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   Table of Contents - Current issue
July-December 2021
Volume 7 | Issue 2
Page Nos. 83-145

Online since Thursday, December 30, 2021

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Are different high tibial osteotomies needed for differing location and severity of deformities? p. 83
Milind Chaudhary
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Acquired long bone defect classifications of the diaphysis: A literature review p. 88
Artem V Komarov, Anton A Semenistyy, Gerard A Sheridan, S Robert Rozbruch, Leonid N Solomin
Introduction: The management of acquired long bone defects (LBDs) is a persistent problem in modern orthopedics with few effective solutions. The goal of this review is to conduct a thorough analysis of existing diaphyseal LBD classifications and to identify if any of these may be adopted for universal application in future. Materials and Methods: A literature review was performed analyzing articles between 1970 and 2019 on PubMed (English) and CyberLeninka (Russian) databases. All studies developing or utilizing a classification tool were eligible for inclusion. The search retrieved a total of 1032 articles from PubMed, 477 from CyberLennika, and 28 articles from reference lists. Any disagreement regarding the inclusion of articles was resolved by consensus between all authors. Results: A total of 18 classifications in the literature underwent analysis. Among the classifications we analyzed, 12 described posttraumatic defects, 6 described osteomyelitis defects or infected nonunions, and 5 described, among other defects, iatrogenic bone. Of the 18 classifications, 12 have a focus on a specific treatment method. We found that consensus exists between most authors regarding the criteria necessary to measure to determine the most appropriate treatment method. These key factors include the size and location of the bone defect. Conclusion: This analysis showed that despite the large number of publications devoted to the classification and treatment of LBD, there is still no consensus among authors regarding not only a universal clinical classification but also a general definition of the term “bone defect.” The classification proposed by Solomin et al. is very useful but in its present form, has significant drawbacks and requires further improvement before it can be adopted as a universal classification system for LBDs.
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Acquired long bone defects classifications: Literature review (Part II – long bone defects around the joint) p. 98
Anton A Semenistyy, Artem V Komarov, Gerard A Sheridan, S Robert Rozbruch, Leonid N Solomin
Introduction: In recent years, multiple classifications of long bone defects around the joint (LBDAJ) have been proposed. However, there is no universal clinical classification of LBDAJ to date. Through comprehensive literature review, we aim to identify the criteria that may be used to develop a future universal classification of LBDAJ. Materials and Methods: We performed a comprehensive review of the literature to identify all articles describing classification systems of LBDAJ in both native and prosthetic joints. Two reviewers searched the following electronic databases independently: The Cochrane Bone, Joint and Muscle Trauma Group, MEDLINE, and eLibrary. Studies investigating bone defects around the joint reporting a classification or any criteria to classify bone defects were included in this review. All studies not related to bone articular surfaces were excluded. Results: A total of 15 classifications for LBDAJ in the preserved joint were. Most systems considered the size of bone defect as a key criterion for clinical decision-making. A total of 31 classifications for periprosthetic bone defects related to hip, knee and shoulder arthroplasty were identified. The following criteria were used by different authors to classify periprosthetic bone defects: Location (n = 22), size (n = 20), containment (n = 9), discontinuity (n = 6), shape or geometrical characteristics of the defect (n = 4), fracture (n = 2), and deformity. Conclusion: Despite the large variety of the existing classifications of bone defects around the joint, there is no classification that could be considered universal. For the development of a future universal classification, defect location, size, and containment are likely to be the main factors to consider as important.
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Prevalence of vitamin D deficiency in adult limb lengthening and deformity correction patients p. 110
Oliver Charles Sax, Nequesha Mohamed, Jessica C Rivera, Philip K McClure, John E Herzenberg
Introduction: Limb lengthening and deformity correction surgery (LLDC) requires adequate bone metabolism for distraction osteogenesis. Low Vitamin D is a common nutritional deficit that places bone health at risk and has been associated with fracture. It is currently unknown what the Vitamin D levels are among patients undergoing elective osteotomy. The goal of this research is to determine the prevalence of Vitamin D deficiency in adult patients undergoing lower extremity osteotomies for LLDC. Materials and Methods: A retrospective review was performed for adult patients (≥18 years old) who underwent an osteotomy surgery at a single institution between 2014 and 2018. The primary outcome measure was perioperative 25(OH)D serum level. Of 139 subjects identified as undergoing a lower extremity osteotomy surgery, 96 (69%) underwent perioperative Vitamin D testing. Deficiency and insufficiency were defined as a 25(OH)D value of <20 ng/mL and between 20 and 30 ng/mL, respectively. Results: Patients undergoing external fixator placement for length and/or deformity correction were most likely to have this laboratory assessed (88%) versus acute correction patients (65%) and intramedullary lengthening patients (62%), (P = 0.033). The mean Vitamin D level was 29.5 ± 17.8 ng/mL (range: 5.7–95.9 ng/mL). A total of 63% of patients had low perioperative Vitamin D: 33.3% deficient, 30.2% insufficient. Conclusion: The majority of adult LLDC patients have deficient or insufficient Vitamin D levels perioperatively. Vitamin D “prehabilitation” whereby testing and repleting before limb lengthening surgery should be highly considered as standard practice.
