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Scholl Schell M, Xavier de Araujo F, Silva MF. Physiotherapy assessment and treatment of patients with tibial external fixator: a systematic scoping review. Disabil Rehabil 2024; 46:1673-1684. [PMID: 37118977 DOI: 10.1080/09638288.2023.2202419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 04/08/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE To map evidence regarding physiotherapy assessment and treatment of patients with tibial external fixator (EF), and to point out literature gaps for further research. METHODS Systematic scoping review conducted in four databases. We included both experimental and non-experimental studies involving patients with tibial EF and outcomes of interest. We recorded study design, population, sample size, sample age, reason for EF use, type of surgery, type of EF used, instruments used for assessing function, pain, quality of life, satisfaction, psychosocial aspects, and physiotherapy treatment descriptions from included studies. We categorised data accordingly to outcomes assessed and physiotherapy treatments description. RESULTS Eighty-six studies were included involving 3070 patients. Causes of fixator use were traumatic conditions, acquired and congenital deformities, and non-traumatic conditions, like compartmental osteoarthritis. Function was assessed in about three-quarters of included studies, though other outcomes were not presented in most studies. Only one study described satisfactorily the physiotherapy treatment. Almost half of the studies did not provide any description of the rehabilitation process. CONCLUSIONS There is little evidence about the assessment of function, pain, quality of life, satisfaction, psychosocial aspects, and other outcomes in tibial EF patients. Physiotherapy treatment in these patients is poorly reported.Protocol registration: Open Science Framework: doi:10.17605/OSF.IO/UT2DA.
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Affiliation(s)
- Mauricio Scholl Schell
- Physiotherapy Department, Post Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | | | - Marcelo Faria Silva
- Physiotherapy Department, Post Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
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Ghaly HM, El-Rosasy MAM, Marei AE, El-Gebaly OA. Simultaneous femoral and tibial lengthening for severe limb length discrepancy in fibular hemimelia. J Orthop Surg Res 2023; 18:844. [PMID: 37936235 PMCID: PMC10631071 DOI: 10.1186/s13018-023-04229-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 09/22/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Fibular Hemimelia (FH) is the most common longitudinal limb deficiency. Significant limb length discrepancy (LLD) will necessitate long treatment times and multiple settings to compensate for LLD when associated with femoral shortening. This study evaluates the outcome of simultaneous femoral and tibial lengthening using the Ilizarov frame. METHODS This retrospective study included the cases of 12 children with severe limb length discrepancy caused by combined FH and ipsilateral femoral shortening from May 2015 to August 2022. The total LLD ranged from 7 to 14.5 cm. All patients underwent single-session femoral and tibial lengthening using the Ilizarov ring external fixator technique. Additional procedures were performed in the same setting, including Achilles tendon lengthening, fibular anlage excision, peroneal tendons lengthening, and iliotibial band release. Follow-up ranged from 2 to 4 years. RESULTS The planned limb lengthening was achieved in ten cases (83%). No cases of joint subluxation or dislocation were encountered. No neurovascular injury has occurred during the treatment course. In all cases, the bone healing index was better on the femoral side than on the tibia. Poor regeneration and deformity of the tibia occurred in two cases (16.6%). CONCLUSION Simultaneous femoral and tibial lengthening using the Ilizarov fixator is a relatively safe procedure with the result of correction of total LLD in one session in a shorter time and less morbidity.
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Hydrotherapy for Patients With External Fixation: Effect on Infectious Events. J Pediatr Orthop 2023; 43:187-191. [PMID: 36728393 DOI: 10.1097/bpo.0000000000002341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgery to achieve long bone lengthening and deformity correction in skeletally immature patients is traditionally performed through external fixators. The incidence of infection during treatment is high. Hydrotherapy is highly beneficial during external fixation management, but the infection rates may impact its utilization. The objective of this paper is to document the incidence and duration of infection in patients who participated in a full hydrotherapy program when performed under medical supervision and in accordance with strict follow-up protocols. METHODS In this retrospective study, we documented the key characteristics of patients who participated in hydrotherapy after lower limb external fixation surgery including age, sex, diagnosis and surgery site, the incidence and duration of pin site infections, and the percentage of cases, which were able to comply with a full hydrotherapy protocol. RESULTS The hydrotherapy pool met all daily water quality metrics. Thirty-four children (19 males and 15 females) had a mean±SD age of 10.9±4.6 years. Of the cases, 80% were unilateral and 20% were bilateral. Diagnoses included congenital hereditary (eg, achondroplasia), congenital nonhereditary conditions (eg, fibular hemimelia), and acquired conditions (eg, traumatic). The location of osteotomy site was quite evenly spread between the femur and the tibia/fibula. Three out of the 34 patients were unable to receive hydrotherapy due to continuous secretions; 2 patients did not miss any sessions. The mean number of treatments was 3 per week. During the entire period, a total of 1200 treatments were performed for these patients with only 32 cancellations (about 3%) due to secretions or other signs of infection. Spearman correlation coefficients showed significantly high correlations between the duration of external fixation and the duration of hydrotherapy. There are no significant correlations between infections and other factors (sex, age segment, whether the problem is unilateral or /bilateral, diagnosis, and duration of treatment). CONCLUSIONS This is the first report, to our knowledge, that documents the low prevalence of infectious events during hydrotherapy treatment and demonstrates its feasibility. LEVEL OF EVIDENCE Level III; retrospective, comparative study.
