Quadricepsplasty for knee stiffness after femoral lengthening in congenital short femur

Antegrade femoral lengthening and simultaneous hemiepiphysiodesis for congenital femoral deficiency

Purpose

Congenital femoral deficiency is characterized by limb length discrepancy and genu valgum. Lengthening of the femur along its anatomic axis increases valgus alignment by medial knee translation. Pairing limb lengthening with simultaneous medial distal femoral hemiepiphysiodesis can simultaneously correct two limb deformities.

Methods

All skeletally immature patients with congenital femoral deficiency who underwent antegrade femoral lengthening and concomitant guided growth over a 4-year period were reviewed. Length and alignment data were quantified during lengthening, consolidation, and for 1 year after guided growth implants were removed or the patient reached skeletal maturity. Digital simulation was performed for all lengthenings to assess the mechanical alignment that would have been achieved had lengthening been performed without medial distal femoral hemiepiphysiodesis.

Results

Nine patients (five males, four females, mean age = 12.3 ± 1.9 years) underwent 10 antegrade intramedullary femoral lengthenings with simultaneous medial distal femoral hemiepiphysiodesis. All had improvement in valgus alignment (average improvement in mechanical axis deviation was 18 ± 11 mm, average change in limb alignment was 6 ± 5°). In simulated lengthenings without guided growth, all limbs would have experienced increased lateral mechanical axis deviation of 5 ± 3 mm. The hemiepiphysiodesis implant and lengthening device were explanted simultaneously in 7 of 10 lengthenings.

Conclusion

Simultaneous medial distal femoral hemiepiphysiodesis with antegrade femoral lengthening for ongenital femoral deficiency can minimize the number of surgical episodes for the skeletally immature patient. The lengthening device and guided growth construct can be removed simultaneously in a majority of cases, saving children one or two additional surgical treatments.

Trends and Practices in Limb Lengthening: An 11-year US Database Study

Aim

Over the past couple of decades, limb lengthening has evolved to encompass various implants and techniques. The purpose of this study was to (1) determine trends in the utilisation of various limb lengthening techniques for the femur and tibia in the United States, (2) determine trends in 1-year readmission rate following limb lengthening procedures and (3) to study the relationship of limb lengthening implant used and payment method used with the underlying diagnosis associated with limb shortening.

Materials and methods

Inpatient data were acquired using the Healthcare Cost and Utilisation Project (HCUP) database from 2005 to 2015 from seven states in the United States. Patients with an International Classification of Diseases (ICD)-9 code for limb lengthening of the femur or tibia were included. A total of 2,563 patients were included. Data were analysed using descriptive statistics, and chi-square test was used for comparison of subcategories. Linear regression analysis was used to examine trends over time.

Results

There was a strong linear trend towards increasing proportional use of internal lengthening of the femur from 2011 to 2015 (R2 = 0.99) with an increase of 10.2% per year. A similar trend towards increasing proportional use of internal lengthening of the tibia was seen from 2011 to 2015 (R2 = 0.87) with an increase of 4.9% per year. There was a moderate correlation showing a decrease in readmission rate of 1.07% per year from 2005 to 2015 (R2 = 0.55). Patients with short stature had increased use of internal lengthening and self-payment compared to patients with congenital, post-traumatic or other diagnoses.

Conclusion

There was increasing use of internal lengthening techniques from 2011 to 2015. Patients with short stature had higher use of internal lengthening technique and self-pay for payment method.

Clinical significance

Intramedullary devices have seen increasing use for limb lengthening procedures. Lengthening technique and payment method may differ by underlying diagnosis.

How to cite this article

Mittal A, Allahabadi S, Jayaram R, et al. Trends and Practices in Limb Lengthening: An 11-year US Database Study. Strategies Trauma Limb Reconstr 2023;18(1):21-31.

What Factors Correlate With Length of Stay and Readmission After Limb Lengthening Procedures? A Large-database Study

BACKGROUND

Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures.

QUESTIONS/PURPOSES

(1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission?

METHODS

Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses.

RESULTS

Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only.

CONCLUSION

When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effects of Judet Quadricepsplasty in the Treatment of Post-traumatic Extension Contracture of the Knee

Objective

To investigate the clinical outcomes and the affecting factors of Judet's quadricepsplasty on the stiffness of post‐traumatic knee flexion.

