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   Table of Contents - Current issue
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January-June 2022
Volume 8 | Issue 1
Page Nos. 1-90

Online since Thursday, June 30, 2022

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EDITORIAL  

Epiphysiodesis: Not just for equalization p. 1
Philip K McClure, John E Herzenberg
DOI:10.4103/jllr.jllr_21_22  
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REVIEW ARTICLE Top

Residual amputee limb segment lengthening: A systematic review p. 3
Anuj Sharad Chavan, Munjed Al Muderis, Kevin Tetsworth, Ilkhomjon Dexter Rustamov, Jason Shih Hoellwarth
DOI:10.4103/jllr.jllr_17_22  
Aims: This study aimed to systematically review the indications, techniques, complications, and insights identified for lower extremity residual amputee limb segment lengthening. Methods: Searches in PubMed, Google Scholar, Ovid Medline, Ovid Embase, and the Journal of Limb Lengthening and Reconstruction were performed using terms including “amputee,” “residual limb,” and “stump” combined with “lengthening,” “distraction,” “histogenesis,” “osteogenesis,” and “Callotasis.” Included articles described lengthening amputated tibias or femurs (other segments excluded). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized. Descriptive statistics were performed. Results: Twenty-two studies reported lengthening 32 femurs and 31 tibias (63 total segments). Fifteen articles described a single segment, five described two to four (15 total segments), and two described five or more (31 total segments). Lengthening was performed to improve prosthesis fit (21/22 studies, 54/63 segments) or to optimize osseointegration (1/22 studies, 9/63 segments) and utilized an external fixator (52/63) or a motorized intramedullary nail (11/63). Femurs were lengthened an average of 7.7 ± 2.5 cm (60% ± 23%) and tibias 5.8 ± 1.8 cm (97% ± 53%) from a starting length of 12.5 ± 4.6 cm for femurs and 6.7 ± 2.3 cm for tibias. The most common minor problem was pin site infection. The most common major problem was over-lengthening bone beyond the soft tissue envelope, requiring flap coverage, bone excision, or knee disarticulation. Conclusions: Amputee lengthening can achieve measurable gains to improve prosthesis use. Over-lengthening can be difficult to manage, if not catastrophic. Osseointegration may be a further rehabilitation solution for amputees struggling with prosthesis problems and willing to consider surgical options.
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ORIGINAL ARTICLES Top

Use and safety of the precice antegrade femoral nail in pediatric patients p. 12
Adam D Geffner, Taylor J Reif, Austin T Fragomen, S Robert Rozbruch
DOI:10.4103/jllr.jllr_12_22  
Context: The Precice internal magnetic lengthening nail is used commonly for adult femur lengthening given its accuracy, precise control of lengthening, and patient comfort throughout the process. The nail is not currently approved by the Food and Drug Administration (FDA) for use in children, although many practices continue to use it off label. Aims: We aim to support the notion that the implant is efficient, reliable, and safe for femur lengthening in skeletally immature pediatric patients. Subjects and Methods: We performed a retrospective chart review of all skeletally immature patients who underwent treatment with a precice antegrade femoral nail to help establish the nail's safety and efficiency in this population. Results: We implanted 30 precice antegrade femoral nails (all trochanteric entry) in 25 patients (11 males, 14 females). The average lengthening goal for all surgeries was 47.62 mm (15 mm to 80 mm), and the average length achieved was 47.63 mm (15 mm to 80 mm). Twenty-four out of 25 patients (96%) achieved their lengthening goal within 5 mm. Average distraction rate was 0.97 mm/day (0.75 mm/day to 1 mm/day), and average bone healing index (time to consolidation/cm lengthened) was 19.69 days/cm (13.77 days/cm to 35.33 days/cm). Three patients experienced complications that required additional surgery, including a hip and knee flexor tendon lengthening, guided growth to correct a knee flexion contracture, and bilateral exchange nailing for implant fracture and delayed union. No patients experienced avascular necrosis of the hip, and all complications were ultimately resolved without permanent deficits. Conclusions: The precice antegrade femoral nail can safely and efficiently manage large lower extremity lengthening in skeletally immature children. Concurrent angular or rotational deformity correction was also possible, and postoperative complications were infrequent and manageable.