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Wei Z, Cao Q, Zhu W, Feng B, Weng X. The Ilizarov technique in the management of haemophilic knee flexion contracture. Haemophilia 2023; 29:855-863. [PMID: 36802090 DOI: 10.1111/hae.14763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/21/2023] [Accepted: 02/06/2023] [Indexed: 02/20/2023]
Abstract
INTRODUCTION The Ilizarov technique has the potential to be an attractive option for severe knee flexion contracture (KFC) patients with a high risk of bleeding. However, studies on this technique in the management of haemophilic KFC are scarce. AIM The purpose of this study was to review and analyse the results of the Ilizarov technique in correcting haemophilic KFC and to evaluate the safety and efficacy of this technique. METHODS Twelve male haemophilia patients with severe KFC who underwent distraction treatment using the Ilizarov technique from June 2013 to April 2019 were included in this study. The hospital day, flexion contracture, range of motion (ROM) of the knees, complications and functional outcomes were recorded and analysed. Functional outcomes were evaluated according to the Hospital for Special Surgery (HSS) knee scores of the preoperation, end of distraction and last follow-up. RESULTS The average preoperative flexion contracture and range of motion (ROM) of the knees were 55 ± 15° and 66 ± 18°, respectively. The average preoperative HSS knee score was 47 ± 5. The average duration of follow-up was 75.5 ± 30.1 months. All flexion contractures achieved full correction (≤5°) at the end of distraction, and the flexion contracture significantly decreased to 6 ± 5° at the last follow-up (p < .0001). The ROM of the knees was significantly increased at the last follow-up compared with that before distraction treatment (p < .0001). The HSS knee scores at the end of distraction and at the last follow-up were both significantly higher than the preoperative HSS knee score (p < .0001). No major complications were encountered. CONCLUSIONS This study provided evidence for the safety and effectiveness of Ilizarov technique plus physical therapy in the management of haemophilic KFC and accumulated clinical experience for the proper application of this technology.
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Affiliation(s)
- Zhanqi Wei
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,School of Medicine, Tsinghua University, Beijing, China
| | - Qing Cao
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Zhu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Feng
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xisheng Weng
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Metikala S, Kurian BT, Madan SS, Fernandes JA. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020; 15:91-97. [PMID: 33505525 PMCID: PMC7801897 DOI: 10.5005/jp-journals-10080-1459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective Ilizarov hip reconstruction (IHR) is a traditional method of salvaging chronic adolescent problem hips but faces practical problems from external fixators leading to reduced compliance. We present the same reconstruction utilising only internal devices with a modification in technique and aim to review early results. Materials and methods We retrospectively evaluated eight patients between 2014 and 2017 with chronic painful hips treated by a two-stage reconstruction; stage 1 included femoral head resection and pelvic support osteotomy using double plating, while stage 2 comprised distal femoral osteotomy avoiding varus followed by insertion of retrograde magnetic nail for postoperative lengthening. Patients continued physiotherapy postoperatively while protecting from early weight-bearing. Results At mean follow-up of 19 months (range 6–36), all osteotomies healed with bone healing index of 47 days/cm (range 30–72). Pain improved from 8.3 (range 7–9) to 2 (range 0–6), while limb length discrepancy got corrected from 4.3 cm (range 3–5) to 1.4 cm (range 0–2.5) at final follow-up. Trendelenburg sign was eliminated in three and delayed in five. No examples of infection or permanent knee stiffness were noted. One patient had plates breakage due to mechanical fall and one had 35 mm of lateral mechanical axis deviation requiring corrective osteotomy. Conclusion Pelvic support hip reconstruction with exclusive internal devices is a technique in evolution with encouraging early results. It avoids common complications of external fixators and facilitates quick rehabilitation of joints. Refraining from distal varus can effectively eliminate Trendelenburg gait, albeit with some degree of lateral mechanical axis deviation. Unlike external fixation where there is a possibility of gradual correction, this staged procedure of internal fixation is technically demanding with a learning curve. Clinical significance Pelvic support hip reconstruction performed by internal implants is a viable alternative to IHR with potential benefits. How to cite this article Metikala S, Kurian BT, Madan SS, et al. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020;15(2):91–97.