Methods

A retrospective survey was analyzed from June 2015 to October 2018. A total of 15 patients (eight males, seven females; mean age, 48.27 years) with extension contracture of the knee were treated by Judet's quadricepsplasty. All cases were injuries induced by fracture trauma. The mean interval between the initial procedure and quadricepsplasty was 56.2 months (range, 13–276 months). The knee range of motion (ROM) was assessed with a goniometer. The results of the procedure were analyzed by measuring the degrees of flexion of the operated knees at different time points (before, immediately after, and late postoperatively). We evaluated Hospital for Special Surgery (HSS) score, Judet's criteria, change in the degree of knee flexion, and complications.

Results

All patients were followed up for 14 to 47 months, with an average of 31.53 months. The degree of flexion increased from 23.33° (range, 10°–50°) preoperatively to 107.33° (range, 100°–125°) intraoperatively, followed by a slight fall in the range of flexion in the late postoperative period, which reached an average of 95.33° (range, 60°–115°) in the last follow‐up. The knee joint function was assessed according to the Judet's criteria, eight cases (53.33%) achieved excellent results, six (40%) good, one (6.67%) fair, and zero (0.00%) poor results at final follow‐up. The long‐term excellent and good rate was 93.33%. The range of flexion of the knee during operation and at the last time of follow‐up was better than that before surgery (P < 0.001). The final flexion was significantly lower than that measured at immediate postoperative (P < 0.001). The mean postoperative HSS score for the entire group was 93.73 (range, 89–96). Fifteen excellent results were obtained according to the HSS knee score. Skin infection was seen in one patient (6.67%). There were no complications such as deep sepsis, intraoperative rupture of the quadriceps tendon, fracture of the lateral femoral condyle, skin dehiscence.

Conclusion

Judet quadricepsplasty is an effective method to treat knee extension contracture and improve knee range of motion (ROM). It should be performed by an experienced orthopaedic surgeon and followed by physiotherapy with continuous passive motion (CPM). The knee ROM obtained with the surgery has an excellent long‐term effect.

All-arthroscopic release for treating severe knee extension contractures could improve the knee range of motion and the mid-term functional outcomes

PURPOSE

To evaluate the safety, feasibility, and effectiveness of an all-arthroscopic technique for the intra- and extraarticular release of severe knee extension contractures.

METHODS

From 2012 to 2016, 25 patients with severe knee extension contractures (less than 45° range of flexion) were treated with an all-arthroscopic release technique. The patients underwent intra- and extraarticular arthroscopic release and arthroscopic-assisted mini-incision quadriceps plasty. The post-operative rehabilitation was initiated the first day after the procedures. Comprehensive clinical follow-up evaluations including the range-of-motion (ROM) assessment, the Lysholm score, and the International Knee Documentation Committee (IKDC) score were performed on all patients.

RESULTS

The median follow-up time was 28 months (range 12-65 months). The ROM improved from 23.9° ± 7.5° pre-operatively to 105.9° ± 6.5° at the final follow-up (P < 0.001). In addition, the Lysholm score increased from 59.9 ± 5.2 pre-operatively to 89.7 ± 3.3 (P < 0.001). The IKDC score increased from 47.6 ± 3.4 pre-operatively to 91.7 ± 2.4 (P < 0.001). All patients were satisfied with their final ROM and functional outcomes.

CONCLUSION

The all-arthroscopic release technique was a safe, feasible and effective method for treating severe knee extension contractures. The severe knee extension contractures may be successfully addressed by the all-arthroscopic release technique during our clinical practice.

LEVEL OF EVIDENCE

IV.

Araújo Motta GA, Rocha de Faria JL, Perez da Motta D, dos Santos Cerqueira F, Adolphson F. Minimally Invasive Quadricepsplasty

A modification of range of motion of the knee can significantly change a patient's quality of life. In general, range of motion of 0° to 125° is adequate for most activities of daily life. The rate of knee arthrofibrosis after ligament reconstruction is reported to be between 0% and 4%; after tibial fracture due to high-energy trauma, the rate is about 7%, with an undetermined incidence after limb lengthening. The purpose of this study was to describe a modification of the operative technique of Judet. We describe minimally invasive quadricepsplasty in 4 steps, aiming to obtain an end result with an arc of movement of at least 120° to 130°. We believe that our technique is a good option for the treatment of the stiff knee, having low morbidity and being an easy method to perform.

