The humerus is the best place for bone lengthening

Age-related Outcomes and Complications of Osteodistraction in the Pediatric Upper Extremity: A Large Retrospective Single-center Study of 61 Cases

BACKGROUND

The study purpose was to assess: (1) the complication rate of osteodistraction in the pediatric upper extremity, its severity and relation to patient-specific and treatment-specific parameters, and (2) dedicated patient-reported outcome scores after these procedures.

METHODS

This retrospective study analyzed a chart of patients undergoing osteodistraction of the upper limb between 2003 and 2020. Demographics, distraction-specific parameters, healing index, and any complications graded according to the Sink grading scale (grades 1 to 5) were extracted. An additional phone interview was performed to assess patient satisfaction and functionality of the elongated limb using the Quick-DASH (Disabilities of Arm, Shoulder, and Hand) score.

RESULTS

This study included 61 cases from 48 individual patients. The mean age at the start of distraction was 11.5±3.6 years. The ulna was the most frequently lengthened bone, with 21 (34.4%) cases. Ninety-four complications were observed, with an average complication rate of 77.0%. Based on the Sink grading scale (1 to 5), grade 3 complications were most common (n=29; 47.5%) followed by grade 1 (n=14; 23.0%), 2 (n=14; 23.0%), and 4 (n=4; 6.6%). A significantly lower and thus better bone healing index was observed for the age category less than 10 years compared with the 14 to 18 years group (P=0.006). The average satisfaction was 4.2±1.0 points of 5. The mean Quick-DASH score was 14.1±12.5, indicating very good clinical outcomes.

CONCLUSIONS

Despite the occurrence of numerous complications, high patient satisfaction and good daily life functionality of the treated limb was observed. An age of more than 14 years at the beginning of therapy had a negative prognostic effect on bone healing during distraction. Thus, osteodistraction in the upper extremity may preferably be performed less than 10 years of age because of enhanced bone regeneration.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Enhancing the Efficiency of Distraction Osteogenesis through Rate-Varying Distraction: A Computational Study

Distraction osteogenesis (DO) is a mechanobiological process of producing new bone and overlying soft tissues through the gradual and controlled distraction of surgically separated bone segments. The process of bone regeneration during DO is largely affected by distraction parameters. In the present study, a distraction strategy with varying distraction rates (i.e., "rate-varying distraction") is proposed, with the aim of shortening the distraction time and improving the efficiency of DO. We hypothesized that faster and better healing can be achieved with rate-varying distractions, as compared with constant-rate distractions. A computational model incorporating the viscoelastic behaviors of the callus tissues and the mechano-regulatory tissue differentiation laws was developed and validated to predict the bone regeneration process during DO. The effect of rate-varying distraction on the healing outcomes (bony bridging time and bone formation) was examined. Compared to the constant low-rate distraction, a low-to-high rate-varying distraction provided a favorable mechanical environment for angiogenesis and bone tissue differentiation, throughout the distraction and consolidation phase, leading to an improved healing outcome with a shortened healing time. These results suggest that a rate-varying clinical strategy could reduce the overall treatment time of DO and decrease the risk of complications related to the external fixator.

Upper Limb Lengthening in Achondroplasia Using Unilateral External Fixation

PURPOSE

The purpose of this study was to analyze the long-term results of humeral lengthening in achondroplastic patients and make suggestions on the most appropriate surgical technique to improve patient outcomes.

METHODS

Fifty-four humeral lengthening procedures performed in 27 achondroplastic patients were reviewed. Elongations were performed by means of callotasis with unilateral external fixation. Inclusion criteria were: achondroplastic patients under 17 years without prior arm operations and minimum follow-up of 36 months.