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Affiliation(s)
- Sreenivasulu Metikala
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital, Sheffield, UK
| | - Binu T Kurian
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital, Sheffield, UK
| | - Sanjeev S Madan
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital, Sheffield, UK; Department of Trauma and Orthopaedics, Sheffield Children's Hospital NHS Trust, Sheffield, UK
| | - James A Fernandes
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital, Sheffield, UK
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Metikala S, Kurian BT, Madan SS, Fernandes JA. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020; 15:34-40. [PMID: 33363639 PMCID: PMC7744672 DOI: 10.5005/jp-journals-10080-1450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim and objective Ilizarov hip reconstruction (IHR) is a traditional method of salvaging chronic adolescent problem hips but faces practical issues from external fixators leading to reduced compliance. We present the same reconstruction procedure using only internal devices with a modification in the technique and review early results. Materials and methods We retrospectively evaluated eight patients between 2014 and 2017 with chronic painful hips treated by two-stage reconstruction; stage I included femoral head resection and pelvic support osteotomy using double plating, whereas stage II comprised distal femoral osteotomy avoiding varus followed by the insertion of a retrograde magnetic nail for postoperative lengthening. Patients continued physiotherapy postoperatively while protecting from early weight-bearing. Results At a mean follow-up of 19 months (range, 6–36), all osteotomies healed with a bone healing index of 47 days/cm (range, 30–72). Pain improved from 8.3 (range, 7–9) to 2 (range, 0–6) while the limb length discrepancy got corrected from 4.3 cm (range, 3–5) to 1.4 cm (range, 0–2.5) at the final follow-up. Trendelenburg sign was eliminated in three patients and delayed in five patients. No examples of infection or permanent knee stiffness were noted. One patient had plate breakage due to mechanical fall, and another patient had 35 mm of lateral mechanical axis deviation (MAD) requiring corrective osteotomy. Conclusion Pelvic support hip reconstruction with exclusive internal devices is a technique in evolution with encouraging early results. It avoids common complications of external fixators and facilitates quick rehabilitation of joints. Refraining from distal varus can effectively eliminate Trendelenburg gait, although with some degree of lateral MAD. Unlike external fixation where there is a possibility of gradual correction, this staged procedure of internal fixation is technically demanding with a learning curve. Clinical significance Pelvic support hip reconstruction performed by internal implants is a viable alternative to Ilizarov hip reconstruction with potential benefits. How to cite this article Metikala S, Kurian BT, Madan SS, et al. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020;15(1):34–40.
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Simpson AHRW, Robiati L, Jalal MMK, Tsang STJ. Non-union: Indications for external fixation. Injury 2019; 50 Suppl 1:S73-S78. [PMID: 30955871 DOI: 10.1016/j.injury.2019.03.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 03/28/2019] [Indexed: 02/02/2023]
Abstract
External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.
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Affiliation(s)
- A H R W Simpson
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom.
| | - L Robiati
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - M M K Jalal
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - S T J Tsang
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
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Zhai J, Weng X, Zhang B, Peng H, Bian Y. Management of knee flexion contracture in haemophilia with the Ilizarov technique. Knee 2019; 26:201-206. [PMID: 30415971 DOI: 10.1016/j.knee.2018.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 07/02/2018] [Accepted: 08/14/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are limited reports about management of Knee flexion contracture (KFC) in haemophiliacs with Ilizarov technique. The aim of this study was to retrospectively analyzed the results of Ilizarov technique to treat KFC. METHODS Six patients with haemophilia A and one with haemophilia B were included in this study, with an average age of 17 years old. The mean preoperative KFC and flexion angle of the knee were 58 ± 21° (mean ± standard deviation) and 127 ± 12°, respectively. Preoperative HSS score (hospital for special surgery knee score) was 51 ± 4. The average time of follow-up was 39.3 ± 23.3 months. RESULTS All the patients achieved full correction of flexion contracture at the end of distraction and maintained at the last follow-up. The mean flexion angle at the end of distraction and at the last follow-up were 41 ± 35° and 38 ± 19° respectively, which were significantly lower than preoperative flexion angle. The mean HSS score at the end of distraction and at the last follow-up were 65 ± 4 and 64 ± 2 respectively, which were significantly higher than the preoperative HSS score. One patient suffered from transient numbness of left leg, and all the patients had loss of range of knee flexion at last follow-up. CONCLUSIONS Ilizarov is an effective and safe procedure to treat KFC in haemophiliacs. However, loss of knee flexion was the most common complication.