A Comparison of Femoral Lengthening Methods Favors the Magnetic Internal Lengthening Nail When Compared with Lengthening Over a Nail

BACKGROUND

Bone lengthening with an internal lengthening nail (ILN) avoids the need for external fixation and requires one less surgical procedure than lengthening over a nail (LON). However, LON has been shown to be superior to femoral internal lengthening using a mechanical nail. The magnetic ILN, a remote-controlled and magnet-driven device, may have overcome the weaknesses of earlier internal lengthening technology and may be superior to LON.

QUESTIONS/PURPOSES

(1) Is the magnetic ILN more accurate than LON for femoral lengthening? (2) Does the magnetic ILN demonstrate more precise distraction rate control than LON? (3) Does the magnetic ILN result in faster regenerate site healing, with more robust callus, than LON? (4) Does the magnetic ILN result in fewer complications, including impediments to knee motion, than LON?

METHODS

We conducted a retrospective comparison of the records and radiographs of 21 consecutive patients with 22 femoral lengthenings using LONs and 35 consecutive patients with 40 femoral lengthenings using remote-controlled magnetic ILNs. Primary outcomes measured included accuracy, distraction rate precision, time to bony union, final knee range of motion, regenerate quality, and complications. The minimum follow-up times for the LON and ILN cohorts were 13 and 21 months, respectively.

RESULTS

Patients treated with ILN had a lower post-treatment residual limb-length discrepancy (0.3 mm) than those treated with LON (3.6 mm). The rate of distraction was closer to the goal of 1 mm/day and more tightly controlled for the ILN cohort (1 mm/day) than that for the LON group (0.8 mm/day; SD, 0.2). Regenerate quality was not significantly different between the cohorts. Bone healing index for ILN was not statistically significant. Time to union was shorter in the ILN group (3.3 months) than that in the LON group (4.5 months). A lower percentage of patients experienced a complication in the ILN group (18%) than in the LON group (45%). Knee flexion at the end of distraction was greater for ILN patients (105°) than that for LON patients (88.8°), but this difference was no longer observed after 1 year.

CONCLUSIONS

Femoral lengthening with magnetic ILN was more accurate than with LON. The magnetic ILN comports the additional advantage of greater precision with distraction rate control and fewer complications. Both techniques afford reliable healing and do not significantly affect knee motion at the final follow-up. The magnetic ILN method showed no superiority in regenerate quality and healing rate.

Ilizarov technique: Bone transport versus bone shortening-lengthening for tibial bone and soft-tissue defects

OBJECTIVE

To compare the outcomes of bone transport and bone shortening-lengthening by Ilizarov technique for treatment of tibial bone and soft-tissue defects.

METHODS

Fifty patients with tibial bone and soft-tissue defects were treated by Ilizarov technique from January 2007 to June 2016. Two subgroups were treated by either bone transport (group A) containing 28 cases or bone shortening-lengthening (group B) including 22 cases.

RESULTS

Bony union was achieved at the distracted sites with a mean of 236 days in group A, while 240 days in group B, showing no significant difference (t = -0.931, P = 0.308). The mean fixation index was 3.91 d/mm and 3.92 d/mm, respectively. There was no obvious difference (t = 2.839, P = 0.006) of the mean union time at the docking sites with 376 days and 320 days, respectively. According to the Paley's criterion, 21 patients had excellent bony union and 5 good in group A, as compared to 18 excellent and 4 good in group B, but no significant difference (X² = -0.308, P = 0.741) was observed. The functional results were excellent in 11 patients, good in 10 and fair in 7, as well as 15 complications in group A, compared with 7 excellent, 10 good and 5 fair, together with 12 complications in group B, and there were no remarkable difference (X² = -0.323, P = 0.751; X² = -0.590, P = 0.562).

CONCLUSION

Overall, the outcomes are similar of bone transport or bone shortening-lengthening by using Ilizarov technique for treatment of tibial bone and soft-tissue defects, although the latter has less union time and higher healing rate.

