Management of late-onset tibia vara in the obese patient by using circular external fixation

Management of femoral shaft infected nonunion through customised Ilizarov external fixator assembly in a morbidly obese patient

A 19-year-old morbidly obese man presented with infected nonunion of femoral shaft fracture. Patient had history of 13 failed fixation surgeries, assessment revealed 3-centimetre limb-length discrepancy with 3-centimetre gap nonunion. Wound debridement, primary compression and external fixation using a customised Ilizarov external fixation assembly were planned. A four-ring customised assembly was applied. Partial weight bearing was allowed from first postoperative day on walker. Patient was kept on a monthly follow-up. After complete union at 10 months after surgery, frame was dynamised. After 6 months of dynamisation, frame was removed, at that time patient was full weight bearing. Knee was still stiff with a range of motion of 0°-20°, and there was 6 cm of limb length discrepancy, which was managed with a shoe raise. At 9 months after frame removal, patient is mobile with fully united bone. Ilizarov external fixator can be a good managing option in such difficult and complicated cases.

Modified oblique high tibial osteotomy with minimal fixation for correction of adolescent tibia vara: a prospective case series study

PURPOSE

To assess the reliability and efficacy of the modified oblique high tibial osteotomy for correction of complex deformity in adolescent tibia vara.

METHODS

A total of 19 patients (25 legs) with adolescent tibia vara were enrolled in this study. There were 16 male (84.2%) and three female (15.8%) patients who had modified Rab oblique osteotomy with minimal fixation performed. The age of the patients at time of surgery ranged from 12 years to 30 years (mean 17.23 (sd 5.27)). The body mass index ranged from 22 kg/m² to 42 kg/m² (mean 32.05 (sd 6.13)). All patients were followed up for over two years (mean 3.4; 2 to 5).

RESULTS

The femoro-tibial angle was improved from -34° to -12° (mean -20.04° (sd 5.24°) preoperatively and from -12° to 7°, postoperatively (mean 2.04° (sd 4.07)). Medial deviation of the mechanical axis corrected from 38 mm to 125 mm (mean 76.13 (sd 23.29)) preoperatively to 0 mm to 36 mm (mean 5.74 (sd 7.3)) postoperatively. The time needed to achieve union ranged from eight weeks to 16 weeks (mean 10.2 (sd 2.42)). According to the Lysholm functional knee score scale, there were 15 excellent (78.9%), two good (10.5%), one fair (5.2%) and one poor (5.2%) after correction of the deformity.

CONCLUSION

Modified Rab osteotomy with minimal fixation by two or three screws shows promising results with good correction of varus deformity (coronal plane), internal torsion (axial plane) and procurvatum (sagittal plane), in management of adolescent tibia vara with minimal morbidity and complications.

LEVEL OF EVIDENCE

IV.

A retrospective comparative study of corrective osteotomy for tibial deformities with the multiaxial correction fixator and the circular fixator

PURPOSE

A multiaxial correction (MAC) fixator is a monolateral type of fixator that can correct multi-planer deformities. The purpose of this study is to compare the clinical outcome of correction for tibial deformities with the MAC fixator and the circular external fixators.

METHODS

We retrospectively reviewed consecutive patients reconstructed with the MAC fixator (MAC group) or circular external fixators (Ring group) due to the congenital diseases or residual conditions after treatment of trauma, infection, tumor, or limb lengthening between 2003 and 2016.

RESULTS

The 30 patients who had angular tibial deformity were included. In patients with tibia vara or lateral bowing, the average pre-operative mechanical medial proximal tibial angle (mMPTA) of the MAC group and the Ring group was significantly increased to 86.9 ± 3.5° in the MAC group and 88.0 ± 3.6° in the Ring group postoperatively. Medial bowing was also successfully corrected in both groups. Regarding the sagittal alignment, post-operative anatomical posterior proximal tibial angle (aPPTA) of the MAC group was deteriorated after coronal correction. The operative time was significantly shorter in the MAC group than the Ring group (p < 0.05).

CONCLUSION

The MAC fixator successfully corrected coronal deformities of the tibia with shorter operative time, but it has a risk of occurrence of the procurvatum deformity compared with circular external fixators. Paying attention to the sagittal alignment, the MAC fixator can be one of the treatment options for correction of the coronal tibial deformities.

Weight gain during external fixation

BACKGROUND/PURPOSE

In our clinical practice we found that some patients treated with external fixation, especially those with Blount disease, had notable weight gain. We hypothesized that correction of Blount disease using external fixation would be associated with weight gain and that the weight gain would be greater than that seen in other patients.

METHODS

This was a retrospective chart review of patients with Blount disease at two children's hospitals. Patients with Blount disease were compared to patients treated with external fixation for fracture or other deformity. The data recorded included initial and post-treatment weight and time in external fixation. Within each group pre-operative weight was compared with post-treatment weight, and weight gain was compared between groups.

RESULTS

The study cohort comprised 39 patients with Blount disease and 13 control patients. The average age and weight of the patients with Blount disease and the controls were 12.8 years and 106.4 kg (1.7 × the 95th percentile weight for age) and 12.2 years and 52.4 kg (0.89 × the 95th percentile weight for age), respectively. Patients with Blount disease gained an average of 3.7 kg (range -12.5 to +43.1 kg) during 18 weeks of treatment (0.19 kg/week), and the controls gained an average of 4.1 kg (range -4.4 to +19 kg) over 17 weeks (0.247 kg/week). The weight gain during treatment was statistically significant for both groups, but was not statistically different between groups.