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Affiliation(s)
- Jiliang Zhai
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xisheng Weng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Baozhong Zhang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huiming Peng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanyan Bian
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Bhave A, Shabtai L, Woelber E, Apelyan A, Paley D, Herzenberg JE. Muscle strength and knee range of motion after femoral lengthening. Acta Orthop 2017; 88:179-184. [PMID: 27892743 PMCID: PMC5385113 DOI: 10.1080/17453674.2016.1262678] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Anil Bhave
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA;,Correspondence:
| | - Lior Shabtai
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Erik Woelber
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Dror Paley
- Paley Advanced Limb Lengthening Institute, St. Mary’s Medical Center, West Palm Beach, Florida, USA
| | - John E Herzenberg
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
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Park H, Shin S, Shin HS, Kim HW, Kim DW, Lee DH. Is Botulinum Toxin Type A a Valuable Adjunct During Femoral Lengthening? A Randomized Trial. Clin Orthop Relat Res 2016; 474:2705-2711. [PMID: 27506971 PMCID: PMC5085937 DOI: 10.1007/s11999-016-5018-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/02/2016] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Hoon Park
- grid.15444.300000000404705454Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soowan Shin
- grid.42505.360000000121566853Department of Biological Sciences, University of Southern California, Los Angeles, CA USA
| | - Han Sol Shin
- grid.15444.300000000404705454Division of Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Woo Kim
- grid.15444.300000000404705454Division of Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Wook Kim
- grid.15444.300000000404705454Division of Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Lee
- grid.15444.300000000404705454Division of Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
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Safety and Efficacy of Botulinum Toxin A in Children Undergoing Lower Limb Lengthening and Deformity Correction: Results of a Double-blind, Multicenter, Randomized Controlled Trial. J Pediatr Orthop 2016; 36:48-55. [PMID: 25730290 DOI: 10.1097/bpo.0000000000000398] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lengthening of the lower limb is a complex procedure in which pain management and complications such as pin-site infections and muscle contractures impact the family and affect the child's quality of life. As a result, the paralytic and antinociceptive actions of neurotoxins may be indicated in managing these complications; however, few studies have explored ways to improve outcomes after lengthenings. The objective of this study was to evaluate the safety and efficacy of botulinum toxin A (BTX-A) in children undergoing lower limb lengthenings and deformity correction. METHODS Participants with a congenital or acquired deformity of the lower extremity requiring surgery to one limb were randomized to receiving either BTX-A as a single dose of 10 units per kilogram body weight, or an equivalent volume of saline solution. Pain, medication, quality of life, and physical function were assessed at different time-points. Adverse events were recorded in all participants. T test and χ tests were used to compare potential differences across both groups. RESULTS Mean age of the 125 participants was 12.5 years (range, 5 to 21 y), and lengthenings averaged 4.2 cm. Maximum pain scores on day 1 postoperatively were lower in the BTX-A group (P=0.03) than in the placebo group, and remained significant favoring botox when stratifying by location of lengthening (femur vs. tibia). Clinical benefits for BTX-A were found for 3 quality of life domains at mid-distraction and end-distraction. When stratifying according to location of lengthening, there were significantly fewer pin-site infections in the tibia favoring botox (P=0.03). The amount of adverse events and bone healing indices were no different in both groups. CONCLUSIONS The clinical differences in quality of life, the lower pain on the first postoperative day, and the lower number of pin-site infections in the tibia favoring BTX-A support its use as an adjunctive treatment to the lengthening process. The detailed analyses of pain patterns help inform families on the pain expectations during lower limb lengthenings. The amount of adverse events were no different in both groups, and bone healing rates were similar, indicating that the use of BTX-A in children undergoing limb lengthening and deformity correction is safe. LEVEL OF EVIDENCE Level I.
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Bhave A, Shabtai L, Ong PH, Standard SC, Paley D, Herzenberg JE. Custom Knee Device for Knee Contractures After Internal Femoral Lengthening. Orthopedics 2015; 38:e567-72. [PMID: 26186317 DOI: 10.3928/01477447-20150701-53] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 09/02/2014] [Indexed: 02/03/2023]
Abstract
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.