Treatment of extraarticular knee extension contracture secondary to prolonged external fixation by a modified Judet quadricepsplasty technique

The goal of this study is to evaluate the functional results of the modified Judet quadricepsplasty for a knee extension contracture secondary to prolonged external fixation. This is a retrospective study of 31 patients with the diagnosis of an extraarticular knee extension contracture who had prolonged external fixation of the femur. Functional assessment was conducted after a minimum follow-up of 1 year. After performing the functional assessment, according to the Judet scale, 51% of the 31 patients had good results and 19.35% (6 cases) showed excellent results. The improvement in mobility from pre-operative to post-operative range of motion was significant. The performance of the technique, following the authors’ described steps and making the subsequent modifications, allowed for partial knee mobility restoration, which significantly improved the patients’ functional status.

Level of evidence: IV. Series of cases.

Distal femoral flexion deformity from growth disturbance treated with a two-level osteotomy and internal lengthening nail

Salter Harris fractures of the distal femur can lead to growth disturbance with resulting leg length inequality and knee deformity. We have looked at a case series (3) of patients who presented with a distal femur flexion malunion and shortening treated with a distal femoral osteotomy and plating and a proximal femoral osteotomy with a magnetic internal lengthening nail. Does a two-level osteotomy and internal fixation approach provide a reliable result both radiographically and functionally? The average knee extension loss was 12°, LLD 47 mm, PDFA 65°, MAD 2 mm. The patients were treated with an acute, posterior, opening wedge osteotomy of the distal femur stabilized with a lateral plate and screws and grafted with cancellous chips and putty. A second osteotomy was made proximally in the femur percutaneously, and the internal lengthening nail was inserted. Lengthening was done at approximately 1 mm/day. The average extension gain was 12°; amount of lengthening at the proximal site was 40 mm, LLD was 3 mm. The average PDFA was 81°, and MAD 3 mm. There were no complications. Functional results were excellent. Bone healing index was 24 days/cm. The average distance from the distal osteotomy to the joint line was 57 mm. The technique of two-level femur osteotomy stabilized with a plate and lengthening nail yielded excellent results with acceptable correction of deformity, full knee extension, and improved function. There were no complications including implant failure, infection, need for blood transfusion, knee stiffness, nonunion, compartment syndrome, or malunion.

Regenerate bone fracture rate following femoral lengthening in paediatric patients

PURPOSE

Femoral lengthening using a circular or mono-lateral frame is a commonly used technique. Fracture at the site of the regenerate bone is a major concern especially following removal of the external fixator. This aim of this study was to assess the rate of fracture of the regenerate bone in this single surgeon series of paediatric patients and determine potential risk factors.

METHODS

Retrospective review of all the femoral lengthening performed by the senior author was performed. The medical and physiotherapy notes were reviewed. The gender, age at time of surgery, disease aetiology, total days in the external fixator and length of the new regenerate bone were recorded. Patients who sustained a regenerate fracture were identified.

RESULTS

A total of 176 femoral lengthening procedures were performed on 108 patients. Eight regenerate fractures occurred in seven patients (4.5%). The mechanism of injury was a fall in five cases and during physiotherapy in three cases. The regenerate fracture occurred a median number of nine days following removal of frame. There was no significant difference between gender, age at time of surgery, total time in external fixator between those who sustained a regenerate fracture and those patients who did not. A significant difference was noted between the amount of lengthening between the 'regenerate fracture group' and the 'no fracture group' (50 mm vs 38 mm, respectively; p = 0.029). There was no association between disease aetiology and risk of regenerate fracture.

CONCLUSIONS

Femoral lengthening of more than 50 mm increases the risk of a fracture at the regenerate site regardless of the disease aetiology. We recommend avoidance of aggressive physiotherapy for the initial four weeks following external fixator removal.

Muscle strength and knee range of motion after femoral lengthening

Background and purpose - Femoral lengthening may result in decrease in knee range of motion (ROM) and quadriceps and hamstring muscle weakness. We evaluated preoperative and postoperative knee ROM, hamstring muscle strength, and quadriceps muscle strength in a diverse group of patients undergoing femoral lengthening. We hypothesized that lengthening would not result in a significant change in knee ROM or muscle strength. Patients and methods - This prospective study of 48 patients (mean age 27 (9-60) years) compared ROM and muscle strength before and after femoral lengthening. Patient age, amount of lengthening, percent lengthening, level of osteotomy, fixation time, and method of lengthening were also evaluated regarding knee ROM and strength. The average length of follow-up was 2.9 (2.0-4.7) years. Results - Mean amount of lengthening was 5.2 (2.4-11.0) cm. The difference between preoperative and final knee flexion ROM was 2° for the overall group. Congenital shortening cases lost an average of 5% or 6° of terminal knee flexion, developmental cases lost an average of 3% or 4°, and posttraumatic cases regained all motion. The difference in quadriceps strength at 45° preoperatively and after lengthening was not statistically or clinically significant (2.7 Nm; p = 0.06). Age, amount of lengthening, percent lengthening, osteotomy level, fixation time, and lengthening method had no statistically significant influence on knee ROM or quadriceps strength at final follow-up. Interpretation - Most variables had no effect on ROM or strength, and higher age did not appear to be a limiting factor for femoral lengthening. Patients with congenital causes were most affected in terms of knee flexion.

