The psychological and social functioning of 14 children and 12 adolescents after Ilizarov leg lengthening

Bone transport combined with sequential nailing technique for the management of large segmental bone defects after trauma

Background

Bone transport technique is widely used for the management of large segmental bone defects. However, several reasons may prevent its successful completion, such as poor osteogenesis, docking site nonunion, severe chronic pain and psychological problems. We used sequential nailing technique to solve these problems. The objective of this study was to analyze the clinical effects of our modified technique for the management of large segmental bone defects after trauma.

Methods

Twenty-three patients using bone transport combined with sequential nailing technique in our institution from June 2011 to June 2020 were included and analyzed retrospectively. There were 15 males and eight females. The age ranged from 19 to 64 years. There were eight cases suffering from basic medical diseases. The initial injury was open in 14 patients. Seven cases encountered femoral defects and 16 for tibia. The main reasons for sequential nailing technique were docking site nonunion (nine cases), poor osteogenesis (five cases), severe chronic pain (five cases) and psychological problems (four cases). The residual bone defects after removing the external fixator, operation plans, complications and follow-up time were recorded. Bone defect healing was evaluated by Paley score.

Results

The mean residual bone defects were (2.9 ± 1.9) cm. The mean time in external fixator was (9.5 ± 3.4) months. The average follow-up time was (23 ± 3) months. With respect to complications, two cases suffered from nonunion again and were treated by bone graft with augmented plate fixation. No infection recurrence was found in these cases. The excellent and good rate of bone defect healing was 91.3%.

Conclusion

Bone transport combined with sequential nailing technique could shorten the external fixation time, overcome the inconvenience of the external frame to patients, eliminate chronic pain and be easy for patients to accept. Patients using this modified technique achieved high satisfaction.

Outcomes of ankle joint distraction in a paediatric and young adult cohort presenting with symptomatic ankle arthritis

Ankle arthritis in paediatric and young adult patients causes significant morbidity; therefore, joint-preserving procedures are preferable. Ankle joint distraction (AJD) is a technique that preserves the native joint. However, only short-term outcomes are reported in paediatric patients. Therefore, this study reports on intermediate-term outcomes in a paediatric cohort. Demographics for all patients who underwent AJD at two centres were prospectively collected. Case records were reviewed retrospectively for complications and further intervention. Mean joint space at baseline and follow-up radiographs were evaluated by two independent observers. All patients were contacted for completion of a Foot and Ankle Outcome Score (FAOS). Seven patients received AJD between February 2016 and June 2019. Median age at surgery was 15 years (9.0-24.6 years). Complications included one superficial pin-site infection and one patient death due to complications from juvenile idiopathic arthritis 6.2 years post-operatively. Two patients were converted to fusion, at 12.6 months and 26.2 months following frame removal; one patient underwent spontaneous fusion at 9 months following frame removal. The four patients who continued without further intervention achieved 2.59 mm mean joint space at last follow-up (0.65-5.08 mm) and FAOS of 35-79%. Mean follow-up length was 4.3 years (2.9-6.3 years) with final radiographs at mean 2.6 years. While recognising the limitations of this retrospective review, several patients had significant, sustained improvements in joint space with good clinical outcome. Complications for this procedure are minimal, and it is a potential joint-preserving option for managing end-stage ankle arthritis in young patients.

A modified hybrid transport technique combined with a retrograde tibiotalocalcaneal arthrodesis nail for the management of distal tibial periarticular osteomyelitis and associated defects

BACKGROUND

This paper aimed to propose a modified technique of bone transport. An annular frame combined with a retrograde tibiotalocalcaneal arthrodesis nail was used in this novel technique for treating large distal tibial periarticular osteomyelitis and associated defects.

METHODS

Our team conducted a retrospective research. Forty-three patients with large distal tibial periarticular bone loss were involved in this study. Sixteen patients were treated using the modified hybrid transport technique (MHT group) while 27 were subjected to traditional bone transport (BT group). The mean bone loss was 7.8 ± 2.4 cm in the MHT group and 7.6 ± 2.6 cm in the BT group. The external fixation index, time in transport frame, self-rating anxiety scale, bone healing results and postoperative complications were recorded.

RESULTS

The mean time in frame for the MHT group was 3.6 ± 1.5 months, while that of the BT group was 10.3 ± 2.7 months (p < 0.05). The mean external fixation index of MHT group was 0.46 ± 0.08 months/cm versus 1.38 ± 0.24 months/cm of the BT group (p < 0.05). There was no statistical difference for the bone healing results between the MHT and BT groups (p = 0.856). The self-rating anxiety scale and total complication incidence of the MHT group were significantly lower than that of BT patients (p < 0.05).

CONCLUSION

Compared to the traditional BT technique, our modified hybrid transport technique showed better clinical outcomes for treating large distal tibial periarticular bone loss, including less time in transport frame, lower external fixation index and complication incidence. Therefore, this modified technique should be further promoted and developed.

Acute shortening and double-level lengthening versus bone transport for the management of large tibial bone defects after trauma and infection

OBJECTIVE

The aim of this study was to present our experience with a new modified Ilizarov technique of acute shortening and double-level lengthening (ASDL) for the management of large tibial bone defects after trauma and infection and compare it with bone transport (BT).

METHODS

A retrospective comparative study was performed on 47 patients with large tibial defects after trauma and infection from June 2014 to June 2018. Depending on different Ilizarov methods, these patients were divided into ASDL group (n = 21) and BT group (n = 26). The difference in bone lengthening time, time in frame, external fixation index, docking site healing time were recorded and compared between the two groups. Bone and functional results were evaluated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. Complications encountered in both groups were categorized according to the classification of Paley, including problems (treated nonoperatively), obstacles (treated operatively), and sequelae (unresolved at last).

RESULTS

All patients were followed for at least two years since the lengthening frame was removed. All cases achieved complete union at the docking site and consolidation of the regenerate callus. The mean bone loss was 8.9 cm (range 6.5-16.0 cm) in ASDL group vs. 10.3 cm (range 5.2-18.5 cm) in BT group. The mean bone lengthening time was 2.4 ± 0.7 months in ASDL group vs. 4.1 ± 1.4 months in BT group (p<0.001); time in frame was 9.1 months (range 7.0-14.5 months) in ASDL group vs. 17.7 months (range 13.5-23.0 months) in BT group (p<0.001); and external fixation index was 1.04 months/cm (range 0.83-1.38 months/cm) in ASDL group vs. 1.91 months/cm (range 1.28-2.70 months/cm) in BT group (p<0.001). The incidence of obstacles occurred in ASDL group was significantly lower than that in BT group (p<0.001). There was no significant difference in the bone (p = 0.635) and functional results (p = 0.293) between the two groups.