RESULTS

Fifty humeri in 25 patients (13 men and 12 women), aged between 9 and 17 years, met the inclusion criteria. Mean humeral lengthening was 8.82 cm (range: 5 to 10.5 cm), which represented an elongation of 54.80% (range: 46% to 63%) of the original length. The healing index was 0.91 months (range: 0.72 to 1.4 mo) per centimeter gained. Shoulder and elbow range of motion and stability were preserved in 47 limbs. Noncomplicated cases consistently experienced a significant functional improvement in the performance of activities of daily living such as putting on footwear and personal hygiene. Short-term complications included 11 pin-tract infections, 1 radial nerve neuropraxia, and 1 failure of the regenerated bone formation. None of these complications prevented from completion of treatment. Long-term complications included 2 cases of nonunion, 3 elbow flexion contractures, and 2 cases of psychological dissatisfaction, all of them in 4 patients. Factors associated with long-term complications were intraoperative fragment displacement and distal humeral osteotomy. No fractures of the regenerated bone were identified in the long term.

CONCLUSIONS

Callotasis with unilateral external fixation is a reliable and well-tolerated procedure for humeral lengthening in achondroplastic patients, with an acceptable complication rate. Guided fixator placement and a proximal humeral osteotomy are strongly recommended technical tips as they may help prevent complications and improve outcomes.

LEVEL OF EVIDENCE

Level IV-case series.

Management of segmental bone defects of the upper limb: a scoping review with data synthesis to inform decision making

PURPOSE

Injuries to the long bones of the upper limb resulting in bone defects are rare but potentially devastating. Literature on the management of these injuries is limited to case reports and small case series. The aim of this study was to collate the most recent published work on the management of upper limb bone defects to assist with evidence based management when confronted with these cases.

METHODS

Following a preliminary search that confirmed the paucity of literature and lack of comparative trials, a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of upper limb long bone defects published between 2010 and 2020.

RESULTS

A total of 46 publications reporting on the management of 341 patients were reviewed. Structural autograft, bone transport, one-bone forearm and the induced membrane technique were employed in an almost equal number of cases. The implemented strategies showed similar outcomes but different indications and complication profiles were observed.

CONCLUSION

Contemporary techniques for the management of post-traumatic upper limb bone defects all produce good results. Specific advantages, disadvantages and complications for each modality should be considered when deciding on which management strategy to employ for each specific patient, anatomical location, and defect size.

Lengthening of the Humerus Using a Motorized Lengthening Nail: A Retrospective Comparative Series

BACKGROUND

Lengthening of the humerus has traditionally been accomplished by the use of external fixation. Intramedullary motorized lengthening nails are now frequently used for lower limb lengthening, and this technology is slowly being adopted for use in the humerus.

METHODS

A retrospective, single-surgeon experience of pediatric humeral lengthenings was performed. The time period surveyed included use of external fixation (EF) for lengthening, and the use of a motorized nail (MN) for lengthening. The primary outcome measures were lengthening magnitude achieved, duration of lengthening, frequency and type of complications encountered, or further procedures required, during each lengthening.

RESULTS

From 1999 to 2018, 13 humeral lengthenings were performed in 9 patients. Six lengthenings were performed using the MN technique and 7 using the EF technique. The average absolute lengthening achieved was 8.5±1.3 cm in the EF group and 6.6±2.3 cm in the MN group. The duration of lengthening averaged 114 days in the MN group and 103 days in the EF group. The average duration of EF time was 215 days. Two patients underwent an initial EF lengthening of a humerus and then underwent a second lengthening using the MN technique. Two of 6 (33%) MN lengthenings and 3 of 7 (43%) EF lengthenings experienced complications during treatment. Two patients in the MN group underwent planned reversal and redeployment of their motorized nails to attain the planned lengthening magnitude.

CONCLUSIONS

Humeral lengthening using motorized intramedullary nails is a safe technique that mitigates some of the complications of EF including pin site infection. It is well tolerated by patients. For lengthenings of a large magnitude, reversal and reuse of MN can be considered.

[Intramedullary upper arm lengthening]

The new technology of motorized intramedullary telescopic nails has simplified the treatment for upper limb lengthening surgery. Improved patient comfort, low infection rates and absence of fractures in the regenerated bone are contrasted by the limitations of the methods, such as a current maximum distraction of 5cm and the fact that they cannot be used when the growth plates are still open.