Is Botulinum Toxin Type A a Valuable Adjunct During Femoral Lengthening? A Randomized Trial

BACKGROUND

Reduced joint ROM and distraction-induced pain are common complaints of patients who have undergone gradual femoral lengthening. Attempts to reduce the effects of lengthening on joint motion have included the use of botulinum toxin to reduce the muscle forces that restrict motion. The benefits of this approach during femoral lengthening, however, have not been conclusively established.

QUESTIONS/PURPOSES

We wished to evaluate the effects of botulinum toxin type A (BtX-A) injection in the anterior thigh muscles during femoral distraction osteogenesis on adjacent joint ROM and distraction-induced pain. We asked: (1) Does injection of BtX-A in the quadriceps muscles lead to improved knee and hip motion during femoral lengthening? (2) Does injection of BtX-A reduce pain during femoral lengthening?

METHODS

A single-center, double-blind, randomized placebo-controlled trial was conducted. Forty-four patients (88 femurs) undergoing bilateral femoral lengthening for familial short stature were included in the study. BtX-A (200 IU) was injected intraoperatively in the quadriceps muscles of one thigh. An equal volume of sterile normal saline was injected in the other thigh as a control. Selection of the limb receiving the toxin was randomized. Clinical evaluation included a VAS score for pain measurement, ROM evaluation of the hips and knees, and measurement of thigh circumference. Side-to-side differences were analyzed throughout the entire consolidation phase. No patients were lost to followup, leaving 44 patients (88 femurs). The mean followup was 26 months (range, 14-40 months). The distraction rate and final length of gain were similar between treated and control limbs. A priori power analysis suggested that 44 legs were required in each group to achieve statistical significance of 0.05 with 90% power to detect a 50% difference in treatment effect between treatment and control groups.

RESULTS

There were no differences in hip ROM, knee ROM, or maximal thigh circumference between the two lower extremities at any time during the study period. VAS scores were no different between the patients who received BtX-A and those who received saline.

CONCLUSIONS

Local injection of 200 IU BtX-A in the quadriceps muscles does not appear to reduce distraction-induced pain nor enhance ROM in the hip or knee during femoral lengthening. Additional studies are needed to evaluate the effect of larger doses or different injection methods. Based on our findings, we do not recommend routine use of botulinum injections during limb lengthening and believe any further use of this drug should only be in the context of a controlled trial.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Custom Knee Device for Knee Contractures After Internal Femoral Lengthening

The development of knee flexion contractures is among the most common problems and complications associated with lengthening the femur with an internal device or external fixator. Conservative treatment strategies include physical therapy, serial casting, and low-load prolonged stretching with commercially available splinting systems. The authors developed an individually molded, low-cost custom knee device with polyester synthetic conformable casting material to treat knee flexion contractures. The goal of this study was to evaluate the results of treatment with a custom knee device and specialized physical therapy in patients who had knee flexion contracture during femoral lengthening with an intramedullary lengthening femoral nail. This retrospective study included 23 patients (27 limbs) who underwent femoral lengthening with an internal device for the treatment of limb length discrepancy. All patients had a knee flexion contracture raging from 10° to 90° during the lengthening process and were treated with a custom knee device and specialized physical therapy. The average flexion contracture before treatment was 36°. The mean amount of lengthening was 5.4 cm. After an average of 3.8 weeks of use of the custom knee device, only 2 of 27 limbs (7.5%) had not achieved complete resolution of the flexion contracture. The average final extension was 1.4°. Only 7 of 27 limbs (26%) required additional soft tissue release. The custom knee device is an inexpensive and effective method for treating knee flexion contracture after lengthening with an internal device.