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Intra-articular osteotomies for medial compartment osteoarthritis: Is adding an extra-articular osteotomy worthwhile? p. 17
Aditya P Apte, Ravi Bhadiyadra, Milind Chaudhary
DOI:10.4103/jllr.jllr_16_22  
Background and Aims: Medial compartment osteoarthritis (MCOA) of the knee presents with varus deformity arising from the upper tibia or lower femur. High tibial osteotomies relieve pain by correcting the varus and improving the mechanical axis deviation (MAD). Closing wedge, opening wedge, and dome osteotomies are popular choices in the upper tibial metaphysis. These are all extra-articular osteotomies (EAO). Recently, attention has turned to detection and treatment of intra articular deformity arising from the knee to treat MCOA. Tibial condylar valgus osteotomy (TCVO) is an intra-articular osteotomy (IAO) which corrects the varus malalignment by elevating the medial tibial condyle and is usually fixed with a plate (Tibial condylar valgus osteotomy-plating [TCVO-P]). A second distal extra articular osteotomy, fixed with an Ilizarov fixator (tibial condylar valgus osteotomy-Ilizarov [TCVO-I]) is performed in some patients for better correction of the mechanical axis. The two groups were treated with different surgical approaches based on preoperative analysis of deformity. Hence this is a level IV study. We aimed to study the improvement in radiological parameters after TCVO in MCOA. We also compared the results between TCVO-P and TCVO-I. Patients and Methods: We performed 64 osteotomies in 55 patients over the last 7 years. 30 (33 tibiae) had a TCVO-P. 25 (31 tibiae) had a TCVO-I. The mean age in TCVO-P was 55 years, and in TCVO-I was 48 years. Results: The mean preoperative (bo) MAD was more in TCVO-I at –37.4% and improved to a mean postoperative MAD of 53.8%. TCVO-P had a lesser mean bo MAD of –7.4%, which corrected to 46.4%. MAD was better corrected by TCVO-I (P = 0.0058). Correction of medial proximal tibial angle, hip knee ankle angle, ankle joint line orientation improved significantly in both groups. The knee joint line orientation was improved by TCVO-I (P = 0.001), but not by TCVO-P (P = 0.075). Joint line convergence angle (JLCA), spine edge angle, and spine vertical distance were all significantly improved in both groups. Condylar plateau angle was not changed significantly in either group. Conclusion: TCVO is an Intra articular osteotomy which effectively corrects the varus deformity arising from the knee joint in MCOA. An isolated TCVO-P slightly under-corrects the mechanical axis. TCVO-I is better at restoring mechanical axis to beyond neutral and is better for younger patients and with intorsion deformities.
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Infected nonunion of the humerus treated by the compression distraction ilizarov technique without radical debridement or bone excision: Case series p. 24
Mohammed Anter Meselhy, Adel Samy Elhammady, Gamal Ahmed Hosny
DOI:10.4103/jllr.jllr_10_22  
Background: External fixators have been proved to be effective in the treatment of infected nonunion fracture humerus. The current study presents the outcome of treatment of infected nonunion of the humerus by a cyclic compression distraction technique using Ilizarov without radical debridement. Materials and Methods: 32 patients, 19 males and 13 females. The mean age of the patients was 39.72 years (range, 27–54); patients were presented by infected nonunited fracture humerus after an average of 1.9 surgeries (range, 1–4). All patients were treated by removal of the hardware if present without radical debridement or bone resection to avoid bone shortening and to preserve the blood supply of the bone and soft tissue, Ilizarov application with cyclic compression distraction. Results: The mean time of the external fixator application was 179.06 days, and the mean follow-up time was 32.8 months. All patients were united, According to the association for the study and application of the method of the ilizarov scoring system, the functional results were excellent in 8 patients, good in 16, fair in 7, and poor in only 1 patient. The bone results were excellent in 9 patients, good in 16, fair in 5, and poor in 2 patients. The mean post-operative DASH score was 32.43 (range, 10–63), the mean visual analog scale (VAS) score for pain was 3.71 (range: 2–5), while the mean VAS score for satisfaction was 7.41 (range: 6–9). Conclusion: Cyclic compression distraction by Ilizarov without radical debridement had shown a satisfactory outcome in the treatment of infected nonunion humerus. Level of Evidence: IV, A retrospective study.
