Introduction: Knee flexion contracture (KFC) is a debilitating condition that may affect patients with neurogenic conditions, congenital deformities, posttraumatic deformities, and after total knee replacement. The recurrence rate of the deformity following either operative or nonoperative treatment remains high. The aim of the present study is to assess clinical outcomes of patients with KFCs and associated ankle equinus using gradual correction with a circular external fixator (CEF). Methods: Twenty-one patients with knee flexion contraction were treated using a CEF. Seven patients were also simultaneously treated for ankle equinus. All but two patients underwent a combination of open or arthroscopic knee arthrolysis, distal hamstrings lengthening, and gastrocsoleus release. The CEF was applied to match the residual deformity, following the minimal incision soft-tissue release. Results: Mean follow-up was 13 months. The mean range of motion (ROM) at final follow-up was −10° extension, 64° flexion, 9° ankle dorsiflexion, and 29° ankle plantar flexion. The difference between preoperative and postoperative ROMs was statistically significant (P < 0.05). Discussion: The present study suggests that gradual distraction using a CEF is a safe and effective technique in the management of KFC and concurrent ankle equinus. It is crucial to maintain the postoperative correction with braces for at least 1-3 months, depending on the severity of the condition.

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Background: The peroneal nerve is often stretched during limb lengthening and deformity correction. If the nerve becomes entrapped under the peroneal muscle fascia and/or anterior intermuscular septum, decompression is indicated to treat nerve compromise. Purpose: The purpose of this study was to quantify peroneal nerve tension after varus osteotomy of the proximal tibia and before and after nerve decompression. Methods: A device, which consisted of a force transducer connected perpendicularly by a hook to the nerve and integrated to a personal computer, was able to indirectly measure the nerve rigidity in 14 lower limbs (seven cadaveric specimens). The nerve was neither cut nor disrupted from its anatomic tract by the rigidity measuring device. We measured the amount of peroneal nerve rigidity before varus angulation, after varus angulation of a proximal tibial osteotomy, and after peroneal nerve decompression in the varus angulation position. Results: Peroneal nerve rigidity increased significantly after limb was angulated into varus (P = 0.0002) and was reduced significantly after decompression (P = 0.0003). No significant difference was noted between measurements obtained before varus angulation and measurements obtained after nerve decompression (P = 0.3664). Conclusions: Varus osteotomy of the proximal tibia significantly increases peroneal nerve rigidity. Peroneal nerve rigidity after decompression is not significantly different from nerve rigidity before varus correction. Clinical Relevance: This study provides biomechanical evidence of the efficacy of nerve decompression in two specific anatomic sites (peroneus longus muscle fascia and lateral, intermuscular septum) in relieving the increase in peroneal nerve rigidity that occurs in association with procedures that stretch the nerve such as limb lengthening and deformity correction.

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Background: Despite the large negative effect of limb deformity on health-related quality of life (QoL), there exists no patient-reported instrument to quantify this impact. Rather, limb deformity research has been performed using global QoL measurements concurrently with joint-specific and/or arthritis outcome scales, thereby requiring the completion of multiple instruments. Furthermore, joint- and arthritis-specific instruments focus on the impact pain has on function, whereas limb deformities may be pain-free with greater social and functional impairment. The purpose of this study was to validate a patient-reported instrument to quantify limb deformity-related QoL. Materials and Methods: Because of the similarities with regard to pain, function, and body image between limb deformity and scoliosis, the Scoliosis Research Society-30 (SRS-30) spine deformity instrument was modified such that the words "back" and "trunk" were replaced with "limb" to create a novel instrument: the limb deformity-SRS (LD-SRS). Testing for construct validity (both convergent and discriminant), reliability, floor and ceiling effects, and minimal clinically important difference (MCID) was performed in a validation cohort of 62 subjects aged 18 years or older with nonarthritic, unilateral lower extremity deformity. Results: Scale reliability was excellent (test-retest reliability, intraclass correlation coefficient = 0.977; internal consistency, Cronbach's alpha = 0.906), scores were normally distributed, and there were no floor or ceiling effects. There was also robust construct validity: convergent validity testing revealed positive correlations between the LD-SRS and all short-form-36 domains, the American Academy of Orthopaedic Surgeons-Lower Limb Module, and higher scores in those who were postcorrection. Discriminant validity was demonstrated with no correlations between the LD-SRS and subject age, sex, body mass index, surgeon-scored Limb Lengthening and Reconstruction Society-AIM Index, or surgeon-generated deformity measurements. MCID was calculated to be 0.3 (on a 4.0-point scale). Conclusions: The LD-SRS score is a reliable and valid instrument to measure limb deformity-related QoL in patients with nonarthritic lower extremity deformity. It is a valuable tool which allows clinicians to quantify patients' deformity-related QoL with a single instrument, rather than repurposing scales which have been validated for other conditions and have limited applicability to the unique challenges of treating patients with a lower limb deformity. Level of Evidence: Diagnostic, Level 2.

