Congenital pseudarthrosis of the tibia: Results of circular external fixation treatment with intramedullary rodding and periosteal grafting technique

OBJECTIVE

This study investigated the clinical and functional results of treating congenital pseudarthrosis of the tibia (CPT) using the combined techniques of hamartoma resection, periosteal grafting, circular external fixator application, and intramedullary rodding.

METHODS

The clinical and radiological data of 17 patients (mean age at the treatment time: 7.6 months (range: 4.6-9.7 months) with CPT, treated by a single surgeon between 1997 and 2017, were retrospectively analyzed. All data regarding surgical interventions, complications, deformity analysis parameters, limb length discrepancy (LLD), ankle joint range of motion, and residual deformities were reviewed. All the patients were followed up at least two years after the last surgical intervention. The mean follow-up time was 8.5 years (range: 2.2 to 15.7 years).

RESULTS

Union was achieved with the index treatment in 15 of the 17 cases (88.2%). The mean age of the patients at the last follow-up visit was 14.2 years (range: 7.6 to 22.1). The mean LLD was 2.1 cm. Nine patients had radiological ankle valgus at the last follow-up. In the entire series, eight patients did not display any complications, four cases reported minor complications, and five cases were complicated by refractures.

CONCLUSION

Circular external fixator application combined with periosteal grafting is a superior method of CPT treatment. This method provides a healthy biological healing environment while correcting the mechanical problems. The combination of periosteal and cancellous bone grafts with intramedullary rods and an external fixator addresses issues that complicate obtaining and maintaining a union during the CPT treatment.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Simultaneous bilateral lengthening of femora and tibiae in achondroplastic patients

OBJECTIVE

The aim of this study was to analyze the results and complications of simultaneous bilateral femoral and tibial lengthening in achondroplastic patients.

METHODS

The study included the 44 femora and 44 tibiae of 22 achondroplastic patients (16 females, 6 males; mean age: 6.36 years, range: 3 to 11 years) that underwent simultaneous lengthening. Orthofix LRS monolateral fixators were used for femoral lengthening and either Ilizarov-type or hexapod-type circular external fixators for tibial lengthening. Tenotomies of the hip flexors and the Achilles tendon were performed to prevent injury to the growth plates and to prevent joint contractures. Results and complications were evaluated according to Paley's scoring and complication systems.

RESULTS

Average follow-up time was 35 (range: 26 to 76) months. The femora were lengthened by an average of 7.07 cm (46.1%), and the tibiae by an average of 6.64 cm (52.9%). Patients gained an average of 16.9 cm in height, including physiological growth. The mean bone-healing index (BHI) was 31.2 days/cm for the femora (range: 17.4 to 43.3 days/cm) and 34.3 days/cm for the tibiae (range: 19.5 to 60.0 days/cm). Complications included 3 delayed maturations, 3 pin track infections, 5 transient fibular paralyses, 5 regenerate fractures, 1 late varus deformity, 1 knee contracture and 1 knee contracture secondary to knee dislocation. Functional scores were excellent in 78 segments, good in 8, fair in 1 and poor in one. There was no growth inhibition related to the lengthening.

CONCLUSION

Bilateral simultaneous lengthening of the femora and tibiae in achondroplastic patients provided a reduction in total treatment and external fixation time, with a low rate of complications.

Cannulated screw and hexapodal fixator reconstruction for compound upper tibial fractures

Objectives:

The aim of the treatment of tibial plateau fractures is to obtain a pain-free and fully functional knee with closed reduction, percutaneous cannulated screw fixation and hexapodal external fixator reconstruction for high energy compound upper tibial fractures.

Methods:

Patients with comminuted tibial plateau fractures underwent closed reduction, percutaneous fixation with cannulated screws, and reconstruction with hexapodal external fixator. The follow-up period was 24 months.

Results:

The clinical and radiological results were good or excellent. The average knee flexion was 125°.

Conclusion:

Our results are successful in the initial stage, however, it should be pointed out that during the long term follow-up osteoarthritis may develop leading to worsening of the condition. Level of Evidence IV, Case Series.

Bilateral Brodie's abscess at the proximal tibia

Brodie's abscess is a form of subacute osteomyelitis, which typically involves the metaphyses of the long tubular bones, particularly in the tibia. The diagnosis is usually made incidentally, as there are no accompanying symptoms or laboratory studies. Bilateral involvement at the proximal tibia is unusual. However, orthopaedic surgeons should be aware of this entity, as it may present without symptoms. Checking the contralateral limb for concomitant Brodie's abscess is recommended.

Combined technique for the correction of lower-limb deformities resulting from metabolic bone disease

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment. The use of intramedullary nails prevented recurrence of deformity and refracture.

Indirect reduction of the radial head using an external fixator to treat chronic radial head dislocations

OBJECTIVES

We evaluated the results of indirect reduction of the radial head via a circular external fixator in pediatric patients with unilateral chronic radial head dislocation.

METHODS

Three male patients (mean age 6.3 years; range 5 to 8 years) with chronic radial head dislocation underwent ulnar lengthening using a circular external fixator for indirect reduction of the radial head. None of the patients had radiographic evidence for deformity of the radial head, dysplasia of the capitellum, or osteoarthritic changes. The etiologic factors were ulnar hemimelia, brachial plexus injury, and congenital radial head dislocation, respectively. Pre- and postoperative assessment of the patients included measurements of the carrying angle, flexion-extension of the elbow, and pronation-supination of the forearm, and anteroposterior and lateral radiographs, on which the congruency of the radiocapitellar joint, the orientation and length of the ulna and radius were assessed. The mean relative shortening of the ulna was 3.2 cm (range 2.5 to 4 cm) preoperatively. Distraction was begun on the seventh postoperative day at a rate of 3x0.25 mm per day and was continued until the achievement of reduction. Upon completion of the consolidation of the distraction callus, the fixator was removed and a brace was applied for three months to prevent fracture of the regenerated bone. The patients were followed-up for a mean of 62 months (range 42 to 98 months).