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Transcutaneous osseointegration for oncologic amputees with and without radiation therapy: An observational cohort study p. 32
Jason Shih Hoellwarth, Kevin Tetsworth, Muhammad Adeel Akhtar, Atiya Oomatia, Munjed Al Muderis
DOI:10.4103/jllr.jllr_15_22  
Context: Transcutaneous osseointegration for amputees (TOFA) consistently confers significant improvement in mobility and quality of life (QOL) for amputees using a traditional socket prosthesis. Limb radiation therapy (XRT) Has traditionally been considered hard contraindication against TOFA but has never actually been examined. Aims: This study evaluated the changes in mobility and QOL, and also the complications, for oncologic amputees provided TOFA: 9 with XRT, and 23 with no radiation therapy (NRT). Settings and Design: A retrospective registry review of all oncologic amputees was performed. Subjects and Methods: The patients' mobility (daily prosthesis wear hours, K-level, Timed Up and Go, and 6-min walk test [6MWT]) and QOL survey data (Questionnaire for Persons with a Transfemoral Amputation) were compared before TOFA and at the latest follow-up. Statistical Analysis Used: Fisher's exact test for frequencies, and Student's t-test for means (significance, P < 0.05). Results: Regarding mobility, the cohorts were similar to one another before and after TOFA, and both cohorts improved following osseointegration (statistically significant: XRT wear hours [P = 0.029], NRT K-level [P < 0.001], and NRT 6MWT [P = 0.046]). Both cohorts' QOL was also similar before and after TOFA, and both cohorts again improved following osseointegration (significant differences: XRT problem score [P = 0.021], NRT problem score [P < 0.001], and NRT global score [P < 0.001]). Three XRT patients (33%) and one NRT patient (4%) required removal (P = 0.048). Conclusions: While radiation therapy may be associated with increased risk of postoperative implant loosening, it seems unjustifiable to flatly contraindicate osseointegration for oncologic amputees solely because of prior limb irradiation.
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Focal dome condylar osteotomy: Early results of alignment of a combined intra- and extra-articular high tibial osteotomy p. 40
Ravi Bhadiyadra, Aditya P Apte, Milind Chaudhary
DOI:10.4103/jllr.jllr_19_22  
Background and Aims: Extra-articular high tibial osteotomies reliably treat varus deformities seen in medial compartment osteoarthritis of knee (MCOA). Recently, attention has turned to the detection and treatment of intra-articular knee deformity to treat MCOA. Tibial condylar valgus osteotomy (TCVO) is an intra-articular osteotomy (IAO) that corrects the varus by elevating the medial tibial condyle and is fixed with a plate. TCVO improves joint line convergence angle (JLCA), spine edge angle (SEA), and spine vertical distance (SVD), which measure intra-articular deformity. It may undercorrect the mechanical axis to <50%. Focal dome condylar osteotomy (FDCO) is recently described and claims to correct both the intra- and extra-articular deformities in MCOA. We aimed to study the immediate results of FDCO and compare its efficacy with TCVO. Patients and Methods: We performed ten FDCO procedures on ten patients over the last year. The mean age was 57 years. We compared the results with a similar retrospective cohort of ten TCVO patients. Results: The mean preoperative (bo) mechanical axis deviation (MAD) in FDCO was −13.8% and improved to 51.6%. TCVO group had a similar mean postoperative (po) MAD of 43.5% (P = 0.38). Although 6 of 10 FDCOs had MAD >50%, only two of TCVOs crossed the midline. The mean bo medial proximal tibial angle in FDCO was 85.9° and improved significantly po to 93°. Hip knee ankle angle, ankle joint line orientation, and knee joint line orientation improved significantly as did JLCA, SEA, and SVD. Condylar plateau angle did not change. Conclusion: FDCO is an IAO with a vertical limb that passes through the lateral tibial spine and a medial curved limb. This single osteotomy can correct the intra-articular and extra-articular varus deformity. Although there was no significant difference in the correction of intra- and extra-articular deformity parameters between FDCO and TCVO, we feel that it was part of our learning curve. FDCO has the potential for better correction of the mechanical axis along with intra-articular deformities.