CONCLUSION

Compared with bone transport, our modified technique of acute shortening and double-level lengthening could reduce bone lengthening time, time in frame, external fixation index and postoperative complications. It showed better clinical effects in patients with large tibial bone defects after trauma and infection.

LIMB-Q Kids—German Translation and Cultural Adaptation

(1) Purpose: Lower limb deformities can have a severe impact on health-related quality of life (HRQL). LIMB-Q Kids is a new patient-reported outcome measure (PROM) aiming to elucidate the experience of 8–18-year-old patients before, during and after treatment, and to measure the different aspects of HRQL. The aim of this study was to translate and culturally adapt LIMB-Q Kids to German. (2) Methods: The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines were followed. Three forward translations, a backward translation, an expert panel meeting with eight participants, and twenty cognitive debriefing interviews led to the final German version of LIMB-Q Kids. (3) Results: In the forward translations, 4/159 items were difficult to translate, and 2/159 items in the backward translation differed from the original English version. Cognitive debriefing interviews with 20 patients identified 7/159 items that were difficult to comprehend/answer, and 2 of these items were changed. (4) Conclusions: Lower limb deformities can have a great impact on children, and it is important to measure and consider the impact on HRQL. In order to be able to use PROMs in different countries, conceptually equivalent translations and cultural adaptations should be performed in order to ensure comprehensibility. The final German version of LIMB-Q Kids is ready for use in an international field test.

Antibiotic calcium sulfate-loaded hybrid transport versus traditional Ilizarov bone transport in the treatment of large tibial defects after trauma

Background

The purpose of this study was to compare the clinical effects of antibiotic calcium sulfate-loaded hybrid transport (ACSLHT) and traditional Ilizarov bone transport (TIBT) in the treatment of large tibial defects after trauma.

Methods

Eighty-five patients with large tibial defects after trauma were selected for retrospective study. The range of tibial defects was 6–22 cm. After thorough debridement and infection controlled, bone transport technique was used to reconstruct tibial defects. Forty-four patients were treated with ACSLHT technique (the ACSLHT group), while the other 41 were treated with TIBT technique (the TIBT group). Time in external fixator was evaluated by EFI score. Enneking score was used to evaluate limb functions. SAS score was used to evaluate postoperative anxiety status. In addition, complication incidence was compared, including axis deviation, docking site nonunion, infection recurrence and so on.

Results

There was no significant difference in preoperative general data between ACSLHT and TIBT group. EFI score in ACSLHT and TIBT group was 0.6 ± 0.1 cm/month and 1.7 ± 0.3 cm/month, respectively (P < 0.05). Enneking score of ACSLHT and TIBT group was 86.5% and 75.1% (P < 0.05). SAS score of ACSLHT group was significantly lower than that of TIBT group (P < 0.05). Complication incidence in ACSLHT group was significantly lower than that in TIBT group (P < 0.05).

Conclusions

Compared with TIBT group, ACSLHT group had shorter time in external fixator, better limb functions, lower postoperative anxiety score and lower complication incidence which is worth of clinical promotion.

What matters to children with lower limb deformities: an international qualitative study guiding the development of a new patient-reported outcome measure

BACKGROUND

Lower limb deformities include conditions such as leg length discrepancy, lower limb deficiency and associated angular and rotational deformities of the hips, knees, ankles and feet. Children with lower limb deformities often have physical limitations due to gait irregularities and pain. The differences in the appearance and function of their lower limbs can discourage participation in social, recreational and leisure activities, which may result in behavioural, emotional, psychological and social adjustment problems. The health-related quality of life (HRQL) of these children is often impacted due to the factors discussed above, as well as by the complex surgical procedures. Surgical treatment options for limb deformities in children vary from limb lengthening and reconstruction to amputation. The lack of evidence demonstrating superiority of either treatment options and their effect on HRQL limits the ability of healthcare providers to counsel families on the best evidence-based treatment option for them. This manuscript describes the international qualitative study which guided the development of a new patient-reported outcome measure (PROM). Individual semi-structured face-to-face interviews with children with lower limb deformities and their parents were conducted at five sites: Canada (2 sites), Ethiopia, India and the USA.

RESULTS

Seventy-nine interviews were conducted at five international sites. Five main themes emerged from the qualitative interviews and formed the basis of the conceptual framework. These themes were: 1) appearance, 2) physical health, 3) psychological health 4) school and 5) social health.

CONCLUSIONS

Lower limb deformities have a substantial impact on the HRQL of children. The concepts of interest identified in our study were similar across children from all countries. The conceptual framework guided the development of outcome scales specific to these patients. The information about the impact of various treatment options on the HRQL of children with lower limb deformities, collected using this new PROM, could be used to inform parents and children about outcomes (physical, social, psychological) associated with specific treatment options. This information could supplement other objective outcome information (e.g., complication rates, how the leg will look, etc.) to help families to come to a more informed decision on a child's course of treatment.

Assessment of the quality of life in patients with varying degrees of equalization of lower limb length discrepancy treated with Ilizarov method

BACKGROUND

Inequalities in leg length result in functional disorders, as they impair the biomechanics of the musculoskeletal system, significantly reducing the quality of life (QoL). This study used the WHOQoL-BREF questionnaire in patients with varying degrees of lower leg shortness who had undergone treatment by the Ilizarov method, compared to a healthy control group.

METHODS

Fifty-eight patients treated with the Ilizarov method for discrepancies in lower limb length were grouped by degree of limb equalization (group 1, 37 treated individuals with limb length discrepancy < 1 cm; group 2, 21 individuals with discrepancy ≥ 1 cm but not more than 4 cm). The control group 3 contained 61 healthy individuals. Patient quality of life (QoL) was assessed using a shortened version of the WHOQoL-BREF questionnaire, at least 24 months after the end of Ilizarov therapy.