Two-staged reconstruction for ankylosed hip with severe limb shortening: a case report

A 58-year-old man developed a 14 cm limb length discrepancy with a shortened and ankylosed right hip as a sequelae of multiple surgeries for recurrent dislocation and periprosthetic joint infection. He was successfully treated by limb elongation with external fixation and subsequent revision total hip arthroplasty. We discuss the efficacy of the two-staged reconstruction with initial limb elongation.

Quadricepsplasty: a sustained functional achievement in front of a deteriorated flexion gain

METHODS

Nineteen cases of extension contracture were operated upon by modified technique of Judet quadricepsplasty, one female and eighteen males. Results were evaluated by HSSKF score as well as Judet criteria.

PURPOSE

The hypothesis is that recurrence of adhesions underneath the quadriceps leads to loss of some of the gained intraoperative flexion range.

RESULTS

In this series, flexion range deteriorates but this was found to be statistically non significant on the functional score of the patients.

Treatment of femoral lengthening-related knee stiffness with a novel quadricepsplasty

BACKGROUND

Knee stiffness is common after femoral lengthening. Certain patients require a quadricepsplasty when therapy does not improve flexion. A small subset of such patients may also have obligate patellar dislocation with knee flexion due to contracture of the extensor mechanism. We describe our surgical approach for both clinical situations and our outcomes in a pediatric population.

METHODS

Six patients, 2 with obligate patellar dislocation, were reviewed (9% of our femoral lengthening population). Indications for surgery included persistent symptomatic restriction of flexion after at least 3 months of therapy or obligate lateral patellar dislocation with knee flexion. Knee range of motion and clinical strength were assessed. Four patients were available for gait analysis and concentric quadriceps strength testing by isokinetic dynamometer. Patient satisfaction was surveyed by questionnaire.

RESULTS

All patients had full flexion before lengthening. The mean length gained (by circular external fixation and/or intramedullary motorized nail) was 10.7 cm. The mean age at the time of quadricepsplasty was 16 years. The average active flexion preoperatively was only 48 degrees. Two patients with obligate patellar dislocation and relatively good knee flexion inflated the average preoperative knee flexion. Although both had knee flexion to 100 degrees, the patella dislocated with flexion beyond 30 degrees. At follow-up (mean, 6.2 y) active flexion averaged 120 degrees (P<0.004). All patients had 5/5 clinical strength and no significant quadriceps lag. No patients had patellar instability postoperatively. Isokinetic dynamometer revealed an average weakness of 63% compared with the nonoperative quadriceps. Gait analysis indicated patients had near-normal gait patterns. All patients were satisfied and would pursue the same treatment.

CONCLUSIONS

Our quadricepsplasty can significantly increase knee flexion and treat obligate patellar dislocation in the setting of extension contracture after femoral lengthening when nonoperative measures fail.

LEVEL OF EVIDENCE

Level IV.

Femoral reconstruction using external fixation

Background. The use of an external fixator for the purpose of distraction osteogenesis has been applied to a wide range of orthopedic problems caused by such diverse etiologies as congenital disease, metabolic conditions, infections, traumatic injuries, and congenital short stature. The purpose of this study was to analyze our experience of utilizing this method in patients undergoing a variety of orthopedic procedures of the femur. Methods. We retrospectively reviewed our experience of using external fixation for femoral reconstruction. Three subgroups were defined based on the primary reconstruction goal lengthening, deformity correction, and repair of nonunion/bone defect. Factors such as leg length discrepancy (LLD), limb alignment, and external fixation time and complications were evaluated for the entire group and the 3 subgroups. Results. There was substantial improvement in the overall LLD, femoral length discrepancy, and limb alignment as measured by mechanical axis deviation (MAD) and lateral distal femoral angle (LDFA) for the entire group as well as the subgroups. Conclusions. The Ilizarov external fixator allows for decreased surgical exposure and preservation of blood supply to bone, avoidance of bone grafting and internal fixation, and simultaneous lengthening and deformity correction, making it a very useful technique for femoral reconstruction.