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Large varus deformities in medial compartment osteoarthritis are difficult to correct with lateral closing-wedge or medial opening-wedge osteotomies. They are easier to correct gradually with opening-wedge or dome osteotomies with external fixation. A focal dome osteotomy can support a large angular correction and yet retains good bony contact. It creates a large proximal fragment that allows for better fixation. However, external fixation devices are cumbersome and not well tolerated by older women and those who cannot follow-up over long distances. Fixator-assisted plating of the focal dome osteotomy combines the advantages of the fixator for accuracy of correction and the convenience of the locking plate. We retrospectively analyzed 34 focal dome high-tibial osteotomies in 31 patients performed over 6 years. Preoperative mechanical axis deviation was −19% (−150%-28%) which improved to 55% (3%-108%). The average preoperative medial proximal tibial angle was 79.8° (88°-63°) which improved to 93° (84°-107°). The average preoperative hip-knee-ankle angle was 195.2° (185°-225°) which improved to 177.5° (166°-204°). Femorotibial angle was 184.6° (182°-220°) which improved to 172° (158°-184°). The tibial slope reduced from 76.9° to 81.1°. Average follow-up was 70 months (45-113). Large varus deformities could be corrected safely with reasonable accuracy in this study.

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Context: Little is known about the energy expenditure following limb salvage with tibiocalcaneal (TC) or tibio-talo-calcaneal (TTC) fusions and optimization of leg lengths. Studies have quantified the energy expenditures of amputees and tibiotalar fusion patients by measuring oxygen (O ₂ ) consumption, but a similar study has yet to be performed on TC or TTC fusion patients. Since limb salvage with TC or TTC fusion is often considered an alternative treatment to a below the knee amputation (BKA), it will be useful to understand the relative energy expenditures of the two treatment groups. Aims: To assess the energy expenditure and self-reported outcomes of patients who have undergone limb salvage with TC or TTC fusions, and to compare the O ₂ consumption of TC and TTC fusion patients to those reported in the literature for patients who underwent BKAs. Subjects and Methods: We gathered data on 12 TC and TTC fusion patients' O ₂ consumptions at rest, their self-selected usual daily walking speed (UDWS), 80% of UDWS, 120% of UDWS, and a fixed speed of 2 miles/h (mph). Short form-36 (SF-36) and visual analog scores were also obtained. Statistical Analysis: We calculated the averages and standard deviations of the O ₂ consumption levels for our cohort of TC and TTC fusion patients. Results: The TTC and TC patients overall averaged 10.4 mL O ₂ /min/kg at an average UDWS of 1.9 mph. This O ₂ consumption rate was 22% higher than normal. The outcome SF-36 scores were 57 and 45 for the mental and physical components, respectively. The visual analog scale was 1.1. Conclusion: Patients after TC and TTC fusions have minimal pain. SF-36 mental component scores were better than those of normal population, and physical component scores were minimally lower than the normal population. While O ₂ consumptions was 22% above normal population, it was less than what has been reported in the literature for BKA patients.

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Context: Previous studies report that valgus deformities of the knee and the ankle joint usually occur due to proximal and distal fibular migration during tibial lengthening with the Ilizarov method. Aims: This study aimed to evaluate complications related to fibular resection during tibial lengthening with the Taylor Spatial Frame. Settings and Design: Retrospective study. Subjects and Methods: We retrospectively reviewed 18 segments (15 patients, mean age 20.5 years) who underwent tibial lengthening of more than one cm with fibular resection. Only Taylor Spatial Frame external fixators were used. The mean follow-up period was 37.8 months. Radiographs were evaluated for proximal fibular migration (PFM), distal fibular migration (DFM), knee and ankle alignment, and the presence of fibular nonunion preoperatively and at the last follow-up. Statistical analysis used: Mann-Whitney U-test. Results: The mean PFM was 9.7 mm and the mean DFM was 3.9 mm. Neither knee nor ankle valgus deformities was seen. Nonunion occurred in 12 segments and union of the fibula occurred in six segments after lengthening. The mean length of the fibular segment was 12.4 mm in cases with nonunion and 5.8 mm in cases with union at the fibula resection sites. Conclusions: We verified the presence of proximal and distal fibular migration reportedly associated with knee valgus and ankle valgus. PFM was not regarded as a definite cause of knee valgus, but it is necessary to fix the tibiofibular joints by transfixing wire and/or cannulated screws both at proximal and distal to minimize PFM and DFM.

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Congenital pseudoarthrosis of the tibia (CPT) is an intractable pediatric orthopedic disease. This study aims to report short-term outcomes of our staged surgery: Gradual realignment with Taylor Spatial Frame (TSF) and conversion to a locking plate for Boyd classification type II CPT. Three males (mean age, 10.3 years) who had undergone past surgeries (average, 3.7) were included. The pseudoarthrosis was atrophic and mobile in all cases. The distal bone fragment was translocated to the proximal anterior direction, resulting in shortening of the leg. In the first surgery, TSF was applied spanning the pseudoarthrosis. A foot ring was placed on the foot, and the distal fragment of the tibia was fixed together with the foot. The deformity correction was initiated a day after surgery. TSF was converted to a locking plate after scheduled alignment was achieved, and cancellous bone of iliac crest was grafted. Bony union was achieved at a mean of 3 months, and patients walked independently after mean 56-month follow-up, without any complications. Although the treatment outcome after the vascularized fibular graft and the Ilizarov method is relatively successful, several issues require long-term relief, and the surgical procedure requires specialized techniques. The present method shortens the duration of external fixation, uses only simple surgical maneuvers, and prevents re-fracture by anatomical alignment and indwelling of the plate.

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