RESULTS

Complete reduction of the radial head was achieved in all the patients within a mean of six weeks, without any loss in position and recurrence of dislocation during the follow-up period. None of the patients exhibited dysplastic or arthritic signs in the radial head at final examinations. All three patients showed improvement in the carrying angle and were satisfied with the cosmetic appearance of the elbow and the length of the upper extremity. The mean flexion-extension improved by 28.3 degrees and the mean supination-pronation improved by 31.7 degrees. The external fixators were removed within a mean of 110 days (range 90 to 135 days). The mean bone healing index was 36 days/cm (range 30 to 42 days/cm). The mean ulnar lengthening was 3.2 cm (range 2.5 to 4.5 cm). Before reconstruction, the patient with congenital radial head dislocation also had a bowing deformity of the ulna and, during lengthening, this deformity was corrected gradually through additional hinges to the Ilizarov frame. The patient with ulnar hemimelia had a history of shish-kabab osteotomy at another center for ulnar bowing. Considering his young age (5 years), after achievement of radial head reduction, the proximal radius was fixed to the frame and the lengthening of the ulna was continued for an additional 7 mm to prevent future redislocation of the radial head due to asymmetric growth. There were no serious complications. Two patients had minor pin track infections that resolved completely by local wound care and oral antibiotics.

CONCLUSION

Albeit technically demanding, chronic radial head dislocations in children can be treated by indirect reduction of the radial head through ulnar lengthening with the use of a circular external fixator. This technique has a very low complication rate.

A review of problems, obstacles and sequelae encountered during femoral lengthening : uniplanar versus circular external fixator

There is currently a consensus regarding the superiority of circular type external fixators over uniplanar fixators for lengthening of the tibia, but femoral lengthening is still subject to the surgeon's preference. This study compares the occurrence rates of significant problems, obstacles and sequelae between these two techniques. Fifty patients (29 male, 21 female), with a mean age of 20 years were assigned to a circular type fixator group (54 lengthening segments), whereas 60 patients (29 male, 31 female), with a mean age of 20 years were assigned to a uniplanar fixator group (67 lengthening segments). The incidence of knee stiffness was significantly higher in the circular external fixator group (031 per segment) compared to the uniplanar external fixator group (0.13 per segment) (p < 0.05). The incidence of pain during lengthening was higher in the circular external fixator group, and patient satisfaction was higher in the uniplanar external fixator group. We recommend the uniplanar external fixator as a preferable device for femoral lengthening.

Correction of forearm deformities in children with multiple osteochondroma, by corrective radial osteotomy and ulnar lengthening by distraction osteogenesis

We retrospectively evaluated the results after ulnar lengthening and radial deformity correction using an external fixator for forearm deformities caused by osteochondromas. Eight forearms were treated surgically in seven patients with multiple hereditary osteochondroma. The mean follow-up time was 40 months (range, 20 to 60 months). The average radial articular angle improved from 43 degrees to 35.5 degrees (range, 28 to 56 degrees) and the carpal slip improved from 69.5% to 55% (range, 40 to 60%) postoperatively. The average shortening of the ulna was reduced from 2.06 cm to 0.44 cm (range 0 to 1 cm) after the treatment. There were no serious complications associated with the surgery; two minor pin track infections were successfully treated by local wound care and antibiotics. Although technically demanding, ulnar osteotomy and gradual lengthening by an external fixator provided promising results in the treatment of forearm deformities in children with multiple osteochondroma.

Radiological analysis of titanium mesh cages used after corpectomy in the thoracic and lumbar spine: minimum 3 years' follow-up

This study analyses radiological outcome of titanium mesh cages used for anterior column support following corpectomy in the thoracic and lumbar spine in 34 patients with a minimum three-year follow-up. The aim of the study was to assess the complications and radiological outcomes of patients with structural cages implanted into the anterior column. Titanium mesh cages for the anterior column became popular for anterior column reconstruction following discectomy and corpectomy. Few clinical studies are published assessing their efficacy as a structural graft after corpectomy and factors for the development of settling and correction loss are not investigated enough. Thirty-four patients with minimum 3-year follow-up were analysed radiologically for correction achievement, cage settling and fusion inside the mesh cage. The effect of fixation technique, anatomical localisation and diagnosis for the development of settling were analysed. Measurements of preoperative and early postoperative local kyphotic angle revealed that a mean correction of 27 degrees (range: 8 to 60) was obtained. While no dislodgement or fracture of titanium mesh cages was observed, there was a mean correction loss of 4 degrees and settling (> 2 mm) was noted in 6 patients. Short posterior and only anterior instrumentation systems were associated with settling. The anatomical location and diagnosis did not affect the development of cage settling. Following corpectomy and mesh cage implantation, isolated anterior fixation or short posterior fixation do not provide enough stability, and correction loss and settling can occur.

A 2-staged method for treatment of deep osteochondral lesions of the knee joint

We performed a 2-staged arthroscopic-assisted surgical procedure to treat a patient with a large osteochondral lesion of the knee joint. The osteochondral lesion was too comminuted to reattach; in addition, the underlying bony defect was too deep. In the first stage, autogenous cortical bone was used for grafting the bony defect along with screw fixation. The second stage consisted of screw removal and transplantation of autogenous osteochondral graft overlying the chondral defect. The osteochondral grafts were taken from the non-weight bearing areas of the same knee.