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Shahcheraghi GH, Javid M, Hadavi F. Pediatric lower limb Ilizarov lengthening with functional evaluation in adulthood: A report on underprivileged patients. J Orthop 2014; 12:S69-74. [PMID: 26719612 DOI: 10.1016/j.jor.2014.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 06/29/2014] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Ilizarov lengthening, with the principles of Ilizarov, requires a collaboration and supervision of the physiotherapist, nurse, and psychologist, preferably in a group-therapy set-up. We report the mid- and long-term functional outcome of cases that had none of the above listed supporting elements. In addition, we tried to observe the effect of the disease category on the final outcome in the patient. METHOD In this study, 35 children who had undergone Ilizarov lower limb lengthening were evaluated using the following methods: clinical, radiographic, and by four functional scoring systems, and parent/patient satisfaction questionnaires, after an average of 17.2 years (10-25 years). RESULTS In this study, 19 boys and 16 girls aged 5-16 years received 18 femoral and 20 tibial lengthening. An average of 6.2 cm lengthening in the femur and 8.4 in the tibia was achieved, with a healing index of 26.5 days. The disease category did not significantly affect the healing index, but the complications, 0.5 per femoral and 0.7 per tibial segment, were more common among congenital, and least among post-traumatic discrepancies. A complete improvement in joint stiffness was observed by 6-12 months post-frame removal in 83% of the cases, following home therapy by parents alone. CONCLUSION The long-term results of Ilizarov lengthening for lower limb discrepancy in children, even without group-therapy or good supportive aids, can improve function and maintain patient satisfaction in two thirds of the cases, over an average period of 17 years. LEVELS OF EVIDENCE IV.
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Affiliation(s)
- Gholam Hossain Shahcheraghi
- Orthopaedic Research Centre, Department of Orthopaedics, Namazee Hospital, Shiraz Medical University, Shiraz 7193711351, Iran
| | - Mahzad Javid
- Orthopaedic Research Centre, Department of Orthopaedics, Namazee Hospital, Shiraz Medical University, Shiraz 7193711351, Iran
| | - Fatemeh Hadavi
- Orthopaedic Research Centre, Department of Orthopaedics, Namazee Hospital, Shiraz Medical University, Shiraz 7193711351, Iran
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Hip reconstruction osteotomy by Ilizarov method as a salvage option for abnormal hip joints. BIOMED RESEARCH INTERNATIONAL 2014; 2014:835681. [PMID: 24895616 PMCID: PMC4033345 DOI: 10.1155/2014/835681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 04/09/2014] [Accepted: 04/14/2014] [Indexed: 11/17/2022]
Abstract
Hip joint instability can be secondary to congenital hip pathologies like developmental dysplasia (DDH) or acquired such as sequel of infective or neoplastic process. An unstable hip is usually associated with loss of bone from the proximal femur, proximal migration of the femur, lower-extremity length discrepancy, abnormal gait, and pain. In this case series of 37 patients coming to our institution between May 2005 and December 2011, we report our results in treatment of unstable hip joint by hip reconstruction osteotomy using the Ilizarov method and apparatus. This includes an acute valgus and extension osteotomy of the proximal femur combined with gradual varus and distraction (if required) for realignment and lengthening at a second, more distal, femoral osteotomy. 18 males and 19 females participated in the study. There were 17 patients with DDH, 12 with sequelae of septic arthritis, 2 with tuberculous arthritis, 4 with posttraumatic arthritis, and 2 with focal proximal femoral deficiency. Outcomes were evaluated by using Harris Hip Scoring system. At the mean follow-up of 37 months, Harris Hip Score had significantly improved in all patients. To conclude, illizarov hip reconstruction can successfully improve Trendelenburg's gait. It supports the pelvis and simultaneously restores knee alignment and corrects lower-extremity length discrepancy (LLD).