RESULTS

Control subjects obtained higher scores in all domains than subjects in both treatment groups, as well as significantly higher self-assessed QoL, and health, in the physical, psychological, social, and general lifestyle domains, as compared to those with inequalities ≥ 1 cm. Furthermore, patients with inequalities ≥ 1 cm had higher odds ratios of low self-assessment (3.28 times; p = 0.043), low self-assessment of health (4. 09 times; p = 0.047), and low physical and psychological domains (respectively 6.23 times; p = 0.005 and 8.46 times, p = 0.049) compared with patients with inequality < 1 cm. The shortened version of the WHOQoL questionnaire was used.

CONCLUSIONS

After at least 24 months of treatment with the Ilizarov method, patients with limb length discrepancy < 1 cm did not differ significantly from healthy individuals in the WHOQoL self-assessment of mental functioning, social, or life satisfaction.

Combined massive allograft and intramedullary vascularized fibula transfer: the Capanna technique for treatment of congenital pseudarthrosis of the tibia

Background and purpose - Congenital pseudarthrosis of the tibia (CPT) is caused by local periosteal disease that can lead to bowing, fracturing, and pseudarthrosis. Current most successful treatment methods are segmental bone transport and vascularized and non-vascularized bone grafting. These methods are commonly hampered by discomfort, reoperations, and long-term complications. We report a combination of a vascularized fibula graft and large bone segment allograft, to improve patient comfort with similar outcomes.Patients and methods - 7 limbs that were operated on in 6 patients between November 2007 and July 2018 with resection of the CPT and reconstruction with a vascularized fibula graft in combination with a bone allograft were retrospectively studied. The mean follow-up time was 5.4 years (0.9-9.6). Postoperative endpoints: time to discharge, time to unrestricted weight bearing, complications within 30 days, consolidation, number of fractures, and secondary deformities.Results - The average time to unrestricted weight bearing with removable orthosis was 3.5 months (1.2-7.8). All proximal anastomoses consolidated within 10 months (2-10). 4 of the 7 grafts fractured at the distal anastomosis between 6 and 14 months postoperatively. After reoperation, consolidation of the distal anastomosis was seen after 2.8 months (2-4). 1 patient required a below-knee amputation.Interpretation - This case series showed favorable results of the treatment of CPT through a combination of a vascularized fibula graft and large bone segment allograft, avoiding the higher reintervention rate and discomfort with ring frame bone transport, and the prolonged non-weight bearing with vascularized fibula transfer without reinforcement with a massive large bone segment allograft.

International multiphase mixed methods study protocol to develop a patient-reported outcome instrument for children and adolescents with lower limb deformities

INTRODUCTION

Our recent systematic review has indicated the lack of a patient-reported outcome (PRO) instrument to measure health-related quality of life (HRQOL) of children and adolescents with lower limb deformities. We are developing a PRO instrument which will be applicable internationally across various countries. This manuscript describes our approach to the development of a new PRO instrument for measuring HRQOL for children and adolescents with lower limb deformities.

METHODS AND ANALYSIS

Three phases in the development of this PRO instrument are as described: (1) This phase involves the development of a conceptual framework of HRQOL and item pool that is used to inform a set of preliminary scales. We have developed a preliminary conceptual framework of HRQOL based on our systematic review. Qualitative interviews are being conducted at five sites in Canada, Ethiopia, India and the USA. An item pool will be generated from this qualitative phase. The preliminary items and scales will be sent out to children at the five participating centres. Cognitive debriefing interviews will gather detailed feedback on the items from the children. Expert opinion will be sought from clinicians from the participating centres. (2) During this phase, an international field-test study will be conducted to refine the scales and examine their psychometric properties. (3) During this phase, tests of reliability, validity and responsiveness will be conducted. Phase 1 will also involve translations and cultural adaptations. At the end of this study, we expect to produce an internationally applicable PRO instrument which is scientifically sound and clinically relevant to the lower limb deformity population.

ETHICS AND DISSEMINATION

This study is approved by Research Ethics Boards for each of the participating sites.Results of this study will be published in peer-reviewed journals and presented at national and international conferences. An integrated knowledge translation approach is applied to engage patients, families and clinicians from the start of the study.

Amputation Versus Staged Reconstruction for Severe Fibular Hemimelia: Assessment of Psychosocial and Quality-of-Life Status and Physical Functioning in Childhood

Background

Fibular hemimelia, a congenital disorder characterized by the partial or complete absence of the fibula, tibial growth inhibition, and foot and ankle deformity and deficiency, is the most common deficiency of long bones. The purpose of the present study of children with congenital fibular hemimelia was to examine the functional and psychosocial outcomes at a minimum of 2 years after treatment either with amputation and a prosthesis or with reconstruction and lengthening.

Methods

Twenty children who were managed with primary amputation were compared with 22 children who were managed with staged limb reconstruction. The average age of the patients at the time of evaluation was 9 years (range, 5 to 15 years). Patients and parents completed psychosocial, quality-of-life, and satisfaction surveys. Patients underwent instrumented gait analysis and a timed 25 or 50-yard dash. The number and nature of surgical procedures were recorded from a retrospective chart review.

Results

Families of children managed with amputation had lower economic and educational levels and were more ethnically diverse compared with the families of children managed with limb reconstruction. Scores on psychosocial and quality-of-life surveys were comparable with those from healthy patient populations. Parents of males treated with amputation perceived a lower school-related quality of life for their child; socioeconomic and ethnic differences between groups might account for this finding. Statistically but not clinically significant differences were measured during instrumented gait analysis at a self-selected walking speed and during a timed 25 or 50-yard dash. The majority of patients and parents reported satisfaction with the treatment method selected and would select the same treatment method again.

Conclusions

At this interim stage of growth, there were no significant functional or psychological differences between groups. Both groups were satisfied with the outcome in mid-childhood, irrespective of the selection of amputation or limb reconstruction.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Interdisciplinary Intervention Contributes to Improved Outcomes of Adolescents Treated With Hip Preservation Surgery

BACKGROUND

Adolescent hip preservation surgery (HPS) candidates typically present with chronic pain, which can negatively affect psychological function and surgical outcomes. A previous study demonstrated high rates of psychological symptoms and maladaptive behaviors in this population. This study quantified psychological and functional improvements in these patients from preoperative presentation to postoperative follow-up. An integrated interdisciplinary approach is also described.

METHODS

A total of 67 patients undergoing HPS were evaluated preoperatively and postoperatively at 1 year by staff psychologists. Perioperative psychological intervention consisted of education, counseling, and administration of self-report measures. Self-report measure scores were compared preoperatively and postoperatively, grouped by orthopaedic diagnoses. Frequency analysis, correlational analysis, and analysis of variance were conducted.

