the femoral group, 75% femur with good morphological quality, 56.6% good morphological quality in tibial group and 55.9% good morphological quality in humeral group. Statistically significant relationships were found between femoral lengthening rate and callus quality ( p  < 0.001; r  = 0.454). However, no significant correlation was found in the humeral and tibial groups. Moreover, the sensitivity and specificity of the lengthening rate for obtaining good morphological quality callus were 72% and 80%, respectively, with an optimum diagnostic cutoff value of 0.976 mm/day for femoral lengthening., Conclusions: A higher-rate good morphological callus was obtained in femoral lengthening compared with tibia and humerus in patients with achondroplasia., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© Indian Orthopaedics Association 2022.)

The present randomized controlled study aims to evaluate whether tourniquet application during total knee arthroplasty (TKA) has an effect on (1) thigh muscle strength (quadriceps and hamstring muscle strength) and (2) clinical outcomes (postoperative knee range of motion [ROM], postoperative pain level, and Knee Society Score [KSS]). The effects of tourniquet application during TKA were investigated in 65 patients randomly allocated to one of two groups: TKA with a tourniquet and TKA without a tourniquet. Patients in both groups were comparable in terms of the demographic and clinical data ( p  > 0.05 for age, number of patients, sex, radiographic gonarthrosis grade, American Society of Anesthesiologists [ASA] classification, and body mass index [BMI]). All patients in both groups were operated by the same surgeon using one type of prosthesis. Isokinetic muscle strength (peak torque and total work) of knee extensors (quadriceps) and flexors (hamstrings) was measured in Newton meters (Nm) using a CYBEX 350 isokinetic dynamometer (HUMAC/CYBEX 2009, Stoughton, MA). The combined KSS (knee score + function score), visual analog scale (VAS), and knee ROM were measured preoperatively and at 1 and 3 months postoperatively to evaluate clinical outcomes. There were no significant differences between the two groups in preoperative and postoperative values of isokinetic muscle strength (peak torque and total work) and aforementioned clinical outcomes ( p  < 0.05). The present study has shown that quadriceps strength and clinical outcomes were not improved in the early postoperative period (3 months) when a tourniquet was not used during TKA., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: This study aims to evaluate the effect of lengthening speed on the quality of callus and complications during distraction osteogenesis and describe an optimal lengthening speed in patients with congenital pseudarthrosis of tibia (CPT)., Methods: Twenty-seven patients with CPT with a minimum follow-up of 36 months who underwent limb lengthening surgery between 1997 and 2016 with external fixator only were included in this study. All patients underwent lengthening procedures after achieving complete bone union in this study. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction period. Complications were noted in post-operative follow-up period. Receiver operator characteristics (ROC) curve analysis was performed to obtain optimal lengthening speed for these patients., Result: The mean age at the time of surgery was 5.74 years. The mean lengthening speed was 0.596 mm/day. Follow-up period of 136.14 months with a mean lengthening period of 92.4 days. Mean amount of lengthening was 5.44 cm for patients with CPT. Total rate of callus with good morphological quality was calculated as 66%. According to ROC analysis, optimal cut-off values of lengthening speed for the obtaining good morphological quality callus was 0.564 mm/day for tibial lengthening in CPT. There was a significantly positive correlation between complication rate and lengthening speed for each group., Conclusion: We recommend a mean lengthening rate of 0.56mm/day for the lengthening procedures with external fixator in patients with CPT who had complete bone union at the area of pseudarthrosis.

