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   Table of Contents - Current issue
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July-December 2022
Volume 8 | Issue 2
Page Nos. 91-143

Online since Thursday, December 29, 2022

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EDITORIAL  

Evolution of limb lengthening: Fortune at top of the pyramid; Innovation and Fortitude at the base p. 91
Milind M Chaudhary
DOI:10.4103/jllr.jllr_34_22  
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ORIGINAL ARTICLES Top

Motorized intramedullary lengthening followed by osseointegration for amputees with short residual femurs: An observational cohort study p. 93
Jason Shih Hoellwarth, Kevin Tetsworth, Muhammad Adeel Akhtar, Atiya Oomatia, Munjed Al Muderis
DOI:10.4103/jllr.jllr_20_22  
Context: Some patients seeking transcutaneous osseointegration for amputees (TOFA) have residual bones so short there is concern whether they provide sufficient surface to support full weight. Our strategy was to lengthen these patients' femurs with a motorized intramedullary lengthening nail (MILN) before TOFA. Aims: The aim of this study is to describe 10 transfemoral amputees' experience with MILN before TOFA, focusing on the complications of MILN and TOFA, and also the patients' preoperative and postoperative quality of life (QOL). Settings and Design: A retrospective registry review of all MILN before TOFA surgeries was performed. Subjects and Methods: The patients' operative complications during/following MILN and TOFA were investigated. Furthermore, the patients' mobility (daily prosthesis wear hours, K-level, Timed Up and Go (TUG), and 6 min Walk Test [6MWT]) and QOL survey data (Questionnaire for Persons with a Transfemoral Amputation [QTFA]) were compared at the initial consultation and at the latest follow-up using Fisher's exact test for frequencies, and Student's t-test for means (significance, P < 0.05). Statistical Analysis Used: Fisher's exact test for frequencies, and Student's t-test for means (significance, P < 0.05). Results: Seven patients had one operative complication each: Three regenerate (autograft and plating), two nail malfunctions (nail replacement), one broken linkage cable (acute length correction with autografting and fixation), and one early consolidation (re-osteotomy). All ten patients had TOFA, an average of 12.0 ± 3.9 months after MILN surgery. One patient had debridement for infection (implant retained) and one patient had the implant removed due to infection. Significant mobility improvements were K-level >2 (2/9 = 22% vs. 9/10 = 90%, P =0.006) and TUG <15 s (1/8 = 13% vs. 6/8 = 75% P = 0.041). Wear hours and 6MWT improved but not significantly. All three aspects of QTFA significantly improved: Global (44.8 ± 29.9 vs. 75.9 ± 26.8, P =0.050), mobility (50.3 ± 30.8 vs. 74.8 ± 18.2, P =.033), and problem (38.8 ± 18.6 vs. 15.6 ± 18.3, P = 0.017). Conclusions: MILN before TOFA reliably achieves stable osseointegration for amputees with short residual femurs. Amputee lengthening remains demanding, but patients report significantly improved QOL and demonstrate improved mobility following TOFA. The minimum length of bone necessary to support a full weight-bearing osseointegrated prosthesis remains unknown.
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Early experience managing complex deformities using Autostrut™ robotic-controlled hexapod external fixators p. 103
Jason Shih Hoellwarth, S Robert Rozbruch, Taylor J Reif, Adam Daniel Geffner, Austin T Fragomen
DOI:10.4103/jllr.jllr_23_22  
Context: Hexapod circular external fixators allow bone manipulation in all planes to correct complex deformities. However, the patient must perform the strut adjustments consistently and correctly, often multiple times daily for weeks or months, to achieve intended corrections. This presents a potential source of variability, error, and anxiety to the patient. A computer-programmed, robotic automated motorized strut adjustment technology (Maxframe Autostrut™ Multi-Axial Correction System, Orthospin Ltd., Yoqneam, Israel) has been developed which automatically adjusts the struts without patient or clinician involvement. Aims: The aims of this study were as follows: first, to determine whether the motors performed the programmed initial and residual schedules and, second, to identify technology-specific problems and their management. Settings and Design: This was a retrospective observational study of a consecutive series of the first 16 patients who had the motorized hexapod frame applied. Subjects and Methods: A chart review was performed to record demographic information, indications and goals for hexapod frame care, whether the care goals were achieved, and whether unexpected and/or adverse events occurred (such as technical difficulties and medical complications) and the management of those issues. Statistical Analysis Used: Not applicable. Results: All patients achieved the index and residual adjustments as programmed. Conclusions: The Autostrut™ system appears reliable and safe. It executes programmed index and residual adjustments as well as strut change scenarios as directed. The system recognizes unexpected mechanical or programming issues and ensures patient safety by halting progress and alerting the patient. Future versions of the technology may benefit from added features such as remote reprogramming or current strut position monitoring.