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Abstract
Any lower limb discrepancy may be equalised by conservative means (insoles, prosthesis and orthosis). However, their long-term acceptance is low in regard to function, costs, expenditure and appearance. Timely epiphysiodesis is the best option in uniplanar deformities with adequate remaining growth and for patients whose predicted final body height is above the 50th percentile. However, many patients present late or with multi-planar deformities, which warrant more sophisticated operative approaches. The history of surgical bone lengthening comprises 100 exciting years of struggling, development and ongoing learning. The initial strategy of acute or rapid incremental distraction had lasted almost half a century until Ilizarov recognised the benefits of biological periosteum-preserving osteotomies and incremental lengthening at slow rates (1 mm/day) at a 4 × 0.25-mm daily rhythm, well appreciated as callotasis. In parallel, ring and wire constructs made complex three-dimensional axial, translational and rotational bone moulding possible. Taylor Spatial Frames-built on hexapod strut-linked platform technology as known from flight simulators-took limb correction to a more reliable, more precise and aesthetical level, all the more that the whole process became web-based. It represents state-of-the-art methodology and technology for complex, multi-plane deformities. Due to the significant risk of secondary malalignment, indications for lengthening by unilateral fixation have shrunken to moderate amounts of length disparity and uni- to bi-planar deformities in patients with still open physes. Mechanical or motorised, minimally invasively placed nails prevent muscle fixation and, therefore, ease rehabilitation, increase patient comfort and potentially shorten the overall time of sick leave and refrain from sports activities. Hence, they offer a valuable alternative for low-grade complexity situations. It remains to be proved if the significantly higher implant costs are compensated by lower treatment costs. Overall, limb lengthening, particularly in combination with multi-planar deformity correction, can still be an arduous endeavour. In any case, wise judgement of the patient's deformity, medical and biological situation, psychosocial environment, selection of the appropriate method and hardware, as well as meticulous operating technique by an experienced surgeon are the cornerstones of successful outcomes.
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Affiliation(s)
- Carol C. Hasler
- Orthopaedic Department, University Children’s Hospital, P.O. Box, 4031 Basel, Switzerland
| | - Andreas H. Krieg
- Orthopaedic Department, University Children’s Hospital, P.O. Box, 4031 Basel, Switzerland
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Petazzoni M, Palmer RH. Femoral angular correction and lengthening in a large-breed puppy using a dynamic unilateral external fixator. Vet Surg 2012; 41:507-14. [PMID: 22239681 DOI: 10.1111/j.1532-950x.2011.00944.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report treatment of a large-breed puppy with combined distal femoral valgus and length deficit caused by partial distal physeal closure. STUDY DESIGN Clinical report. ANIMALS Bernese Mountain Dog (4.5-month-old male). METHODS The puppy was admitted for evaluation of a progressive severe left pelvic limb lameness (grade 3/4) of 6-week duration. Distal femoral valgus and severe length deficit deformity were treated by acute angular correction using a closing wedge ostectomy and progressive rapid-rate callus distraction using a dynamic, telescoping unilateral External Skeletal Fixator (ESF) designed for people. After acute angular correction and a 3-day latency period, a mean linear distraction rate of 3 mm/day was maintained for 3 weeks. The dynamic ESF (dESF) was removed at 4 weeks, after a 1-week consolidation phase. RESULTS The dESF was stable and functional during distraction and bone healing. Distal femoral valgus conformation improved 50° (from 41° to 91°) and femoral length increased 42 mm at dESF removal (from 158 mm to 200 mm; 27%). After cessation of bone growth, no valgus and minimal (6%) length deficit were detected. At 4, 5, 6, 12, and 24 months after surgery, the dog was walking, trotting, and galloping normally. CONCLUSION Acute angular correction and progressive rapid-rate callus distraction using a unilateral dESF allowed satisfactory treatment of combined distal femoral valgus and length deficit in a large-breed puppy.
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Abstract
BACKGROUND The limb lengthening over plate eliminates the associated risk of infection with limb lengthening over intramedullary nail. We present our experience of limb lengthening in 15 patients with a plate fixed on the proximal segment, followed by corticotomy and application of external fixator. MATERIALS AND METHODS 15 patients (7 females, 8 males) were included in this consecutive series. The average age was 18.1 years (range 8-35 years). Fifteen tibiae and one femur were lengthened in 15 patients. Lengthening was achieved at 1 mm/day followed by distal segment fixation with three or four screws on reaching the target length. RESULTS The preoperative target length was successfully achieved in all patients at a mean of 4.1 cm (range 1.8-6.5 cm). The mean duration of external fixation was 75.3 days (range 33-116 days) with the mean external fixation index at 19.2 days/cm (range 10.0-38.3 days/cm). One patient suffered deep infection up to the plate, three patients had mild procurvatum deformities, and one patient developed mild tendo achilles contracture. CONCLUSION Lengthening over a plate allows early removal of external fixator and eliminates the risk of creating deep intramedullary infection as with lengthening over nail. Lengthening over plate is also applicable to children with open physis.