Objective: To evaluate a combined technique for treating distal femoral bone defects after debridement of osteomyelitis, using an external fixator together with a short supracondylar nail., Design: Retrospective study., Setting: Single tertiary referral center., Methods: Between 2003 and 2018, 23 patients with a mean age of 37.2 years (26-56) underwent surgery with the same technique to manage postdebridement defects in the distal femur due to osteomyelitis. This involved acute shortening and intramedullary fixation of the defect site, together with relengthening from a proximal osteotomy using simultaneous external fixation. Radiographic union, range of motion of the hip and knee, external fixation time and external fixation index, and limb length discrepancy were assessed., Results: The mean follow-up was 51 months (18-192). Union was achieved in all patients without recurrence of infection during this follow-up period. The mean knee flexion was 120 degrees, and the mean extension deficit was 5 degrees at final follow-up. The mean limb length discrepancy improved from 5.5 cm (3-7) to 0.5 cm (0-2). The mean external fixation index was 29.2 d/cm (20-50), and the mean external fixation time was 115 days (90-150). Radiographic scores were excellent in 15 cases, good in 6, and fair in 2. Functional scores were excellent in 14 cases, good in 7, and fair in 2., Conclusion: This combined strategy was an effective method for treating distal femoral segmental bone defects after debridement of osteomyelitis, with a high rate of union and acceptable complication rates., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective: The aim of this study was to investigate whether there is an increased risk of anterior knee pain (AKP) after total knee arthroplasty (TKA) without patellar resurfacing in patients with rheumatoid arthritis (RA) versus primary osteoarthritis (OA)., Methods: This study was a retrospective review of 388 patients (577 knees) who underwent TKA without patellar resurfacing between 2003 and 2011, with a minimum of 5 years of follow-up. Patients were divided into two groups: Group OA (273 knees of 206 patients; 83 males, 123 females; mean age: 64.4 (47-87) years) and Group RA (304 knees of 182 patients; 92 males, 90 females; mean age: 50.7 (21-72) years). In the clinical evaluation, the knee range of motion (ROM) and several outcome measures such as The Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and International Knee Documentation Committee (IKDC) scores were used preoperatively and at the final follow-up visit. The quality of life was measured using Short Form (SF)-36 MCS and PCS scores. The primary outcome was the frequency and severity of patient-reported AKP. The AKP Scale was used to determine the severity of AKP., Results: The IKDC raised from 21.62 (range, 13-29.9) preoperatively to 85.1 (range, 80-88) for group OA and from 21.8 (range, 13-29.9) to 85.2 (range, 81-88) for group RA (p < 0.001). The mean KSS improved from 28.35 (range, 22-38) preoperatively to 90.04 (range, 88-95) for group OA and from 21.9 (range, 18-35) preoperatively to 89.7 (range, 86-95) for group RA. The mean WOMAC increased from 20.61 (range, 17.4-24.2) preoperatively to 95.7 (range, 90.9-97.7) for group OA (p < 0.001) and from 20.2 (range, 16.7-24.2) preoperatively to 95.8 (range, 90.9-98.5) for group RA (p < 0.001). The mean ROM improved from 80.14° (range, 55°-130°) preoperatively to 113.17° (range, 95°-140°) in group OA (P = 0.003) and from 73.4° (range, 10°-130°) to 112.8° (range 90°-140°) in group RA (P = 0.003) postoperatively. The frequency of AKP was 8% in Group OA and 7% in Group RA (p = 0.27). For patients with AKP, the mean AKP Scale was 92.74 (range, 84-98) in Group OA and 93.39 (range, 82-98) in Group RA (p = 0.3)., Conclusion: After TKA without resurfacing the patella, patients with RA were determined to have a similar risk for AKP as those with OA., Level of Evidence: Level III, Therapeutic Study., (Copyright © 2019. Production and hosting by Elsevier B.V.)