RESULTS

Psychological function improved significantly at follow-up: decreased emotional symptomatology (46.1 to 43.6, P=0.013), anxiety (49.6 to 45.8, P<0.001), school problems (46.6 to 44.7, P=0.035), internalizing problems (46.3 to 44.1, P=0.015), social stress (44.5 to 42.3, P=0.024), sense of inadequacy (49.0 to 46.0, P=0.004), and increased self-concept (51.1 to 54.1, P=0.003). Resiliency factors also significantly improved: increased mastery (50.3 to 52.9, P=0.001) and resourcefulness (49.7 to 52.0, P=0.046), decreased emotional reactivity (46.3 to 42.9, P=0.001), and vulnerability (47.7 to 44.7, P=0.011). Physical function and return to activity also significantly improved (University of California-Los Angeles: 7.1 to 8.7, P=0.017; modified Harris Hip Score: 67.3 to 83.8, P<0.001). Return to activity positively correlated with optimism and self-efficacy (P=0.041). Femoroacetabular impingement and hip dysplasia patients consistently reported feeling less depressed (P=0.036), having fewer somatic complaints (P=0.023), fewer internalized problems (P=0.037), and exhibiting fewer atypical behaviors (P=0.036) at follow-up. Slipped capital femoral epiphysis patients did not demonstrate improvements in psychological functioning postoperatively.

CONCLUSIONS

Perioperative psychological education and counseling, in combination with HPS, improved postoperative psychological and physical function. Patients reported reduced anxiety, school problems, and social stress, with marked increase in resilience. Increased mobility and return to activity significantly correlated with improved optimism and self-efficacy.

LEVEL OF EVIDENCE

Level II-therapeutic studies-investigating the results of treatment.

The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate

Aims

The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria.

Patients and Methods

Between January 2012 and January 2015, 14 consecutive patients were treated for an infected nonunion of the tibia with a gap and were included in the study. During stage one, a radical debridement of bone and soft tissue was undertaken with the introduction of an antibiotic-loaded cement spacer. At the second stage, the tibia was stabilized using a long lateral locked plate and a six-pin monorail fixator on its anteromedial surface. A corticotomy was performed at the appropriate level. During the third stage, i.e. at the end of the distraction phase, the transported fragment was aligned and fixed to the plate with two to four screws. An iliac crest autograft was added to the docking site and the fixator was removed. Functional outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. Patient-reported outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score.

Results

The mean age of patients was 38.1 years (sd 12.7). There were 13 men and one woman. The mean size of the defect was 6.4 cm (sd 1.3). the mean follow-up was 33.2 months (24 to 50). The mean external fixator index was 21.2 days/cm (sd 1.5). The complication rate was 0.5 (7/14) per patient. According to the classification of Paley, there were five problems and two obstacles but no true complications. The ASAMI bone score was excellent in all patients. The functional ASAMI scores were excellent in eight and good in six patients. The mean MSTS composite score was 83.9% (sd 7.1), with an MSTS emotional acceptance score of 4.9 (sd 0.5; maximum possible 5).

Conclusion

Composite fixation (rail-plate) decreases fixator time and the associated complications, in the treatment of patients of infected nonunion tibia with a segmental defect. It also provides good anatomical and functional results with high emotional acceptance. Cite this article: Bone Joint J 2018;100-B:1094-9.

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 psychological impact of external fixation using the Ilizarov or Orthofix LRS method to treat tibial osteomyelitis with a bone defect

OBJECTIVE

To examine the psychological impact of external fixation for a tibial bone defect due to osteomyelitis, and to compare the Orthofix limb reconstruction system (LRS) with the Ilizarov external fixator.

MATERIALS AND METHODS

The SCL-90-R questionnaire was administered at four different time points (before surgery, while patients wore the external fixation device, when the device was removed, and two to three months after). The scores at the four time points were compared, as were the two different methods of external fixation (Orthofix LRS vs. Ilizarov).

RESULTS

The patients experienced a significant adverse impact on their mental health, with the worst outcomes at Time 2 (while wearing the external fixator), but with some negative effects still present even several months after removal of the fixation device. Although the Orthofix LRS and Ilizarov groups showed similar mental health scores at Time 1 (preoperatively) and Time 3 (upon removal of the fixation device), the Orthofix LRS was associated with better scores, specifically in the Hostility (Time 2), Phobic Anxiety (Time 2), Psychoticism (Times 2 and 4), and Other (Time 2) sub-scores, as well as the total score (Times 2 and 4).

CONCLUSIONS

Although both Ilizarov and Orthofix LRS fixation resolved the bone defects, external fixation had a negative impact on the patients' mental health, which persisted even after removal of the devices. Although both methods led to negative effects on the patients' mental, the impact of the Orthofix LRS was less severe.

Bone lengthening using the Fitbone(®) motorized intramedullary nail: The first experience in France

INTRODUCTION

Intramedullary limb lengthening systems include mechanical systems (the Albizzia nail and the ISKD nail) as well as motorized systems with the Fitbone(®) (Wittenstein, Igersheim, Germany) and the Precice(®) (Ellipse Technologies, Irvine, CA, USA) nails. We hypothesized that limb lengthening using the Fitbone(®) nail was reliable, reproducible, and comfortable for the patient.

PATIENTS AND METHODS

Between 2010 and 2013, a prospective single-center, single-operator (FA) study was conducted on patients who had undergone limb lengthening using the Fitbone(®) nail. The inclusion criteria were length discrepancy of the limbs equal to or greater than 25 mm or a short stature. The exclusion criteria were indications for cosmetic reasons and/or growth plates that were still open. The lengthening parameters were assessed postoperatively and at the last follow-up. Lengthening was considered achieved when the lengthening objective did not differ by more than 5 mm. All complications were noted. A statistical analysis was performed.

RESULTS

Twenty-six Fitbone(®) nails were implanted in 23 patients, in the femur in 15 cases and the tibia in 11 cases. The patients' mean age was 22.5 years (range: 15-53 years) and the mean follow-up was 3.4 years (range: 2-5.3 years). The limb lengthening targeted was obtained in 23 cases (88%) and the mean lengthening was 45.3±18 mm (range: 20-80 mm). The mean time to healing was 277±167 days (range: 86-638 days). The mean healing index was 73±57 days/cm for the femurs and 83.5±65 days/cm for the tibias. The mean complication rate was 15.4%.