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Femoral lengthening using ilizarov ring fixator and slotted plate p. 110
Sujay Milind Kulkarni, Ruta M Kulkarni
DOI:10.4103/jllr.jllr_24_22  
Background: Femoral lengthening is generally considered a cumbersome procedure due to the long fixator duration and complexity of the surgery. Lengthening over nail and lengthening over plate (LOP) have solved most of the problems but are associated with the risk of deep infection and plate prominence, respectively. We report a series of 14 cases with the use of a slotted plate to minimize both the problems. Materials and Methods: The study includes 14 patients, 8 females and 6 males, including four children. The average age of patients was 17.8 years, ranging from 7 years to 30 years. Femoral lengthening was performed with Ilizarov external fixator and slotted plate. Results: The target length ranged from 3 cm to 7 cm with an average of 4.6 cm. External fixator duration achieved ranged from 42 days to 92 days with a mean external fixator duration of 61.5 days. The mean external fixator index was 13.3 days/cm. We had no incidence of plate prominence or deep infection. We had four cases of knee stiffness, of which one needed surgery. All the patients had good quality regenerate and consolidation. Conclusion: The use of a slotted plate for LOP in femoral lengthening is a useful technique to minimize the incidence of plate prominence associated with LOP.
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Transcutaneous osseointegration for amputees with short residual bone: Is there increased risk for complications? – A pilot study p. 115
Jason Shih Hoellwarth, Adam Daniel Geffner, Taylor J Reif, S Robert Rozbruch
DOI:10.4103/jllr.jllr_22_22  
Aims: Transcutaneous osseointegration for amputees (TOFA) provides improved mobility and quality of life for most patients versus a traditional socket prosthesis. One uncertainty regarding TOFA is whether a minimum residual bone length is necessary to achieve solid fixation. This study evaluated the relationship between residual bone length and occurrence of post-TOFA complications requiring operative intervention. Patients and Methods: A retrospective review of our osseointegration registry was performed. Inclusion criterion was index osseointegration at least 12 months prior. Chart review included demographics and whether additional surgery occurred to manage noninfected loosening, periprosthetic fracture, and infection. Occurrence rates were compared using binary logistic regression analysis and by stratifying implants as <140 versus ≥140 mm. Results: Sixty segments were included (58 patients and 2 bilateral femur amputees). The implant length averaged 129.4 ± 31.1 (48–200) mm. No noninfected loosening occurred. Six patients (10%) had infection-related post-TOFA operation, at lengths ranging from 130 to 160 mm (representing the central 60% of implant lengths): five were debridement with implant retention and one other was removed. No implants below 130 mm (n = 19, 32%) required debridement or removal. Three patients (5%) had periprosthetic fracture (all femurs), at lengths ranging from 140 to 160 mm (the central 55% of implant lengths); no implants below 140 mm (n = 22, 37%) had periprosthetic fracture. Regression identified no association between length and noninfected loosening (P = 1.000), periprosthetic fracture (P = 0.999), or infection (P = 0.124). Dichotomized <140 versus ≥140 mm rates of complication were as follows: noninfected loosening (0/22 = 0% vs. 0/38 = 0%, P = 1.000), fracture (3/38 = 7.9% vs. 0/22 = 0%, P = 0.292), and infection (5/38 = 13.2% vs. 1/22 = 4.5%, P = 0.400). Conclusion: Residual bone length does not appear to be associated with post-TOFA reoperation to address noninfected loosening, periprosthetic fracture, or infection. The "minimum necessary" length of bone to achieve stable transcutaneous osseointegration capable of supporting full body weight remains uncertain.