Introduction: We studied the safety and incidence of complications from the treatment of gunshot-induced femur diaphysis fractures with locked intramedullary nailing in comparison to external fixation., Methods: Patients who had femoral diaphysis fracture operations due to gunshot injuries (107 femurs of 99 patients) between 2003 and 2014 were retrospectively reviewed, and 66 femurs of 60 patients were place into two groups (Group A: intramedullary nailing-38 femurs of the 36 patients; Group B: external fixator-28 femurs of 24 patients). The mean follow-up was 76.3 months (22-131). The study outcomes were patient complications, infection rate, union time, need for secondary surgery, functional assessment with lower extremity functional scale, and radiological evaluation with orthoroentgenograms., Results: The mean age of the patients was 37.3 ± 7.4 years in Group A and 39 ± 6.1 years in Group B. There was no significant difference between the two groups in age, gender or follow-up. There were two deep infections (5.2%) in Group A and one deep infection (3.5%) in Group B. Delayed union was observed in four patients (10.5%) in Group A and in two patients (7.1%) in Group B. There was one non-union (2.6%) and one non-union (3.5%) in Group A and Group B, respectively. There was no significant difference between the two groups in incidence of union, delayed union or deep infection. The mean union time was 3.1 ± 2.5 months in Group A and 5.8 ± 1.4 months in Group B. The union time was significantly lower in the intramedullary nailing group (p = 0.023). There were no significant differences between the two groups in regards to radiological and functional evaluation., Discussion: This study showed similar complication rates and functional results both for external fixator and intramedullary nailing for the treatment of femoral diaphysis fractures due to gunshot injuries., Level of Evidence: Level 3 retrospective comparative clinical study.

Introduction: The rare Nievergelt syndrome (NS) is the most severe form of mesomelic dysplasia and is characterized by disproportionate shortness of the limbs. The aim of this case report was to describe the clinical and radiological features of a rare case of NS., Presentation of Case: Here we describe a female patient originally presenting with bilateral hand, lower leg, and foot deformities at the age of 10 years old. In addition to the characteristic features of NS, this patient presented with finger-like projections on her heels, bilateral hand anomalies, and atypical facial features. She underwent concomitant bilateral tibial lengthening and deformity correction using external fixators due to severe bilateral lower leg deformities with shortness. At 10 years of age, this patient was able to walk independently with significant improvement in her ambulation., Discussion: There is a clear gap in the literature regarding the orthopedic management of mesomelic limb deformities due to NS. No studies have been designed to illustrate surgical planning in the management of orthopedic deformities in this rare syndrome., Conclusion: Limb lengthening and deformity correction using an external fixator can be considered as a salvage method or alternative to amputation for patients with severe mesomelic limb deformities due to NS., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Salvage or amputation for grade 3C open fracture of tibia is not well responded question universally because of surgical innovations, cultural believes, difficulties in estimate the outcome, coasts, and different results in the literature. The aim of this study was to evaluate the surgical outcomes of Gustilo grade 3C open tibia fractures with at least two years follow-up in non-military adults., Methods: Twenty-two non-military patients with a mean age of 31.1 were operated with grade 3c open fractures at tibia level in last 10 years in our clinic. We evaluated them retrospectively and asked about their daily life, pain, and if present, about the wish for secondary amputation. We also asked if they would prefer a first day amputation rather than their present status., Results: Mean operation time after the injury was 13 h. Seven patients had nerve injury. Mean operation number was 3.5. Eight patients (%36) (all due to circulatory problem) had to have amputation. All patients treated with temporary unilateral external fixation than converted to circular external fixators when soft tissue healing was completed. Two patients were reoperated because of deformity. Four patients needed revision surgery because of non-union. At long term follow, we had osteomyelitis in one patient., Conclusions: Scoring systems and the ischemic time are not the only predictors of amputation. The decision of the treatment mode should be made by the patient and the care team after discussing the options and outcomes rather than relying on a scoring system.

Purpose: To review the outcome of Wagner double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in 7 adolescents., Methods: Records of one male and 6 females aged 15 to 20 years who underwent modified Wagner osteotomy for trochanteric overgrowth and a short femoral neck by a single senior surgeon were reviewed. The diagnoses were coxa vara (n=2), developmental dysplasia of the hip (n=3), Leg-Calve-Perthes (n=1), and proximal femoral focal deficiency (n=1). Radiological indication for double intertrochanteric osteotomy included a neck-shaft angle (NSA) <120º or a centre trochanter distance (CTD) <28 mm. Function was evaluated using the Children's Hospıtal Oakland Hip Evaluation Scale (CHOHES). The articulotrochanteric distance (ATD), CTD, NSA, and the distance between the centre of the femoral head and the centre of the acetabulum (MZ) were measured on radiographs., Results: The mean follow-up duration was 61 (range, 28-86) months. The ATD improved from 16±11.5 mm to -6.3±10.2 mm (p=0.018), the CTD from 27.9±3.5 mm to 36.4±7.1 mm (p=0.018), the NSA from 112º±24.4º to 131º±16º (p=0.028), the MZ from 12.7±6.5 mm to 7.7±4.2 mm (p=0.028), and the CHOHES score from 62.1±8.7 to 84±9.6 (p=0.017). One patient had delayed union. Two patients had persistent Trendelenburg gait. Two patients declined second-stage surgery for acetabular dysplasia after solving the femoral side problems at the first stage. One of them developed hip arthrosis., Conclusion: Double intertrochanteric osteotomy is a viable treatment option for adolescents with trochanteric overgrowth and a short femoral neck.