Innovative Technique in Extended Intramedullary Humeral Lengthening: A Case Report

CASE

Intramedullary humeral lengthening is still a very uncommon procedure to treat humeral limb length discrepancy (LLD). This approach has various advantages compared with external devices but is limited in its ability to lengthen bones because of the length of the telescopic nail. This case report describes a middle-aged patient with a short right humerus secondary to a childhood growth plate injury that was successfully lengthened with an off-label application of a tibial distracting device. Hereby, a novel treatment technique with unlocking, backwinding, and reinterlocking of the telescopic nail for extended humeral distraction was performed.

CONCLUSIONS

Extended intramedullary humeral lengthening with unlocking, backwinding, and reinterlocking of the nail is a cost-effective, minimally invasive procedure in cases of massive humeral LLD with limitations in the distraction capacity of the telescopic nail.

Complications and Outcomes Following Humerus Lengthening - An Illustrative: Case Report

Introduction

Upper limb physeal injuries are dealt with differently simply because they do not hinder with the functional abilities of an individual. Humerus lengthening was first attempted in 1978 after which it encouraged many surgeons to safely perform the procedure. Radial nerve palsy occurring as a complication of humeral lengthening was a major concern.

Case Report

We report a case of a 17-year-old girl with physeal arrest at the proximal physis of the humerus with etiology of post-trauma/post-infection. She presented with a shortening of 8 cm and restricted shoulder movements. We performed a lengthening of the humerus based on the principle of distraction osteogenesis. We used the paediatric limb reconstruction system to distract the corticotomy. However, postoperatively, she developed radial nerve palsy, despite our intraoperative precautionary measures. Distraction was started at 1mm/day. She then showed the progress of radial nerve recovery and full recovery was noted by 5 months post-operatively. The length of the distraction compression assembly had to be changed twice to longer sizes to accommodate the required amount of lengthening. After consolidation of regenerate was confirmed with serial radiographs, external fixator was removed. She was then maintained on a functional brace. We were able to achieve 8cm of lengthening following distraction, and the cosmetic appearance of the patient improved to the patient's and attenders' satisfaction.

Conclusion

Humeral lengthening can safely be performed. Careful insertion of the distal pins and performance of the corticotomy will ensure the safety of the radial nerve. Even if radial nerve palsy occurs after all precautions are taken, recovery can be expected.

Surgical technique and outcomes for bilateral humeral lengthening for achondroplasia: 26-year experience

BACKGROUND

Elongation in patients with achondroplasia provides better overall skeletal proportionality and significantly improves such individuals' access to their perineal region to self-manage personal hygiene. This paper describes our surgical technique and outcomes for bilateral humeral lengthening in achondroplasia patients over 26 years.

METHODS

Ours was a retrospective study of 55 patients with achondroplasia-related short stature, in whom bilateral humeral lengthening was performed from 1990 to 2016. We describe the surgical technique and analyze mean gain in humeral length, days using an external fixator, mean percentage of lengthening, external fixation index, type of callus, and complications. Pre- and postoperative radiographic measurements were obtained. Patients also were contacted by telephone and asked about their ability to perform peri-anal self-hygiene and about their overall satisfaction.

RESULTS

In total, 110 humeri were lengthened (28 males and 27 females) with medium elongation of 9.5 cm on the right and 9.6 cm on the left, while averaging 220 days in an external fixator. We observed 14 minor complications. There was no significant association between pin position and type of callus, and elongation most often external and in the presence of a straight callus. Before elongation, 77.1% of patients reported difficulties with perineal hygiene and 85.4% could not put their hands in their pockets. Upon completion of lengthening, 100% could perform both tasks and 94.5% were very satisfied.

CONCLUSIONS

Bilateral humeral elongation yields significant improvements in patient autonomy, with a relatively low complication rate and very high patient satisfaction.

Aneurysmal bone cyst healing response with intramedullary lengthening nail

We report the treatment process of a pediatric patient with deformity and shortening in the arm after a recurrent aggressive aneurysmal bone cyst (ABC) in the proximal humerus. The patient was treated with curettage of the lesion and lengthening on an intramedullary nail following an osteotomy just distal to the ABC. The period of lengthening was approximately 50 days. At the end of the treatment the lengthening goal was achieved without any neurovascular complication. There was a minimal loss in shoulder hyperabduction due to the deformity of the humeral head.