CONCLUSION

Patients with Blount disease as well as those with other conditions treated with prolonged external fixation experience significant weight gain which could complicate rehabilitation or return to previous activity.

Does Langenskiold staging have a good prognostic value in late onset tibia vara?

BACKGROUND

Although many literature studied the effect of many factors on the prognosis of the early-onset Blount disease, studies that were written on the prognostic factors affecting late onset tibia vara are still limited.

PURPOSE

The aim of this study is to evaluate the prognostic value of the Langenskiold classification system for late onset tibia vara.

METHODS

Twenty children from the Sporting Health Insurance Student Reference Hospital-Alexandria, with a diagnosis of late onset tibia vara were evaluated for the effect of the Langenskiold staging system on the prognosis after they all had been treated by gradual correction by Ilizarov technique using the so called "juxta-articular hinge assembly" after a mean follow-up period of 4.9 years (range : 4-6, SD 0.75).

RESULTS

The difference in varus recurrence rates between the "low grade group" and "high grade group" was found to be statistically significant (p = 0.008) as will be discussed later. There was no statistically significant relation between the age of the patients at the time of operation, sex, length of the follow up period and the degree of pre-operative varus deformity angle (DA) and the recurrence (p > 0.05).

CONCLUSION

We concluded that Langenskiold staging system is a reliable, reproducible and a good prognostic factor for late onset tibia vara.

Correction of Blount's disease by a multi-axial external fixation system

BACKGROUND

Blount's disease is a multi-planar deformity affecting the pediatric population which leads to varus alignment of the lower extremities. The Multi-Axial Correction (MAC) monolateral external fixation system (Biomet, Parsippany, NJ, USA) is a non-circular fixator that was developed as a response to the technical difficulty for both patients and physicians of placing, managing, and tolerating a circular fixator. The purpose of this study was to determine the efficacy of the MAC system for the treatment of pediatric patients with Blount's disease.

METHODS

A retrospective analysis of 17 consecutive patients with surgically corrected Blount's disease using the MAC system with tibial and fibular osteotomies was identified. Patient charts and radiographs at three different time points (pre-operative, fixator removal, and final follow-up) were reviewed. The mechanical axis deviation (MAD), tibial-femoral angle (TFA), medial proximal tibial angle (MPTA), and posterior proximal tibial angle (PPTA) were measured in the MAC group at the three time points mentioned previously. The total wear time, total operative time, and post-operative complications were noted.

RESULTS

The MAC system was able to correct the deformity of Blount's disease as measured by a decrease in the MAD (40.2 +/- 29.3 mm; P </= 0.001) and TFA (15.9 +/- 13.7 degrees ; P </= 0.001), as well as an increase in the MPTA (15.7 +/- 14.6 degrees ; P = 0.001) at the time of fixator removal. The correction was maintained for these parameters at the time of final follow-up (P </= 0.025). The absolute values obtained at final follow-up for MAD (20.5 +/- 12.7 mm medial), TFA (8.0 +/- 4.1 degrees varus), and MPTA (83.7 +/- 8.1 degrees ) after correction with the MAC system were close to what is considered as normal for these indices. The most common complications noted were superficial pin tract infections and/or cellulitis, with no patients having nerve palsy, compartment syndrome, non-union, or leg length discrepancies. The total time that the fixator was on the patients prior to removal was 130.6 days (standard deviation [SD] = 44.8). The mean operative time was 120.6 min (SD = 21.2).

CONCLUSIONS

Correction of Blount's disease with osteotomy of the tibia and fibula as well as dynamic fixation with the MAC system achieved deformity correction as measured by radiographic indices with minimal intra- and post-operative complications. The ease of application and adjustment of the MAC system makes it an attractive option for Blount's deformity correction.

[Operative management and fracture care of the lower leg with the Ilizarov fixator in morbidly obese patients: literature review and results]

Given the rising prevalence of obesity, surgeons and hospitals must become more familiar with the treatment and operative management of obese patients. Several additional pre- and postoperative considerations must be involved such as appropriate assessment of comorbidities and requirements for special equipment. There are still very few data regarding morbidly obese patients with BMIs >50 kg/m(2). After a general literature review of operative management of obese patients, we report on fracture care of the lower limb in such patients with custom-made Ilizarov ring fixators. We found them suited to bear enormous weight-loading but that associated comborbidities can limit successful fracture care.

Length changes in tibial osteotomy with angular correction

Twelve boys, aged 11-17 years, who underwent percutaneus proximal tibial osteotomy with acute angular correction and application of external fixator for unilateral Blount's disease were retrospectively reviewed. Preoperative radiographs were compared with radiographs at healing to evaluate changes in tibial length and overall limb length. Angular correction increased overall limb length by a mean of 1.4 cm (range -0.4 cm to 3.2 cm). This increase was a mean 0.7 cm less than was predicted by adding the preoperative tibial and femoral lengths. This failure to achieve the predicted limb length occurs due to shortening in the tibia and should be considered when planning an osteotomy.