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Prevalence of vitamin D deficiency in pediatric limb lengthening and deformity patients p. 114
Oliver C Sax, Ethan A Remily, Nequesha S Mohamed, Philip K McClure, John E Herzenberg
Background: Vitamin D deficiency is one of the most common vitamin deficiencies in the world, afflicting over 1-billion children. Currently, there is a shortage of studies evaluating Vitamin D levels in pediatric limb lengthening or deformity correction (LLDC) patients. The purpose of this study is to determine the prevalence of Vitamin D deficiency in pediatric patients undergoing lower extremity osteotomies for LLDC. Materials and Methods: We retrospectively analyzed pediatric patients undergoing a lower extremity long bone osteotomy for lengthening/deformity correction at a single center from 2014 to 2018. Of 214 subjects, 80% had perioperative 25-hydroxyvitamin D (25[OH]D) levels available. Variables included age, sex, race, diagnosis, long bone treated, and perioperative 25(OH) D levels. Most patients were female, Caucasian, had a congenital diagnosis, and averaged 12.7 years old. Results: A single long bone was treated in 138 subjects (80%), while 19 patients (11%) underwent ipsilateral femur and tibial surgery and 15 patients (9%) underwent a bilateral surgery. The mean 25(OH)D level was 28.7 ng/mL. Deficient levels were found in 32% of subjects, and insufficient levels were found in an additional 41%. All patients healed appropriately. Conclusions: LLDC requires optimal bone metabolism for the generation of new bone. This study revealed a high proportion of Vitamin D insufficiency in pediatric limb-lengthening patients. Identifying these patients preoperatively may allow for Vitamin D “prehabilitation” to optimize bone health before limb-lengthening procedures in order to obtain satisfactory outcomes.
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Multicentre review of intramedullary lengthening nails: A middle-income country perspective p. 119
William D Harrison, Maritz Laubscher, Saleh Al Saifi, Ahmed Abdelaziz, Annette-Christi Barnard, Franz Birkholtz, Nando Ferreira
Background: Lengthening nails (ILN) are an established method of limb reconstruction for leg length discrepancy (LLD). Literature on these nails is predominantly from developed countries, with more accessible resources for the procurement of devices and post-operative therapies. This paper aims to present the results and lessons learned from four tertiary level limb reconstruction units working within two middle-income countries (MIC). Methods: Ethical approval was obtained from all four units. All ILN (PRECICE II, NuVasive, USA) undertaken between 2013 and 2020 were included. Demographics, etiology, surgical approach, and information about the planned versus achieved correction were compared. Data on time to consolidation and complications were recorded with a 12-month minimum follow-up. Complications were classified according to the Black et al. criteria. Results: Sixty limb segments lengthened in 56 patients, of which 46 were femora, 12 tibiae and two humeri. Etiology of LLD was predominately posttraumatic (33%), congenital (26%), and growth plate injuries (22%). Mean distraction length was 46 mm (20–90 mm). Fifty-four segments (90%) had <5 mm discrepancy of planned distraction lengths. Mean healing index was 34.6 days/cm (range: 18–180 days/cm). Thirteen patients experienced complications, of which ten required further surgery. Conclusion: The findings of our work support the use of intramedullary ILN in MIC with equivalent complication rates and healing indices compared to the literature. Patient compliance and remote geography were not an issue during treatment. The lack of access to weekly rehabilitation therapy did not seem to impact the majority of patients. Reusing nails for extensive LLD cases were safe but should be used with caution.
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Masquelet's induced membrane technique for reconstruction of large extra-articular intercalary bone defect p. 125
Mouhammed Elsayed Soliman, Mohamed Mansour Elzohairy, Ahmed Mohamed AbdelWahab, Yousuf Mohamed Khaira, Yasser Elbatrawy, Usama Gaber Abdalla, Saher Mohamed Mansour, Sherif Dabash, Ibrahim Elsayed Abdellatif Abuomira, Ahmed M Thabet
Background: Intercalary bone defects are challenging for both surgeon and patient. The Masquelet's induced membrane technique saves bone consolidation time is less technically demanding than other techniques and achieves good results in the reconstruction of large extra-articular intercalary bone defects. Patients and Methods: This prospective study reviewed 60 patients treated with the induced membrane technique. Patients with femoral or tibial extra-articular intercalary bone defects ≥5 cm long, occurring either posttraumatically or after debridement of infected bone, were included in the study. Patients with bone defects <5 cm long were excluded from the study. The male-to-female ratio was 17:3. Patient age ranged from 10 to 50 years. Recorded outcomes included union, infection, residual deformity, soft-tissue healing, persistent pain, return to previous occupation, permanent joint contracture, and patient satisfaction. Results: Mean follow-up was 3.1 years (range, 2.2–4 years). Mean intercalary bone defect measured 7.5 cm (range, 5–13 cm) in length. Forty-five of 60 patients had open fractures. Thirty-nine underwent Ilizarov fixation, 12 with locked plates, and nine with a limb reconstruction system. The mean interval between the first and second stages was 56 days (range, 42–84 days). Bony union was achieved in 51 patients (85%). Twelve patients experienced relapsed infection during treatment, three because of flap failure, and nine because of inadequate debridement. Three were treated with repeat debridement and free vascularized flap after gastrocnemius flap, six underwent bone transport, and three required amputation. Conclusion: The Masquelet's induced membrane technique was highly effective in achieving the union of large femoral intercalary bone defects, with mixed results in the tibia.