The prevalence of the complications and their associated factors in humeral lengthening for achondroplasia: retrospective study of 54 cases

The aim of this study is to evaluate the complications of humeral lengthening and their associated factors. Fifty-four achondroplastic patients were treated by bilateral humeral lengthening. Our original shoulder sling was sufficient to prevent shoulder dislocation. Pre-existing radial head dislocation was observed in 18 patients. Lengthening was accomplished in all cases without a decrease in the elbow function. Seven humeri fractured after the fixator removal. The risk factors for postoperative fracture were a waiting period of less than 5 days, a healing index less than 25, and the concave shape of the callus. There was no radial nerve palsy.

Humeral Lengthening with the PRECICE Magnetic Lengthening Nail

BACKGROUND

Different types of external fixators have been used for humeral lengthening with successful outcomes reported in literature. Motorized intramedullary (IM) lengthening nails have been developed as an alternative to external fixators for long bone lengthening in the lower extremity.

QUESTIONS/PURPOSES

This case series reports on using the new technology of IM lengthening nails for humeral lengthening. We assessed the radiological healing and functional outcomes after using the PRECICE IM nail for humeral lengthening.

METHODS

This multicenter retrospective study included a total of six humeri in five patients (mean age was 20 years) that underwent lengthening with the magnetic IM PRECICE nail in two centers in the USA. The etiology was humeral growth arrest post-bone cyst (two segments), post-septic growth arrest (two segments), and multiple hereditary exostosis (bilateral segments in one patient). The outcomes measured were the length achieved, distraction index (DI; the length achieved in mm divided by the duration of lengthening in days), consolidation index (CI; number of days from surgery until consolidation divided by the length of the regenerate in cm), complications encountered, and functional outcomes (shoulder and elbow range of motion, the upper extremity functional index (UEFI), and QuickDASH functional scores).

RESULTS

The mean follow-up period was 1.8 years (0.9 to 2.4 years). All segments achieved the goal of lengthening; the mean was 5.1 cm (4.5 to 5.8 cm). Mean DI was 0.7 mm/day (0.5 to 0.8). Mean CI was 36 days/cm (25 to 45 days/cm). No complications were observed. At the last follow-up, all patients maintained their preoperative range of motion (ROM) except one patient had reduced shoulder ROM. QuickDASH score and upper extremity functional index showed postoperative improvement compared to the preoperative scores.

CONCLUSION

IM lengthening nails can provide successful and safe humeral lengthening. Specifically, the PRECICE nail has accurate control over the lengthening process.

Humeral lengthening in patients with achondroplasia and in patients with post-septic shortening: comparison of procedure efficiency and safety

PURPOSE

Although humeral lengthening in patients with achondroplasia is an accepted procedure for improving functional status, there is still a paucity of information about the effectiveness of the method. Therefore, the aim of this study was to evaluate the efficacy and safety of humeral lengthening using monolateral fixators in patients with achondroplasia and unilateral shortening.

METHODS

Twenty-one patients (31 humeri) were included in this study. The study group consisted of eight patients with achondroplasia (16 segments). The control group consisted of 13 patients with post-septic shortening of the humerus (15 segments). All subjects underwent distraction osteogenesis with the use of a monolateral fixator.

RESULTS

The mean lengthening in the patients with achondroplasia was 8.29 cm, whereas in the control group it was 7.34 cm (p = 0.1677). The mean lengthening percentage in the patients with achondroplasia (50% of the initial length of the humerus) was significantly greater than in the control group (33% of the initial length of the humerus) (p = 0.0007). The mean healing index was 24.8 days/cm in the patients with achondroplasia and 28.56 days/cm in the control group (p = 0.1832). The overall complication rates for the achondroplastic and post-septic patients were, respectively, 175% and 160% (p = 0.1420).

CONCLUSIONS

Humeral lengthening with use of monolateral fixators in patients with achondroplasia is an efficient method. Although the segment lengthening percentage is significantly greater in patients with achondroplasia than in patients with post-septic shortening of the humerus, the safety of this procedure is comparable.