DISCUSSION

This study emphasizes the good short-term results of this motorized intramedullary lengthening system. An evaluation over the longer term and with a higher number of patients remains necessary.

LEVEL OF EVIDENCE

IV: uncontrolled, prospective, continuous study.

Does Integrated Fixation Provide Benefit in the Reconstruction of Posttraumatic Tibial Bone Defects?

BACKGROUND

Limb salvage in the presence of posttraumatic tibial bone loss can be accomplished using the traditional Ilizarov method of distraction osteogenesis with circular external fixation. Internal fixation placed at the beginning of the consolidation phase, so-called integrated fixation, may allow for earlier removal of the external fixator but introduces concerns about cross-contamination from the additional open procedure and maintenance of bone regenerate stability.

QUESTIONS/PURPOSES

Among patients deemed eligible for integrated fixation, we sought to determine: (1) Does integrated fixation decrease the time in the external fixator? (2) Is there a difference in the rate of complications between the two groups? (3) Are there differences in functional and radiographic results between integrated fixation and the traditional Ilizarov approach of external fixation alone?

METHODS

Between January 2006 and December 2012, we treated 58 patients (58 tibiae) with posttraumatic tibial bone loss using the Ilizarov method. Of those, 30 patients (52%) were treated with the "classic technique" (external fixator alone) and 28 (48%) were treated with the "integrated technique" (a combination of an external fixator and plating or insertion of an intramedullary nail). During that period, the general indications for use of the integrated technique were closed physes, no active infection, and a healed soft tissue envelope located at the intended internal fixation site; the remainder of the patients were treated with the classic technique. Followup on 30 (100%) and 28 (100%) patients in the classic and integrated techniques, respectively, was achieved at a minimum of 1 year (mean, 3 years; range, 1-8 years). Adverse events were reported as problems, obstacles, and complications according to the publication by Paley. Problems and obstacles are managed by nonoperative and operative means, respectively; in addition, they resolve completely with treatment. Complications, according to the Paley classification, result in permanent sequelae. Functional and radiographic results were reported using the Association for the Study and Application of Methods of Ilizarov scoring system.

RESULTS

Overall, there was a mean of four (range, 2-5) surgical procedures to complete the tibial reconstruction with a similar incidence of unplanned surgical procedures (obstacles) between the two groups (p = 0.87). Patients treated with integrated fixation spent less time in the external fixator, 7 months (range, 5-20 months) versus 11 months (range, 1-15 months; p < 0.001). There were seven problems, 15 obstacles, and zero complications in the classic group. Ten problems, 15 obstacles, and one complication occurred in the integrated fixation group. There was no difference in the severity (p = 0.87) or number (p = 0.40) of complications between both groups. Good to excellent Association for the Study and Application of Methods of Ilizarov function and bone scores were obtained in 100% and 98% of patients, respectively.

CONCLUSIONS

The integrated fixation method allows for a more efficient limb salvage surgical reconstruction in patients carefully selected for that approach, whereas the frequency of adverse events and ability to restore limb lengths was not different between the groups with the numbers available. Careful placement of external fixation pins is critical to decrease cross-contamination with planned internal fixation constructs. In this study of posttraumatic tibial bone defect reconstruction, good/excellent results were found in all patients after a mean of four surgical procedures; however, a larger multicenter prospective study would allow for more robust and generalizable conclusions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Clinical Implications of Psychosocial Factors on Pediatric External Fixation Treatment and Recommendations

BACKGROUND

Pediatric limb reconstruction using circular external fixation is a prolonged treatment that interrupts patients' daily function. Patient personality characteristics and expectations may interfere with planned treatment, making complicated medical procedures more challenging. The aims of this study are to identify factors impacting treatment outcome and recommendations for preoperative evaluation and planning.

QUESTIONS/PURPOSES

(1) Are there group differences between patients with and without a preexisting mental health condition(s) in terms of unplanned reoperations? (2) Does the number of surgical procedures before current external fixator placement correlate with the number of unplanned readmissions, unplanned reoperations, and days spent in circular external fixation? (3) Are there group differences between single- compared with two-parent households in terms of inpatient narcotic doses, length of inpatient stay, number of unplanned readmissions, length of readmission(s), and/or unplanned outpatient clinic visits? (4) Does patient age at the time of surgery have an impact on treatment duration, postoperative complications, and treatment outcome?

METHODS

This is a retrospective chart review of pediatric patients who underwent limb reconstruction between 2008 and 2012. Patients with limb length discrepancy > 4 cm or severe angular deformity and who agreed to intervention were treated with circular external fixation. Sixty-seven patients were included; 16 patients were excluded. Statistical analyses included Pearson r correlation and t-test.

RESULTS

Patients who reported preexisting mental health diagnosis (13%) had more unplanned reoperations than patients who did not (no mental health diagnosis; 87%) (mental health diagnosis 3.4 ± 10.3 versus no mental health diagnosis 0.2 ± 0.5 reoperation[s], p = 0.022). Number of previous surgical procedures correlated with number of unplanned reoperations (r = 0.448, p < 0.001), number of unplanned readmissions (r = 0.375, p < 0.001), and number of days in an apparatus (r = 0.275, p = 0.018). Compared with patients from two-parent households, patients from single-parent households received a greater number of inpatient narcotic doses (single-parent 129 ± 118 versus two-parent 73 ± 109 doses, p = 0.039), longer length of inpatient stay (single-parent 73 ± 63 versus two-parent 40 ± 65 days, p = 0.036), more unplanned readmissions (single-parent 0.4 ± 0.1 versus two-parent 0.2 ± 0.2 readmission, p = 0.024), longer hospitalization when readmitted (single-parent 5 ± 11 versus two-parent 1 ± 3 day(s), p = 0.025), and fewer unplanned outpatient visits (single-parent 0.2 ± 0.8 versus two-parent 0.9 ± 1.1 visit, p = 0.005). Apparatus applications with successful outcome had higher average age than those with poor outcome (successful outcome 16 ± 3 versus poor outcome 13 ± 4 years old, p = 0.011). Age at time of apparatus application correlated with number of prescribed antibiotics (r = 0.245, p = 0.036) and number of days in an apparatus (r = 0.233, p = 0.047).