The reported incidence of infection in total knee arthroplasty (TKA) varies from 0.5 to 15%. The most common indication for knee arthrodesis is persistent infection after repeated staged knee replacement. The purpose of this study is to investigate the success of fusion with monoplanar fixators and eradication rates of infection, and to evaluate the satisfaction of patients who underwent a last-resort TKA due to infection.This is a retrospective review of infected knee arthroplasties that were treated with knee arthrodesis using unilateral external fixators at a single institution from 1999 through 2012. The patients' charts were analyzed for demographics, types of external fixators used, infection parameters, external fixator indexes, complications, positions of fusion, and leg length discrepancies (LLDs). Patients were called back to return for additional follow-up. A self-administered general health status questionnaire (SF-36) was assessed to evaluate life quality.There were 14 women and 3 men with an average age of 67 ± 16.6 years. Antibiotic-loaded acrylic cements were used as a spacer for an average of 3.4 ± 1.2 months in all patients. Monoplanar type of external fixator was used in all 17 patients. Fusions were achieved in all but one patient. The mean duration of fusion was 6.8 ± 2.2 months and external fixator duration was 7.6 ± 2.4 months. Average LLD was 2.9 ± 1.7 cm. The mean coronal alignment of fusion was 6.8 degrees (± 3.3 degrees, range 4-15 degrees) valgus and mean flexion was 11.3 degrees (± 6.5 degrees, range 3-30 degrees). Compared with the healthy controls, the SF-36 scores were significantly lower in patients with knee arthrodesis (physical component score [PCS]-arthrodesis: 39.3 vs. PCS- healthy controls: 47.9, p  < 0.05; mental component score [MCS]-arthrodesis: 38.6 versus MCS-healthy controls: 47.7, p  < 0.05).Use of monoplanar fixators for arthrodesis in infected TKA can achieve high fusion rates with the control of infection. If fusion can be achieved, the patient satisfaction is low with acceptable pain relief and functionality. We observed that monoplanar external fixators increased patients' comfort levels compared with circular external fixators. Further studies are needed to compare different arthrodesis modalities in patients with infected TKA., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The management of nonunion and limb length discrepancy has remained a constant challenge in hemophilic patients. In this study, we aimed to present the treatment of femur infected nonunion and limb length discrepancy in a twenty-seven-year-old patient with hemophilia type A. A 27-year-old male patient with hemophilia type A referred to our institution for the treatment of right femur infected nonunion and 10 cm shortness of the femur. Resection of the nonunion site and bone-to-bone fixation with autologous bone grafting were performed. Compression to the pseudoarthrosis site and distraction from new osteotomy site were applied with the unilateral external fixator. Union was achieved, and 6 cm lengthening was obtained according to the initial length. Patient was followed up for 7 years. After this treatment, the patient is able to walk with full weight bearing on the affected extremity with 4 cm shortening which is compensated by the heel lift. The results of this case indicate that limb lengthening and treatment of nonunion with the external fixation could be reliable and effective method for hemophilic patients.