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Evaluation of lateral column lengthening using autogenous fibular graft in the treatment of supple flat foot p. 47
Ayman Ali Elattar, Gamal A Hosny, Osama Mohamed Essawy, Mohmoud Kandeel, Mohammed Anter Meselhy
DOI:10.4103/jllr.jllr_11_22  
Background: Treatment options of flat foot vary from using orthosis to arthrodesis and the surgical procedure varies from soft-tissue operations till bony osteotomies. We hypothesized that the clinical, functional, and radiological outcomes of lateral calcaneal lengthening osteotomy using fibular graft in the treatment of symptomatic flatfoot are satisfactory. Materials and Methods: A prospective study was conducted involving 25 feet of 25 patients who underwent lateral calcaneal lengthening due to symptomatic flexible flat foot. All patients underwent clinical and radiological evaluation preoperatively and postoperatively, American Orthopedic Foot and Ankle Society (AOFAS) hindfoot/ankle scoring preoperatively and postoperatively. All patients underwent osteotomy of the calcaneus using a saw, after a satisfactory correction of the deformity obtained, autogenous fibular graft was inserted in the osteotomy site, and tendon Achilles lengthening was performed. Results: In our study, we had 25 patients, the average age was 11.48 years. There were 15 girls and 10 boys. The average AOFAS preoperative score was 68.56 ± 5. A 3-month postoperative. The average score was 86.40 ± 3.65. A final AOFAS hindfoot/ankle score at the time of maximal follow-up (average 21 months; range, 6–36 months) had an average score of 95.19 ± 1. A final AOFAS hindfoot/ankle score at the time of maximal follow-up (average 21 months; range, 6–36 months). Conclusion: Isolated lateral column lengthening using autogenous fibular graft was found to provide significant correction of all components of the supple pes planovalgus and forefoot abduction deformity. Level of Evidence: Level IV.
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Universal long bone defect classification p. 54
L Solomin, Artem Komarov, Anton Semenistyy, Gerard A Sheridan, S Robert Rozbruch
DOI:10.4103/jllr.jllr_3_22  
Introduction: Treatment of long bone defects is a challenging problem in orthopedics that requires a robust and comprehensive classification system to guide diagnosis and management. The Universal Long Bone Defect Classification (ULBDC) is an alphanumeric system detailing the size and location of the defect. It is designed to describe the bone defect and indicate the appropriate treatment for both diaphyseal and articular long bones defects. Methods: The location, size, and morphology of the bone defect are the main criteria used in the treatment of both extra-articular and intra-articular bone defects. The proposed classification system utilizes the following nomenclature for both periarticular defects and diaphyseal defects: location (bone and segment) and morphology (type, group, and subgroup). Discussion: The ULBDC is based the same principles of coding as the “gold standard” AO/OTA Fractures Classification system with alpha-numeric coding “from simple to complex.” The choice of treatment method depends on the type, group, and subgroup of the defect as described. The principles of treatment of diaphyseal defects, as well as the principles of treatment of extra-articular fractures, are based on the restoration of the alignment, length, and rotation of the segment. Bone shortening and deformity are considered bone defects because their treatment requires the use of the same principles (osteotomies, bone grafting, bone transport, or combination of these methods) as treating real bone defects. Conclusion: The proposed classification is an attempt to classify all types of long bone defects and its use in clinical practice and research will allow for optimal and standardized treatments for the various types of bone defects to improve the treatment outcomes.
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Can a checklist protocol improve limb lengthening? p. 63
Monica Paschoal Nogueira, João Pedro Osseti Felicio Silva, Ana Maria Ferreira Paccola, Sandra Meire Prado
DOI:10.4103/jllr.jllr_43_21  
Background: In recent years, hexapodal external fixators and telescopic nails have improved the accuracy of limb lengthening and correction of deformities. However, careful follow-up in the postoperative period is extremely important; complications are still frequent and directly interfere with patient's outcome. Aims and Objectives: We have developed a follow-up limb lengthening reconstruction checklist. Materials and Methods: Like a flight checklist, professionals systematically record relevant data in every postoperative visit, to improve clinical management during distraction and consolidating phases. Results: LLR-Checklist was used in 53 consecutive patients, from 2006 to 2020. Average age was 11 (2-45) years. A pattern was found in the 18 patients with fibular hemimelia in relation to the use of antibiotics. Superficial infection was common. 21% of patients had delayed ossification in the regenerate. 25% of patients had nerve injuries; 9,4% of them had nerve decompression, all had total recovery. Contractures and pain improved with physical therapy. Conclusion: This checklist can improve quality in the treatment and is a valuable teaching tool for young practitioners.