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Affiliation(s)
- Ruta Kulkarni
- Department of Orthopaedics, Fracture and Orthopaedic Hospital, Post Graduate Institute of Swasthiyog Pratisthan, Miraj, Maharashtra, India
| | - Nishant Singh
- Department of Orthopaedics, Fracture and Orthopaedic Hospital, Post Graduate Institute of Swasthiyog Pratisthan, Miraj, Maharashtra, India,Address for correspondence: Dr. Nishant Singh, Department of Orthopaedics, Fracture and Orthopaedic Hospital, Post Graduate Institute of Swasthiyog Pratisthan, Extension Area, Miraj - 416410, Maharashtra, India. E-mail:
| | - Govind S Kulkarni
- Department of Orthopaedics, Fracture and Orthopaedic Hospital, Post Graduate Institute of Swasthiyog Pratisthan, Miraj, Maharashtra, India
| | - Milind Kulkarni
- Department of Orthopaedics, Fracture and Orthopaedic Hospital, Post Graduate Institute of Swasthiyog Pratisthan, Miraj, Maharashtra, India
| | - Sunil Kulkarni
- Department of Orthopaedics, Fracture and Orthopaedic Hospital, Post Graduate Institute of Swasthiyog Pratisthan, Miraj, Maharashtra, India
| | - Vidisha Kulkarni
- Department of Orthopaedics, Fracture and Orthopaedic Hospital, Post Graduate Institute of Swasthiyog Pratisthan, Miraj, Maharashtra, India
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Marimuthu K, Joshi N, Sharma CS, Bhargava R, Meena DS, Bansiwal RC, Govindasamy R. Ilizarov hip reconstruction in skeletally mature young patients with chronic unstable hip joints. Arch Orthop Trauma Surg 2011; 131:1631-7. [PMID: 21853244 DOI: 10.1007/s00402-011-1376-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE Hip reconstruction with subtrochanteric valgus extension pelvic support osteotomy and distal femoral osteotomy for lengthening and varus correction is one of the options available for salvage of chronic unstable hips and is also known as Ilizarov hip reconstruction (IHR). This study evaluated the outcomes and complications associated with IHR in skeletally mature young patients. METHODS Twelve patients (7 males, 5 females) with a mean age of 23 years underwent IHR for chronically dislocated hips due to various causes. Preoperative clinical and radiological evaluations were used to determine the site of osteotomies and the required angulations. Postoperatively the patients were followed up clinically and radiologically for a minimum of 36 months. Ilizarov fixator was removed when adequate lengthening was achieved and there was radiological evidence of union. Harris Hip Score was used to document hip function preoperatively and at final evaluation. RESULTS Significant improvements occurred in limb length discrepancy (LLD) 5.11 cm preoperatively to 0.9 cm at final evaluation, Harris Hip Score 44.33 points preoperatively to 70.83 points (p < 0.0001) at final evaluation. Trendelenberg sign disappeared completely in nine patients and was delayed in three at final evaluation. The abduction at the hip increased from the preoperative mean of 12.08° (range 0°-25°) to 22.5° (range 15°-35°) postoperatively. The fixed flexion deformity at the hip decreased from 22° (range 10°-35°) preoperatively to 3° postoperatively (range 0°-10°). The amount of free flexion at the operated hips decreased from the preoperative mean of 88.33° (range 70°-120°) to 70.42° (range 45°-105°) at final follow up. The mean fixator interval was 7.33 months (5-12 months) and the mean follow up duration was 59.4 months (38-86 months). CONCLUSIONS IHR is effective in improving the hip biomechanics, correcting the LLD and eliminating the Trendelenberg sign. Lengthy period of fixator wear, knee stiffness and pin tract infections, though minor are known limitations of this procedure.
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Affiliation(s)
- Kanniraj Marimuthu
- All India Institute of Medical Sciences, 251 Type III Quarters, Ayur Vigyan Nagar, August Kranti Marg, New Delhi 110049, India.
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Nayagam S. Femoral lengthening with a rail external fixator: tips and tricks. Strategies Trauma Limb Reconstr 2010; 5:137-44. [PMID: 21286358 PMCID: PMC2994627 DOI: 10.1007/s11751-010-0098-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Accepted: 10/20/2010] [Indexed: 11/20/2022] Open
Abstract
Lengthening the femur with an external fixator is commonly practised for a wide variety of pathologies. This technical report includes tips derived from observation and experience in a busy limb reconstruction unit. It focuses on the use of a rail fixator, although some of the descriptions are applicable to lengthening by circular fixators.