Humeral lengthening and deformity correction

INTRODUCTION

Ilizarov principles and hybrid fixation have improved the results of humeral lengthening. We reviewed the literature on humeral lengthening using different fixators with regard to indications, operative technique, results and complications. We also retrospectively reviewed 56 segments in 46 patients treated with humeral lengthening and deformity correction using Ilizarov external fixation. The etiology was achondroplasia (10 patients), epiphyseal injury (8 cases), infection (11 cases) and Erb's palsy (17 cases). The average age at surgery was 14 years (range 8-20 years). The patients were assessed clinically and radiographically and DASH score was available for 36 segments. Follow-up ranged from 1-11 years. The magnitude of lengthening achieved ranged from 5-15.5 cm with an average of 9 cm. The average healing index was 29.5 cm (range 26-37 days). The percentage of area of lengthening to the original length ranged from 25 to 100% with an average of 55%. The average DASH (available for 36 segments only) score ranged from 15-40 preoperatively to 7-16 (P = 0.04) at last follow-up. Functionally, all the patients returned to their preoperative jobs and daily activities including sports.

COMPLICATIONS

Complications included pin track infection in 46 segments, radial nerve palsy which recovered completely in 2 patients, fracture of the regenerate in 7 cases and premature consolidation of the regenerate in one case.

CONCLUSION

Humeral lengthening, whether unilateral or bilateral, is a valid method that improves the outcome following arm shortening and deformity correction, including angulation and rotation. Extensive lengthening up to 100% of the original length could be achieved without increasing the risk of complications.

LEVEL OF EVIDENCE

IV, retrospective cohort.

Bone Lengthening in the Pediatric Upper Extremity

➤Bone lengthening has been used successfully for several congenital and acquired conditions in the pediatric clavicle, humerus, radius, ulna, and phalanges.➤Common indications for bone lengthening include achondroplasia, radial longitudinal deficiency, multiple hereditary exostosis, brachymetacarpia, symbrachydactyly, and posttraumatic and postinfectious growth arrest.➤Most authors prefer distraction rates of <1 mm/day for each bone in the upper extremity except the humerus, which can safely be lengthened by 1 mm/day.➤Most authors define success by the amount of radiographic bone lengthening, joint motion after lengthening, and subjective patient satisfaction rather than validated patient-related outcome measures.➤Bone lengthening of the upper extremity is associated with a high complication rate, with complications including pin-track infections, fixation device failure, nerve lesions, nonunion, fracture of regenerate bone, and joint dislocations.

Two stage reconstruction of septic non-union of the humerus with the use of circular external fixation

Achieving quiescence in chronic osteomyelitis remains challenging. Wide resection of all infected and necrotic tissues improves the chances of achieving remission of the disease. Extensive debridement however decreases the already compromised bone stock that increases the complexity of reconstruction. We report on the outcome of eight patients with Cierny and Mader stage IV chronic osteomyelitis of the humerus who underwent debridement followed by bone graft and circular fixator application as a second stage procedure. Resolution of infection and humeral shaft union was achieved in all patients. Our study finds that two-stage reconstruction of stage IV chronic osteomyelitis with the use of circular external fixation is effective in achieving infection control and union in these complex cases.

Intramedullary magnetically actuated limb lengthening in a patient with congenital humeral limb shortening

The treatment of leg length discrepancy has become a common procedure in orthopaedic surgery. However, lengthening of humeral deformities is still infrequent. The purpose of this case report was to present humeral lengthening with a new intramedullary lengthening device (PRECICE® P2 for tibia) in a 32 year old female patient with congenital shortening. Hereby the telescopic device presents a promising tool for humeral limb lengthening with excellent outcome at short-term in this case.

Limb lengthening in achondroplasia

BACKGROUND

Stature lengthening in skeletal dysplasia is a contentious issue. Specific guidelines regarding the age and sequence of surgery, methods and extent of lengthening at each stage are not uniform around the world. Despite the need for multiple surgeries, with their attendant complications, parents demanding stature lengthening are not rare, due to the social bias and psychological effects experienced by these patients. This study describes the outcome and complications of extensive stature lengthening performed at our center.