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Decisional authority' and compliance in cosmetic limb lengthening: A reverse patient-consultant role? Lies and noncompliance and their role in complications p. 121
Jean-Marc Guichet, Maria Grazia Parisi, Ferdinando Salamino
DOI:10.4103/jllr.jllr_18_22  
Introduction: Cosmetic lengthening are heavy procedures, often undervalued by patients, decided for psychological improvements of their life and not for diseases or deformities. The surgical trauma can induce a subconscious freeze stress response; at that moment, the 'emotional brain' takes over the 'rational brain' for actions. Previous trauma or archaic imprints resurge and constitute references for these actions. Rational thoughts are lost. As a result, patients take the Decisional Authority over the surgeon for treatment decisions and become non-compliant to guidelines of the surgeon who is the 'knowledgeable person' in the treatment. Reaction patterns are 'Fight', 'Flight' or 'Fright'. Materials and Methods: A series of 288 cosmetic lengthening with fully weight bearing nails pointed out the patients reaction patterns, some failures of traditional psychological and psychiatric evaluations, the need for treating previous trauma (e.g. the 'Fast-Reset' technique) and having a strong physical and psychological coaching to secure a constant result. Results: Lies, sometimes difficult to detect, and deviations from guidelines generate complications, some resulting in new surgeries. Real responsibility of the patient in complications should be evaluated. Conclusions: Separating the patient and surgeon responsibilities will help to better anticipate and support deviating patients, in order to secure a faster and optimised physical and psychological results, and a quieter Patient-Doctor relation.
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Surgical and functional outcomes of infective non union of femur and tibia using ilizarov ring fixator p. 130
Aditya K Agrawal, Chetan P Puram, Yash M Mutha, Vatsal J Mehta, Shubham Arora, Paresh Golwala
DOI:10.4103/jllr.jllr_31_22  
Introduction: Nonunion of long bone fractures is a common condition encountered by an orthopedic surgeon in daily practice. For effective treatment of nonunion, internal fixation with or without bone grafting can be done but, an infected non union can prove to be a tough challenge. The aim of our study is to assess the surgical and functional outcomes of infected nonunion of femur and tibia treated with debridement, corticotomy and Ilizarov ring fixator. Materials and Method: This was a multi-centric prospective study of twenty patients in a time span of three years from May 2017 till April 2020. Observations and Results: Patients were assessed using clinical and functional results as per Association for the Study and Application of Methods of Ilizarov (ASAMI) Scoring System. Conclusion: The Ilizarov method remains one of the most successful and versatile means of achieving bone-healing in infected nonunion of long bones of lower limbs with benefits of correcting deformities, bone defects and limb length discrepancy.
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Identification and consequences of fine wire and half-pin loosening for external framing p. 138
James Nutt, Lucy Sinclair, Simon Matthew Graham, Alex Trompeter
DOI:10.4103/jllr.jllr_26_21  
This review article discusses the published methods of identification and consequences of fine wire and half-pin loosening. The evidence is reviewed and presented for the clinical, radiological, and histological analysis of the half-pin and fine wire to bone interface. Materials and Methods: A PRISMA compliant systematic review was conducted. Studies investigating the use of external fixators with descriptions on measurement of half-pin and fine wire loosening were included in this review. Results: Eight studies were eligible and included. No randomized controlled trials were identified. Torque measurement was most frequently used to quantify the half-pin-to-bone interface, histological analysis was performed by three studies, and radiographic analysis was performed by five papers including plain film and microcomputed tomography CT techniques. Discussion: The available evidence was of poor quality, with a lack of homogeneity in quantitative data for torque measurements and a prevalence of arbitrary figures for the definition of loosening. There was no mechanical analysis of fire wire loosening, and the most common clinical measure used for loosening was a scale validated for infection. Micro-CT was validated against torque figures and appears to be the most repeatable measure which could be applied clinically, however has only been used in canine studies. We recommend a study to compare the clinically relevant measurement of loosening against a standard model to provide a validated method of identification or prediction of half-pin and fine wire loosening.
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