CONCLUSIONS

As a result of the inherent challenges of limb reconstruction, surgical candidates should be preoperatively assessed and mitigating psychosocial factors managed to maximize successful treatment outcome.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Lengthening in Congenital Femoral Deficiency: A Comparison of Circular External Fixation and a Motorized Intramedullary Nail

BACKGROUND

Circular external fixation for limb-lengthening is associated with frequent and numerous complications. Intramedullary lengthening devices represent a potential advance in limb-lengthening. The purpose of this study was to compare the outcomes of femoral lengthening in pediatric patients treated by either circular external fixation or a motorized intramedullary nail.

METHODS

All patients with a diagnosis of congenital femoral deficiency who had undergone femoral lengthening with either circular external fixation or a motorized intramedullary nail were identified. The motorized intramedullary nail (FITBONE) was used with approval of the U.S. Food and Drug Administration on an individual compassionate-use basis.

RESULTS

Fourteen skeletally mature patients underwent fourteen femoral lengthening sessions using circular external fixation, and thirteen patients underwent fifteen lengthening sessions using the motorized nail. The amount lengthened was similar, with a mean of 4.8 cm (range, 1.0 to 7.4 cm) in the circular fixation group and 4.4 cm (range, 1.5 to 7.0 cm) in the motorized nail group. Complications occurred in all lengthening sessions in all fourteen patients managed with the circular external fixation and in 73% of fifteen lengthening sessions in the thirteen patients managed with the motorized nail. The circular external fixation group averaged 2.36 complications per lengthening session compared with 1.2 per session in the motorized nail group. Twenty-nine percent of the circular fixation group failed to achieve a lengthening goal of at least 4 cm compared with 27% of the motorized nail group who failed to reach the goal. Eight patients had undergone eleven femoral lengthening sessions with circular external fixation prior to undergoing ten lengthening sessions by motorized nail. These patients had a comparable rate of complications with both types of lengthening, but the total number of complications averaged 2.6 per lengthening session with circular external fixation compared with 1.6 per lengthening session with the motorized nail.

CONCLUSIONS

A decreased number of complications was noted with use of a motorized intramedullary nail compared with circular external fixation in pediatric patients undergoing femoral lengthening for congenital femoral deficiency.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric and adolescent applications of the Taylor Spatial Frame

Limb deformity can occur in the pediatric and adolescent populations from multiple etiologies: congenital, traumatic, posttraumatic sequelae, oncologic, and infection. Correcting these deformities is important for many reasons. Ilizarov popularized external fixation to accomplish this task. Taylor expanded on this by designing an external fixator in 1994 with 6 telescoping struts that can be sequentially manipulated to achieve multiaxial correction of deformity without the need for hinges or operative frame alterations. This frame can be used to correct deformities in children and has shown good anatomic correction with minimal morbidity. The nature of the construct and length of treatment affects psychosocial factors that the surgeon and family must be aware of prior to treatment. An understanding of applications of the Taylor Spatial Frame gives orthopedic surgeons an extra tool to correct simple and complex deformities in pediatric and adolescent patients.

Lower limb lengthening and deformity correction using the Fitbone motorized nail system in the adolescent patient

Leg lengthening by an external fixation is associated with various difficulties. Pin-tract infections are commonly encountered, and muscle contractures and joint stiffness are additional complications associated with this method. Several researchers explored a purely intramedullary solution for leg lengthening since the 1970s. The purpose of this study was to evaluate the results of 10 adolescent patients who underwent leg lengthening with a motorized intramedullary lengthening device (the Fitbone System). We aimed to evaluate the effectiveness of the Fitbone system in deformity correction and lengthening of the femur and tibia in the pediatric and adolescent patients looking at whether the incidence of complications commonly associated with external fixators could be reduced. We compared our preliminary results with those from other reports, with a focus on leg length achieved and rate of complications. Ten patients were included, nine femoral nails and five tibial nails were implanted. The average lengthening distance was 4.8 cm (range, 2.8-10 cm). In 10 patients, leg lengthening was combined with successful correction of the mechanical axis alignment in three patients. The consolidation index averaged 24 days/cm (range, 20-39 days/cm). The average hospital stay was 8 days. No bone or soft tissue infections were observed. Only one patient had irritation and pain from the antenna system after lengthening and recovered fully after antenna removal. Our results suggest that the difficulties commonly associated with external fixators can be reduced with this method. It also allows good angular correction in patients with mechanical axis deviation. These features combined with a short time of hospitalization make it a promising procedure for limb lengthening in adolescent patients.

Long-term psychosocial functioning after Ilizarov limb lengthening during childhood

BACKGROUND AND PURPOSE

Few studies have been concerned with the patient's perception of the outcome of limb lengthening. We describe the psychological and social functioning after at least 2 years of follow-up in patients who had had a leg length discrepancy and who had undergone an Ilizarov limb lengthening procedure.

PATIENTS AND METHODS

Self-esteem and perceived competence were measured in 37 patients (aged 17-30 years) both preoperatively and at a mean follow-up of 7 (2-14) years. At follow-up, health-related quality of life, functioning at school, daily activities, and treatment-related experiences were measured, and also retrospectively for the preoperative period.

RESULTS

Preoperative and follow-up scores for self-esteem were similar. Overall perceived competence scores at follow-up were comparable to that of a healthy normal population. Patients' perceived athletic competence was lower and their perceived level of behavioral conduct was higher. At follow-up, patients had more positive appraisal of their physical appearance. Most health-related quality of life scores were not significantly different to those of the healthy normal population, apart from a reduced gross motor function, less vitality, and more pain. Patients with a remaining leg length inequality (LLI) of more than 2 cm had lower quality of life scores for gross motor function, sleep, pain, vitality, and depressive feelings.

INTERPRETATION

At an average of 7 years after an Ilizarov limb lengthening procedure, patients still have physical restraints, but they appear to have normal psychosocial functioning, self-esteem, and perceived competence. These patients have quality of life scores comparable to those of norm groups, apart from a reduced gross motor function, less vitality and more pain. Residual LLI of more than 2 cm remains important even after long-term follow-up; these patients report lower quality of life.