MATERIALS AND METHODS

Eight achondroplasic and one hypochondroplasic patient underwent bilateral transverse lengthening for tibiae, humeri and femora. Tibia lengthening was carried out using a ring fixator and bifocal corticotomy, while a monolateral pediatric limb reconstruction system with unifocal corticotomy was used for the femur and humerus. Lengthening of each bone segment, height gain, healing index and complications were assessed. Subgroup analysis was carried out to assess the effect of age and bone segment on the healing index.

RESULTS

Nine patients aged five to 25 years (mean age 10.2 years) underwent limb lengthening procedures for 18 tibiae, 10 femora and 8 humeri. Four patients underwent bilateral lengthening of all three segments. The mean length gain for the tibia, femur and humerus was 15.4 cm (100.7%), 9.9 cm (52.8%) and 9.6 cm (77.9%), respectively. Healing index was 25.7, 25.6 and 20.6 days/cm, respectively, for the tibia, femur and humerus. An average of 33.3% height gain was attained. Lengthening of both tibia and femur added to projected height achieved as the 3(rd) percentile of standard height in three out of four patients. In all, 33 complications were encountered (0.9 complications per segment). Healing index was not affected by age or bone segment.

CONCLUSION

Extensive limb lengthening (more than 50% over initial length) carries significant risk and should be undertaken only after due consideration.

Bilateral humeral lengthening in achondroplasia with unilateral external fixators

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.

Cite this article: Bone Joint J 2015;97-B:1577–81.

Role of hybrid monolateral fixators in managing humeral length and deformity correction

BACKGROUND AND PURPOSE

Humeral lengthening and deformity correction are now being done increasingly for various etiologies. Monolateral external fixators have advantages over traditional Ilizarov circular fixators; they are easy to apply, they are less bulky, and they are therefore more convenient for the patient. We assessed the effectiveness of hybrid monolateral lateral fixators in humeral lengthening and deformity correction.

METHODS

We retrospectively reviewed 23 patients (40 humeri) with various pathologies who underwent lengthening-with or without deformity correction using monolateral external fixator-between 2003 and 2008. Mean age at the time of the surgery was 14 (10-22) years. The mean follow-up time was 3.4 (1-7) years.

RESULTS

The average duration of external fixator use was 8.3 (6-19) months. The mean lengthening achieved was 8.8 (4-11) cm and percentage lengthening was 49% (19-73). The healing index was 28 (13-60) days/cm. The major complications were refracture in 3 humeri and varus angulation of 2 humeri. The minor complications were superficial pin tract infection (6 segments), transient radial nerve palsy (1 segment), and elbow flexion contracture (5 segments). All complications resolved.

INTERPRETATION

Hybrid monolateral fixators can be used for humeral lengthening and deformity correction. The advantage over circular fixators is that they are less bulky and patients can perform their day-to-day activities with the fixator in situ.

Comparison between upper and lower limb lengthening in patients with achondroplasia: a retrospective study

Lengthening of the humerus is now an established technique. We compared the complications of humeral lengthening with those of femoral lengthening and investigated whether or not the callus formation in the humerus proceeds at a higher rate than that in the femur. A total of 24 humeral and 24 femoral lengthenings were performed on 12 patients with achondroplasia. We measured the pixel value ratio (PVR) of the lengthened area on radiographs and each radiograph was analysed for the shape, type and density of the callus. The quality of life (QOL) of the patients after humeral lengthening was compared with that prior to surgery. The complication rate per segment of humerus and femur was 0.87% and 1.37%, respectively. In the humerus the PVR was significantly higher than that of the femur. Lower limbs were associated with an increased incidence of concave, lateral and central callus shapes. Humeral lengthening had a lower complication rate than lower-limb lengthening, and QOL increased significantly after humeral lengthening. Callus formation in the humerus during the distraction period proceeded at a significantly higher rate than that in the femur. These findings indicate that humeral lengthening has an important role in the management of patients with achondroplasia.