A retrospective study was performed in 18 patients with achondroplasia, who underwent bilateral humeral lengthening between 2001 and 2013, using monorail external fixators. The mean age was ten years (six to 15) and the mean follow-up was 40 months (12 to 104). The mean disabilities of the arm, shoulder and hand (DASH) score fell from 32.3 (20 to 40) pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A mean lengthening of 60% (40% to 95%) was required to reach the goal of independent perineal hygiene. One patient developed early consolidation, and fractures occurred in the regenerate bone of four humeri in three patients. There were three transient radial nerve palsies. Humeral lengthening increases the independence of people with achondroplasia and is not just a cosmetic procedure., (©2015 The British Editorial Society of Bone & Joint Surgery.)

Background: Infection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained., Questions/purposes: In a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus?, Methods: An open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection., Results: Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43-340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3-16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2-3) in the infection group and complete union was observed (Lane and Sandhu score of 3-4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9)., Conclusions: Retaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result., Clinical Relevance: This model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

Grade 3C open femur fractures are challenging injuries with higher rates of complications. This is a retrospective review of grade 3C open femur fractures with vascular repair between 2002 and 2012. Outcomes included initial MESS score, additional injuries, duration of operation, complications, secondary operations or amputations, and social life implications. Thirty-one of 39 total patients were selected for revascularization and fracture fixation based on soft tissue injury and MESS score. The intra-operative approach included temporary arterial shunt replacement, orthopedic fixation, arterial reconstruction venous and/or nerve repair and routine fasciotomies. An external fixation and reverse saphenous vein graft was used in a majority of the patients (respectively; 93.5%, 90.3%). The mean follow up was 5.4 years (range 2.2-10). The decision to amputate versus salvage should be left up to patients and their care teams after discussing options and future possibilities rather than using a scoring system.

Haemophilia, a bleeding disorder, causes recurrent intra-articular bleeding of the joints result-ing in chronic haemophilic arthropathy with fixed knee flexion deformity. Mid-long-term results (between 2002 and 2006) of deformity correction in haemophilic patients with Ilizarov type circular external fixators were retrospectively evaluated. There were six patients (five haemophilia A and one haemophilia B). The mean age was 14.7 years (range, 8-22 years) at the time of initial surgery. The mean knee flexion contracture was 45 degrees (range, 30-75 degrees). The mean arc of motion was 58.3 degrees (range, 40-100) before the surgery. The mean duration of follow-up was 8 years (range, 5.5-10 years). The mean duration of external fixation was 4.4 months (range, 2.5-10.5 months). Full extension of the knee joint was obtained in all patients in the early postoperative period. No bleeding, neurological or vascular complications were encountered. The mean amount of recurrence in knee flexion contracture was 10 degrees (range, 0-15 degrees). The amount of the correction was significant (P = 0.0012) and the mean arc of motion was 51.6 degrees (range, 25-90 degrees) that show a decrease of 6.7 degrees (P = 0.04) at the end of follow-up. The circular external fixator is an important, safe and less invasive alternative surgical treatment modality with low recurrence rate. Using the external hinges and distraction during the correction has a protective effect on the joint. It requires a team-work consisting of a haematologist, an orthopaedic surgeon and a physical therapist., (© 2014 John Wiley & Sons Ltd.)

Objective: The aim of this study was to analyze the results and complications of simultaneous bilateral femoral and tibial lengthening in achondroplastic patients., Methods: The study included the 44 femora and 44 tibiae of 22 achondroplastic patients (16 females, 6 males; mean age: 6.36 years, range: 3 to 11 years) that underwent simultaneous lengthening. Orthofix LRS monolateral fixators were used for femoral lengthening and either Ilizarov-type or hexapod-type circular external fixators for tibial lengthening. Tenotomies of the hip flexors and the Achilles tendon were performed to prevent injury to the growth plates and to prevent joint contractures. Results and complications were evaluated according to Paley's scoring and complication systems., Results: Average follow-up time was 35 (range: 26 to 76) months. The femora were lengthened by an average of 7.07 cm (46.1%), and the tibiae by an average of 6.64 cm (52.9%). Patients gained an average of 16.9 cm in height, including physiological growth. The mean bone-healing index (BHI) was 31.2 days/cm for the femora (range: 17.4 to 43.3 days/cm) and 34.3 days/cm for the tibiae (range: 19.5 to 60.0 days/cm). Complications included 3 delayed maturations, 3 pin track infections, 5 transient fibular paralyses, 5 regenerate fractures, 1 late varus deformity, 1 knee contracture and 1 knee contracture secondary to knee dislocation. Functional scores were excellent in 78 segments, good in 8, fair in 1 and poor in one. There was no growth inhibition related to the lengthening., Conclusion: Bilateral simultaneous lengthening of the femora and tibiae in achondroplastic patients provided a reduction in total treatment and external fixation time, with a low rate of complications.