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New measurements to determine changes after intra-articular high tibial osteotomy p. 132
Milind Chaudhary, Aditya P Apte, Jitsen Manna, Ravi Bhadiyadra, Prafulla Herode
Background: Most high tibial osteotomies (HTO), performed for medial compartment osteoarthritis of the knee (MCOA) are extra-articular osteotomies of the upper tibia. Recently, attention has turned to detecting and treating intra-articular deformities of the upper tibia causing MCOA. Chiba introduced the tibial condylar valgus osteotomy (TCVO) in Japan and few English language articles have described indications, surgical techniques of results of these osteotomies. Two angles commonly measure and detect the intra-articular deformity and measure the difference between preoperative and postoperative parameters: Joint line convergence angle (JLCA) and condylar plateau angle (CPA). Aims and Objectives: JLCA is relatively easy to measure as it uses clearly visible landmarks to draw tangents to femoral and tibial condyles to subtend the angle. CPA is a little difficult to measure and we found it to be less reliable in intra-observer as well as interobserver readings. Materials and Methods: We decided to measure the intra-articular deformity by using spine edge angle (SEA) and spine vertical distance (SVD) as two new measurements. These have proved to be reliable in intra as well as interobserver measurements. We compared readings of SEA and SVD in 57 patients each who had an intra-articular TCVO and also an extraarticular medial open wedge HTO (OWHTO). Results: We found a significant change between preoperative and postoperative measurements of SEA and SVD in patients who underwent TCVO, but no change in patients who underwent OWHTO. Conclusions: The two new measurements of SEA and SVD accurately measure the change in intra-articular deformity parameters in patients who undergo TCVO and are more reliable than CPA.
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Bifocal femoral lengthening with intramedullary magnetic lengthening nail following osteotomy propagation p. 139
Jordan Taylor Carter, Madison Craft, Sherif Dabash, Ahmed M Thabet, Amr Abdelgawad
Techniques in limb lengthening have evolved since the early 1900s. The external fixation using an Ilizarov frame was the current gold standard. Recently, intramedullary devices have been utilized in limb lengthening procedures to avoid complications related to the bulky external fixators. Here, we present the case of a 41-year-old female with long-term limb length discrepancy (LLD) corrected with magnetically driven intramedullary nailing. An intraoperative fracture of the distal femur led to bifocal lengthening at both the osteotomy site and the fracture site. This case cautioned the orthopedic surgeons involved in limb lengthening surgery about potential complications that can happen during the procedure. It demonstrated the possible efficacy of bifocal lengthening procedures using a magnetically driven intramedullary nail in the setting of complex LLD.
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Limb lengthening of a rare case of congenital femoral deficiency with an unstable knee p. 142
Ricardo Marta, Armando Campos, António Oliveira, João Carvalho
Congenital femoral deficiency (CFD) is a rare birth defect that is characterized by a short femur, associated with hip and knee deformity, deficiency, or instability. Children with severe CFD may need multiple deformity correction or lengthening procedures to reduce axial malalignment and limb length discrepancy (LLD). During limb lengthening, it can occur knee subluxation or dislocation, a severe treatment-related complication. We report a 15-year-old girl with a CFD with a previous episode of posterior subluxation of the knee during a femoral lengthening using a monolateral external fixator. She had a 13 cm LLD and coxa vara; therefore, it was applied a knee spanning Ilizarov fixator with a double osteotomy of the femur for gradual correction. At 11 months following Ilizarov application, a complete correction was achieved, and the circular fixator was removed. Knee joints of patients with CFD show highly variable grades of instability. Adequate surgical techniques, preventive measures, and early detection of signs of subluxation can lead to good functional results. Femur lengthening with a preventive bridging of the knee with an Ilizarov frame is a safe and effective way of treating patients with CFD.
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Erratum: Risk factors for focal osteolysis in a stainless-steel limb-lengthening device p. 145

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