Measurement of health-related quality of life in children undergoing external fixator treatment for lower limb deformities

BACKGROUND

External fixator treatment (EFT) of lower limb deformities is expected to optimize gait and physical appearance, which might improve the child's health-related quality of life (HRQOL). Although EFT can impose a significant psychologic burden on the children and their families, there is a lack of studies on the HRQOL of children undergoing EFT. The purpose of this paper is to determine the construct validity and the responsiveness of the Pediatric Quality of Life Inventory (PedsQL) generic module in children with lower limb deformities undergoing EFT and to describe the use of other outcome measures in this population.

METHODS

Fifty-two children (mean age: 13.0 y, SD: 4.2) who enrolled in the pilot phase of a randomized controlled trial to examine the safety and efficacy of botulinum toxin type A injections in children undergoing EFT of the lower limb were included in this study. Pain and functional mobility were measured at baseline. HRQOL was assessed with the child self-report and parent proxy-report formats of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) at baseline, at mid-distraction, mid-consolidation, 1-week post-frame removal, and 3 months post-frame removal time points. The known groups method was used to measure the construct validity of the PedsQL; paired t tests, Cohen's d estimate of effect size (ES) and standardized response mean were used to calculate its responsiveness.

RESULTS

Children and parents reported significantly lower HRQOL scores on all PedsQL domains compared with norms. ES and standardized response mean calculations both show largest amounts of change in the Physical Health domain, with children and parents reporting worse HRQOL at mid-distraction than at baseline. The PedsQL shows statistically significant changes only in the emotional functioning score of the child self-report from 3 months post-frame removal compared with baseline.

CONCLUSIONS

The PedsQL is able to discriminate HRQOL between children with leg length discrepancy and the normal population. The responsiveness of the PedsQL in children with lower limb deformities was shown through patient change over time as a result of EFT. Our findings indicate the importance of assessing a wide range of domains including physical, psychosocial, and emotional components of health in children with leg length discrepancy undergoing EFT.

LEVELS OF EVIDENCE

Level IV. Case series.

Botulinum toxin type A injection in alleviating postoperative pain and improving quality of life in lower extremity limb lengthening and deformity correction: a pilot study

BACKGROUND

The Ilizarov technique is commonly used for lengthening and deformity corrections of the lower limbs in children. Postoperative pain can be significant, affecting quality of life and functional mobility, and often requiring prolonged medication use. Several studies have investigated the antinociceptive actions of botulinum toxin type A (BtX-A), yet evidence for its use in this population is limited. The objectives were to (1) establish the feasibility of a randomized clinical trial in children undergoing limb lengthening or deformity correction and (2) provide preliminary evidence of the beneficial effects of BtX-A in this population.

METHODS

Fifty-two patients with a mean age of 13.7 years (range, 5 to 21 y) were randomized to receive either BtX-A or an equivalent volume of sterile saline solution (placebo group), as a single dose during the surgical procedure. Pain, medication use, quality of life, and functional mobility outcomes were assessed in all patients. Adverse events were reported for all patients and classified as minor or major.

RESULTS

Differences between groups did not reach statistical significance; however, pain at mid-distraction was found to be slightly lower in the BtX-A group, as compared with the placebo group. Patients in the BtX-A group used less parenteral pain medication in the first 4 days after the surgery, had higher quality of life scores at 3 of the 5 time points assessed, and slightly higher functional mobility scores. All adverse events were expected complications of the lengthening process. No event was considered to be a serious adverse event related to the BtX-A injection itself. There was a trend toward fewer major adverse events in the BtX-A group.

CONCLUSIONS

This pilot study established the feasibility of a randomized controlled trial design for in this population. Its findings indicate that BtX-A injections appear to be safe and effective for reducing pain and improving the quality of life and functional mobility of children undergoing lengthening or deformity corrections of the lower limbs. A larger-scale study is currently underway to confirm these preliminary findings.

Postoperative impact of daily life after primary treatment of proximal/distal tibiafracture with Ilizarov external fixation

AIMS AND OBJECTIVES

To describe patients' experience of the impact of their health-related life situation on their daily life two and four weeks after primary fracture treatment with Ilizarov external fixation.

BACKGROUND

A few studies have been conducted postoperatively focussing on fracture treatment with Ilizarov fixation.

DESIGN

A prospective descriptive research design.

METHOD

Patients who had been treated for a proximal/distal tibial fracture were invited to participate in the study. Data were collected with a semi-structured questionnaire where 20 patients described in their own words their situation at home two and four weeks postoperatively. The process used when analysing the data was similar to content analysis.

RESULTS

Four key themes were identified: 'limitations in the home environment', 'limitations outside the home', 'limitations to social relations' and 'experience of having an Ilizarov fixation'. The patient's life situation was strongly affected during the first postoperative month. This took the form of clear limitations on activities outside the home and a degree of limitation on coping with household chores and personal hygiene. These limitations became less severe after between 2-4 weeks and were very much a consequence of using crutches.

CONCLUSION

This study points to limitations in the patient's daily life situation in the home. The results from the study make it obvious that the information given to patients prior to discharge, concerning the value of putting weight on the leg, had not been clear or that the patients had not understood it. This had a negative impact on the patient's daily life after discharge. Further data are needed to uncover the extent of the issue to be able to optimise patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

There is a need for clearer and more active information from the nurse before discharge but also a need to follow up how the information given is understood.

Lower limb deformity due to failed trauma treatment corrected with the Ilizarov technique: factors affecting the complication rate in 52 patients

BACKGROUND AND PURPOSE

Failed treatment of fractures may be corrected by the Ilizarov technique but complications are common. In 52 patients with compromised healing of femoral and tibial fractures, the results of secondary reconstruction with Ilizarov treatment were investigated retrospectively in order to identify the factors that contribute to the risk of complications.

METHODS

52 consecutive patients was analyzed. The median interval between injury and secondary reconstruction was 3 (0.1-27) years. The patients had failed fracture treatment resulting in bone defects, pseudarthrosis, infection, limb length discrepancy (LLD) caused by bone consolidation after bone loss, malunion, soft-tissue loss, and stiff joints. Most patients had a combination of these deformities. The results were analyzed by using logistic regression in a polytomous universal mode (PLUM) logistic regression model.

RESULTS

The median treatment time was 9 (4-30) months, and the obstacle and complication rate was 105% per corrected bone segment. In 2 patients treatment failed, which resulted in amputation. In all other patients healing of nonunion could be established, malunion could be corrected, and infections were successfully treated. The statistical analysis revealed that relative bone loss of the affected bone was the only predictor for occurrence of complications. From these data, we constructed a simple graph that shows the relationship between relative bone loss of the affected bone and risk of complications.