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Continuous irrigation as dead space management for fracture-related Type 1 intramedullary chronic osteomyelitis p. 67
Jan-Petrus Grey, Marilize Burger, Leonard Charles Marais, Nando Ferreira
DOI:10.4103/jllr.jllr_7_22  
Introduction: Dead space management following intramedullary debridement and reaming can be challenging and several alternatives have been described. The main objective of this study was to investigate the clinical outcome and resolution rate in patients treated for fracture-related Cierny and Mader anatomical type 1 intramedullary chronic osteomyelitis by means of continuous irrigation (modified Lautenbach system) as dead space management following intramedullary reaming. Materials and Methods: A consecutive series of thirty patients with Cierny and Mader type 1 chronic osteomyelitis, treated between May 2016 and September 2019, were evaluated retrospectively. Patient history and clinical information, including imaging and laboratory results, were reviewed. Treatment procedures and antibiotic profiles were also recorded. Results: The initial cohort included 30 cases with 18 tibias, 11 femurs, and one humerus. Seven patients were excluded; three patients did not return for follow-up and four patients had <6 months of follow-up. Of the remaining 23 patients, 91% (21/23) achieved resolution of infection over a median follow-up period of 16 months (interquartile range [IQR] 7–21 months). Infecting organisms where isolated in 65% (15/23). The median duration of hospital stay was 6 days (IQR 4–7 days). Postoperative complications were noted in two cases and involved a tibial and femoral refracture, respectively. Both patients however achieved union without recurrence of infection following surgical intervention. Conclusion: Continuous irrigation is a cost-effective single-stage surgical option for dead space management during the treatment of intramedullary chronic osteomyelitis. It provides the advantage of instilling high dose intramedullary antibiotics and negates the need for a second surgical procedure while achieving similar outcomes than other dead space management techniques. Level of Evidence: IV, single-center retrospective study
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Intramedullary limb lengthening: Comparative mechanical testing of different devices p. 73
Nader Maai, Maria Alexandra Bernstorff, Matthias Koenigshausen, Thomas Armin Schildhauer, Nando Ferreira
DOI:10.4103/jllr.jllr_42_21  
Background: Intramedullary limb lengthening has become more popular in the past two decades. This study aimed to investigate the mechanical properties of the various intramedullary lengthening devices currently available to orthopedic surgeons. Materials and Methods: A load cell connected to an electromechanical tensile testing machine was used to apply a bending force to nine intramedullary lengthening nails: Albizzia Ø 11 mm, intramedullary skeletal kinetic distractor Ø 10.7 mm, Precice Ø 10.7 mm, G-Nail Ø 13 mm, and Betzbone Ø 9 mm to Ø 13 mm. The force needed to deform each nail by 0.01 mm, 0.05 mm, 1 mm, and 3 mm was measured and compared. Results: The nail with the smallest diameter (Betzbone Ø 9 mm) needed the least force to deform. The nails with the biggest diameter (G-Nail Ø 13 mm and Betzbone Ø 13 mm) needed the most force to deform. Comparing similar-sized implants, nails manufactured from surgical steel or cobalt-chrome were more resistant to plastic deformation than titanium nails. Conclusion: Intramedullary lengthening device's ability to resist bending deformation depends on the diameter and material of the nail. Surgical steel and cobalt-chrome alloy nails showed higher resistant to plastic deformation when compared to titanium nails.