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Affiliation(s)
- Selvadurai Nayagam
- Consultant in Orthopaedic Surgery, Royal Liverpool Children's and Royal Liverpool University Hospital, Liverpool, UK
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Barker KL, Lamb SE, Simpson HRW. Recovery of muscle strength and power after limb-lengthening surgery. Arch Phys Med Rehabil 2010; 91:384-8. [PMID: 20298828 DOI: 10.1016/j.apmr.2009.11.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Revised: 10/21/2009] [Accepted: 11/04/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To report muscle strength, power, and function after limb-lengthening surgery performed by using the Ilizarov technique. DESIGN Prospective, longitudinal observational study of a cohort of consecutive patients who underwent limb-lengthening distraction followed up for 2 years after surgery. SETTING National Health Service hospital specializing in orthopedic surgery. PARTICIPANTS Patients (N=16) who had undergone limb-lengthening surgery performed by using the Ilizarov method (11 men, 5 women; mean age=27 y; range, 13-56 y). INTERVENTIONS None. MAIN OUTCOME MEASURES Muscle strength and power were assessed by using 2 validated measures: isokinetic concentric strength of the quadriceps and hamstrings measured by using a dynamometer and leg extensor power. Measures were recorded preoperatively and at 6, 12, and 24 months after the completion of lengthening. Function was measured by 2 timed tests of functional performance: stair climbing and sit-to-stand. RESULTS Overall results were good with high reports of function and satisfactory clinical examination. Both concentric muscle strength and leg power showed a clear pattern of decreased muscle strength at 6 months after frame removal, improving throughout the study period until it was within 3% of the preoperative value at 2 years. By 2 years, self-reported function and ability to complete timed functional tests had returned to or improved on the preoperative values. Muscle strength remained slightly below the preoperative value; this was more pronounced in the quadriceps than the hamstrings. There was no association between muscle strength and the amount of lengthening that had been undertaken. CONCLUSIONS This study suggests that there is a small residual decrease in muscle strength and power after limb-lengthening surgery but that these do not adversely impact on a patients' ability to perform everyday functional activities.
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Affiliation(s)
- Karen L Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre National Health Service Trust, Oxford.
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Barker KL, Shortt NL, Simpson HR. Predicting the loss of knee flexion during limb lengthening using inherent muscle length. J Pediatr Orthop B 2006; 15:404-7. [PMID: 17001245 DOI: 10.1097/01.bpb.0000218032.83181.84] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Limb lengthening procedures can be associated with loss of range of knee movement, although the amount of knee flexion lost varies markedly between patients. The exact aetiology of this problem is not fully understood. This study investigates whether the amount of joint range that is lost during limb lengthening might be affected by the inherent passive compliance and length of the patients' soft tissues determined preoperatively. A simple mathematical model has been developed to calculate the inherent length and 'spare' length of the hamstring and quadriceps muscle groups in 28 patients undergoing limb lengthening procedures. The range of knee motion was recorded preoperatively and loss of movement recorded during follow-up. The results show a strong correlation between predicted 'spare' length of quadriceps and loss of knee flexion. An association was noted between loss of knee extension and the straight leg raise and correlation of knee extension and the spare length of the hamstrings. The straight leg raise test, and calculation of spare quadriceps length using our formula, as part of the preoperative assessment, can help predict which patient is at risk of a reduced range of motion of the knee.
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Affiliation(s)
- Karen L Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford, UK
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Abstract
UNLABELLED Pelvic support osteotomies for chronically dislocated hips improve stability but result in limb-length discrepancy and valgus deformity of the knee. We prospectively evaluated and followed up 16 patients (14 females, two males) to ascertain whether a monolateral external fixator could achieve a pelvic support osteotomy and eliminate the limb-length discrepancy without disturbing knee motion. The patients had a mean age of 25.3 years at the time of surgery. The Harris hip score, knee range of motion, and Trendelenburg sign were evaluated preoperatively and at followup. The average time from fixator application until removal was 7 months (range, 5.2-9.5 months). The followup averaged 52.5 months (range, 26-84 months). The mean Harris hip score increased from 50 points (range, 32-73 points) preoperatively to 87.6 points (range, 67-98 points) at last followup. Four patients retained a positive Trendelenburg sign. At the time of fixator removal, 88% of preoperative knee range of motion was retained, and preoperative knee motion was achieved at last followup in all patients. The monolateral external fixator was suitable for a pelvic support osteotomy, equalizing limb-length discrepancy, and obtaining lower extremity alignment. This method achieved a pain-free, functional hip and good knee motion. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Muharrem Inan
- Inonu University Medical Faculty, Orthopaedic Department, Malatya, Turkey.
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