INTERPRETATION

Relative bone loss of the affected bone segment is the main predictor of complications after Ilizarov treatment of previously failed fracture treatment. The visualization of the analysis in a simple graph may assist comparison of the complication rates in the literature.

Leg lengthening with a motorized nail in adolescents : an alternative to external fixators?

Leg lengthening by external fixation is associated with various difficulties. We evaluated eight adolescent patients who underwent leg lengthening with a motorized intramedullary lengthening device. We asked whether this method could reduce the time of hospitalization and rehabilitation and whether the incidence of complications commonly associated with external fixators could be reduced. We compared our preliminary results with those from other reports, with a focus on leg length achieved, time of rehabilitation, and rate of complications. The average leg-length discrepancy was 3.8 cm (range, 3-5 cm). The average lengthening distance was 3.8 cm (range, 2.9-4.7 cm). In six patients, leg lengthening was combined with successful correction of the mechanical axis alignment. The consolidation index averaged 26 days/cm (range, 19-41 days/cm). The average hospital stay was 9.6 days. No bone or soft tissue infections were observed. In comparison to other studies (1.0-2.8 complications/patient), our results suggest that the difficulties commonly associated with external fixators can be reduced with this method. It also allows good angular correction in patients with mechanical axis deviation. These features combined with a short time of hospitalization and rehabilitation make it a promising procedure for limb lengthening.

LEVEL OF EVIDENCE

Level IV Therapeutic study.

Does leg lengthening pose a threat to a child's mental health?: An interim report one year after surgery

Previous studies suggest that children react with functional and psychological disturbances after leg lengthening (LL). Long-term effects are not known, and there is a lack of prospective studies. The aim of this interim prospective study was to investigate the psychological impact of the Ilizarov technique on a sample of children 1 year after surgery.

METHODS

: The subjects were 27 patients aged 6 to 16 years treated using the Ilizarov technique at the Pediatric Orthopaedic Department, Uppsala University Hospital, between 1997 and 2005. A control group of healthy children matched for age and sex were also included.Semistructured interviews and psychometric measures (anxiety, depression, self-esteem, behavior) were administered to patients and parents before surgery and 1 year after. Psychological measures were correlated with medical records (days of hospitalization, gained length, etc). The control group was examined at initial assessment only.

RESULTS

: Before reconstructive surgery, the LL group had a significantly lower self-esteem compared with the control group. Aggressive behavior, attention and externalization problems, anxiety, and depression were significantly reduced after LL. Parents' state anxiety was also reduced. There were no differences in trait anxiety between the parents of patients and the parents of the control children.

CONCLUSIONS

: Patients reported pain, psychological discomfort, complications, and restrained function during LL. However, there were no adverse psychological effects at 1-year follow-up; rather, there were signs of improved mental health. No single psychological parameter could predict the outcome after LL.

Impact of External Fixation on Adolescents

PURPOSE

To define the state of nursing knowledge about the psychological impact of treating adolescents with external fixation devices (EFDs).

METHOD

An integrated research review was conducted on literature available from CINAHL, MEDLINE, and PsycINFO. Keywords used were external fixation, fracture fixation, orthopaedic or orthopaedic, limb lengthening, Ilizarov, halo traction, Orthofix, EBI fixator, pelvic fixator, ring fixator, body image, self-concept, self-esteem, self-perception, adaptation, emotional, behavior, and outcome. Inclusion criteria for studies were (a) publication from 1990 to 2003, (b) focus on psychosocial and functional outcomes of treating adolescents with EFDs, and (c) publication in English. Studies were categorized by author, year, discipline(s), design, focus, sample, measurement, findings, and research recommendations. Findings and recommendations were compared across publications.

RESULTS

All studies reported psychological and behavioral changes after EFD treatment. Pain and pin-site infections were the most problematic physical findings. Depression was universally evident to varying degrees, with some suicidal ideation and self-destructive behaviors, although mostly reported as transient. This predominantly retrospective cohort of studies reported social isolation as well as eating and sleep disturbances. Family and nursing support, a multiple disciplinary approach, and better preoperative preparation were crucial to adolescents psychological health after EFD treatment.

CONCLUSION

Adolescents treated with EFDs require significant psychosocial support. The findings reveal major gaps in the knowledge on adolescents treated with external fixation for traumatic injury and none focused on EFD treatment in the acute period.

Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents

BACKGROUND

Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results.

METHODS

Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees. Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients.

RESULTS

The mean preoperative arc of total elbow motion was 37 degrees. The mean pronation was 46 degrees, and the mean supination was 56 degrees. After a mean duration of follow-up of thirty-four months, all patients but two had achieved a functional arc of motion of 100 degrees. The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration.

CONCLUSIONS

Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.

Living with the Ilizarov frame: adolescent perceptions

INTRODUCTION

The Ilizarov technique has become an established method in the treatment of children with serious skeletal disorders. Whilst the technique is acknowledged for solving difficult conditions, the application of the external fixator marks the beginning of an arduous treatment programme. Research has suggested that undergoing such treatment can negatively impact upon the physical and psychological well-being of the young person. Yet limitations in research design reduce the usefulness of the findings, given in that most of the previous studies have used retrospective, quantitative data collection approaches, often with a heterogeneous sample population. We wished to gain a richer insight into the experiences of adolescents living with the frame by drawing on both qualitative and quantitative approaches.

AIMS

To explore adolescents' perceptions of the anticipated and actual impact of the Ilizarov frame on aspects of daily activity.

DESIGN

A mixed-method approach, using a prospective and longitudinal study design.

METHOD

Fifteen adolescents undergoing the Ilizarov treatment were contacted at several predetermined time-points during the course of their treatment to share their perceptions of living with the frame. At several of these points semi-structured interviews were used to ascertain their perceptions, whilst quantitative data were gained at all time-points by adolescents completing a range of psychometric measures.

FINDINGS

Adolescents found that life with the frame was not as bad as anticipated, and they adopted a pragmatic approach, appreciating that this was something they 'just had to get through'. Peers had a substantial role in supporting their friend to adjust and cope with the frame. Psychometric scores were largely within normal limits.

CONCLUSION

This study suggests that, while the Ilizarov treatment is demanding for adolescents, it is one that they can tolerate without sustained adverse psychological impact.