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A linear regression model using computed tomography of forearm osteology to predict radius and ulna characteristics for surgical planning p. 78
Henry Sean Pretorius, Nando Ferreira, Marilize Cornelle Burger
DOI:10.4103/jllr.jllr_5_22  
Introduction: The radius and ulna are commonly fractured bones. The restoration of the native anatomy is the primary surgical objective but can be difficult due to a mismatch between the bones' shape and available implants. A thorough understanding of the underlying anatomical relationships between the radius and ulna could allow for a more accurate prediction of variables, thus enabling the surgeon to treat patients more effectively. Methods: A cross-sectional investigation of forearm computed tomography scans and measurements were conducted on 97 forearms. Pearson's correlations were used to evaluate relationships between variables, and those with a coefficient of r > 0.4 and P < 0.001, as well as those considered clinically relevant, were carried forward into a multiple linear regression for each outcome variable, namely: (i) radius length, (ii) radius of curvature, (iii) the minimum diameter of the radial canal, (iv) ulna length, and (v) the minimum diameter of the ulna canal. A stepwise approach was used for the multiple linear regression analysis, with a significance level of 0.05 for predictor variables. Results: Radius length: in the multiple linear regression model, only ulna length remained in the model (adjusted R2 = 0.85). The radius of curvature: the final model only included ulna length (adjusted R2 = 0.30). Radius canal minimum width: three measurements were included in the final model (adjusted R2 = 0.82). Ulna Length: six independent correlations between individual measurements and the ulna length were observed, with radius length and the radial neck length being included in the final model (adjusted R2 = 0.86). Ulna canal minimum width: the final regression model included four variables: the maximum diameter of the distal third of the radial canal, the minimum diameter of the radial canal, and the minimum diameter of the proximal and middle third aspects of the ulna canal (adjusted R2 = 0.80). Conclusion: The results of this investigation illustrate that anatomical predictions for bone size can be made using other anatomical landmarks except for the radius of curvature. The clinical application and implementation of this statistical model need further research.
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Hydrosurgical debridement of Grade VI external fixator pin site infection p. 84
Aaron Kumar Saini, JP Grey, Rudolph Venter, Nando Ferreira
DOI:10.4103/jllr.jllr_6_22  
Background: Pin site infection is a common complication with external fixation, with a reported incidence of 26%–71% in the context of limb reconstruction. The Checketts and Otterburn (C&O) classification is frequently used, with minor infections (C&O I–III) treated with pin site care and enteral antibiotics. Major infections (C&O IV–VI) require removal of the infected pin or fine wire. Surgical debridement is indicated where the infection persists following pin removal (C&O grade VI). The Versajet hydrosurgery system (Smith & Nephew, Memphis, Tennessee) utilizes a saline jet to debride biological tissue. Methods: A retrospective review was conducted on all patients who underwent Versajet hydrosurgery debridement with C&O grade VI pin site infections between January 2011 and January 2021. Data regarding patient demographics, fixator type, indication for the initial surgery, and treatment outcome were recorded. Results: The cohort comprised seven males (87.5%) and one female (12.5%) with a mean age of 41.4 years ± 17.74 (range 16–61). Mean follow-up was 11.8 months ± 6.2 (range 7–25). The mean time in external fixator was 155 days ± 85.19 (range 83–354), and the mean time between fixator removal and Versajet debridement was 46 days ± 33.83 (range 3–116). No perioperative complications were experienced, and all patients (n = 8, 100%) were found to be infection-free at the last clinical review, with healed overlying soft tissue. Conclusion: The Versajet hydrosurgical debridement system is effective in managing C&O grade VI pin site infections. The method is reproducible and provides long-term clearance of infection, allowing subsequent soft tissue healing.
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CASE REPORT Top

First metatarsal distraction lengthening without arthrodesis after failed first metatarsal phalangeal joint replacement p. 88
Lorenzo Monti, Fabrizio De Marchi, Luigi Lovisetti, Ilaria Alice Crippa, Maurizio A Catagni
DOI:10.4103/jllr.jllr_8_22  
Arthrodesis is the most common salvage procedure for failed first metatarsophalangeal joint replacement arthroplasty. However, such procedure is not without limitations. Hereafter, we present the first case of replacement arthroplasty by distraction lengthening without associated arthrodesis as a salvage procedure for a failed first metatarsophalangeal joint replacement arthroplasty.
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