Prognostic factors and long-term outcomes following a modified Thompson’s quadricepsplasty for severely stiff knees

Between 1987 and 2006 we performed a modified Thompson’s quadricepsplasty on 40 fracture-related stiff knees and followed the patients for a mean of 7.9 years (2 to 11.1). The factors affecting the final gain of movement were investigated. A total of 15 knees required lengthening of the rectus femoris. The mean flexion gain was 70.2° (42.3° to 112.5°). According to Judet’s criteria, the results were excellent in 30 knees, good in seven, and fair in three. The range of movement which was achieved intra-operatively was related to the gain of knee flexion on univariate analysis. Five patients had complications: deep infection in one, recurrent patellar dislocation in one, and rupture of the extensor mechanism in three. This modified technique gives satisfactory results. Achieving maximum knee flexion intra-operatively seems to be the most important factor in enhancing the outcome in patients with stiffness of the knee following fracture.

Limited quadricepsplasty for contracture during femoral lengthening

Extension contracture of the knee is a common complication of femoral lengthening. Knee flexion exercises to stretch the contracture with physical therapy can be effective but take a prolonged amount of time to work and place increased stress across the patellofemoral joint. We developed a minimal-incision limited quadricepsplasty surgical technique to treat knee extension contracture secondary to femoral lengthening and retrospectively reviewed 16 patients treated with this procedure. The mean age of the patients was 23 years. Range of motion of the knee and quadriceps strength were recorded preoperatively, after femur lengthening but before additional surgery, after quadricepsplasty, and at each followup. The mean femoral lengthening performed was 4.4 cm. We compared range of motion and time to regain knee flexion with those of historical controls. The minimum followup after quadricepsplasty was 6 months (mean, 38 months; range, 6-84 months). The mean range of motion was 129 degrees preoperatively, 29 degrees after the distraction phase of femoral lengthening, and 108 degrees after limited quadricepsplasty, and at final followup, the mean knee flexion was 125 degrees . There were no major complications. Limited quadricepsplasty improved knee flexion after a knee extension contracture developed secondary to femoral lengthening. In comparison to historical controls who did not have quadricepsplasty, the patients with limited quadricepsplasty had quicker return of knee flexion, although there was no difference in knee flexion achieved ultimately.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Lengthening of proximal femoral focal deficiency using a hybrid fixation with inclusion of the knee joint]

BACKGROUND

A major problem in lengthening a short femur in proximal focal deficiency of the femur (PFFD) is the development of contractures and dislocation of the hip and knee joint. The knee joint is particularly prone to dislocation because of the cruciate ligament insufficiency associated with PFFD. Axis deviations also need specific attention.

PATIENTS AND METHODS

In four patients (age 2.5-11 years) with PFFD (PAPPAS class III in one patient and VII in three patients), five femoral lengthenings with mechanical axis corrections were performed by the callotasis technique using a hybrid fixation system (Monotube/Triax) connecting the femur and the tibia with a fixed hinged knee joint to protect the knee against contracture and dislocation.

RESULTS

All patients retained their hip and knee function. Hip flexion contracture during lengthening may make inclusion of the hip joint into the fixation system necessary, but was not carried out in the four patients presented.

CONCLUSION

Four consecutive lengthenings of the femur with focal deficiency were carried out under protection by a hinged knee bridging external fixator. A dislocation could be prevented in all patients. We consider that such a system could be used during these lengthening procedures.

Femoral lengthening over an intramedullary nail using the external fixator: risk of infection and knee problems in 22 patients with a follow-up of 2 years or more

BACKGROUND

The time for femoral lengthening is shortened if external fixation is combined with intramedullary nailing. However, several complications have been reported with this procedure.

PATIENTS AND METHODS

We retrospectively reviewed the outcome of femoral lengthening performed over an intramedullary nail using external fixation in 22 patients. These patients were followed for a mean of 3.2 (2-5.2) years. The mean age was 22 (13-35) years at the time of the index procedure. The mean lengthening was 5 (2.7-8.1) cm and the external fixator was removed after median 20 (8-30) weeks. The mean external fixation index was 24 (11-35) days/cm and the mean consolidation index was 43 (26-55) days/cm of lengthening.

RESULTS

3 patients who had a past history of infection or open trauma developed osteomyelitis which required removal of the nail. There were 4 knee joint complications when the lengthening was over 20%, including posterior knee subluxation and patella subluxation. In 1 patient, the lengthened segment collapsed with breakage of locking screws.

INTERPRETATION

Although lengthening over a nail can reduce the duration of external fixation, caution is required to prevent major complications.