There is currently a consensus regarding the superiority of circular type external fixators over uniplanar fixators for lengthening of the tibia, but femoral lengthening is still subject to the surgeon's preference. This study compares the occurrence rates of significant problems, obstacles and sequelae between these two techniques. Fifty patients (29 male, 21 female), with a mean age of 20 years were assigned to a circular type fixator group (54 lengthening segments), whereas 60 patients (29 male, 31 female), with a mean age of 20 years were assigned to a uniplanar fixator group (67 lengthening segments). The incidence of knee stiffness was significantly higher in the circular external fixator group (031 per segment) compared to the uniplanar external fixator group (0.13 per segment) (p < 0.05). The incidence of pain during lengthening was higher in the circular external fixator group, and patient satisfaction was higher in the uniplanar external fixator group. We recommend the uniplanar external fixator as a preferable device for femoral lengthening.

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed. The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60). One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation. We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.

Unlabelled: Diraçoğlu D, Alptekin K, Dikici F, Balci HI, Ozçakar L, Aksoy C. Evaluation of needle positioning during blind intra-articular hip injections for osteoarthritis: fluoroscopy versus arthrography., Objective: To evaluate needle positioning during blind/anatomically referenced hip joint injections for osteoarthritis (OA)., Design: Experimental clinical study., Setting: Operating theater of a university hospital., Participants: Patients (N=16) (10 women, 6 men), who were diagnosed as having OA according to the American College of Rheumatology criteria and whose radiologic grades were II or III according to Kellgren-Lawrence., Interventions: Three bilateral and 13 unilateral hip injections were performed (3 times at 1-week intervals). After it was presumed blindly that the needle was within the joint, the location of the needle was checked with backflow technique and fluoroscopy. Entrance to the joint cavity was also ensured by reconfirmation with contrast medium, and the procedure was then terminated with hyaluronic acid injection., Main Outcome Measures: Assessment of blind needle placement into the hip joint by using backflow technique, fluoroscopic images, and contrast enhancement., Results: The location of the needle was fluoroscopically confirmed to be at the proper position in 38 (66.7%) of the 57 blind interventions. Furthermore, in 29 (76.3%) of those 38 interventions, localization of the intra-articular needle could be confirmed by intra-articular contrast uptake. Overall, 29 of 57 (50.9%) blind interventions exhibited intra-articular contrast enhancement. Backflow was not observed in 23 (79.3%) of these 29 interventions. Five (17.9%) of 28 interventions with no contrast uptake showed backflow., Conclusions: In light of our results, we suggest that blind injection of the osteoarthritic hip joint can be inaccurate even with careful technique. Further, the backflow method does not appear to be reliable, and guidance during the injection seems to be necessary.

We retrospectively evaluated the results after ulnar lengthening and radial deformity correction using an external fixator for forearm deformities caused by osteochondromas. Eight forearms were treated surgically in seven patients with multiple hereditary osteochondroma. The mean follow-up time was 40 months (range, 20 to 60 months). The average radial articular angle improved from 43 degrees to 35.5 degrees (range, 28 to 56 degrees) and the carpal slip improved from 69.5% to 55% (range, 40 to 60%) postoperatively. The average shortening of the ulna was reduced from 2.06 cm to 0.44 cm (range 0 to 1 cm) after the treatment. There were no serious complications associated with the surgery; two minor pin track infections were successfully treated by local wound care and antibiotics. Although technically demanding, ulnar osteotomy and gradual lengthening by an external fixator provided promising results in the treatment of forearm deformities in children with multiple osteochondroma.

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.