Modified osteotomy for treatment of forearm deformities (Masada IIb) in hereditary multiple osteochondromas: a retrospective review

Purpose Approximately 30% of patients with hereditary multiple osteochondromas (HMO) have forearm deformity and dysfunction. The aim of this retrospective study was to review our experience with the surgical treatment of children with HMO and Masada IIb forearm deformities. Methods Data of eight children treated for HMO Masada IIb forearm deformity at our hospital between 2015 and 2019 were collected from the hospital records and retrospectively reviewed. All patients underwent ulnar lengthening by distraction osteogenesis using either the Orthofix or Ilizarov external fixator. Range of movements at the elbow and wrist joints, and forearm supination/pronation, before and after the operation were recorded. Radiographs were evaluated by the Fogel method, and wrist joint function by the Krimmer method. Results Follow-up radiographs showed significant improvement in relative ulnar shortening after treatment (pre-operative 9.23 ± 5.21 mm; post-operative 0.33 ± 4.13 mm). Changes in radial articular angle (pre-operative 33.55° ± 3.88° to 32.78° ± 6.57°) and carpal slip (pre-operative 45.00% ± 19.09%; post-operative 43.13% ± 16.68%) were not significant. Elbow flexion and extension, wrist flexion and extension, ulnar and radial deviation at wrist, and forearm rotation were significantly improved after surgery. Wrist function was graded as excellent in seven patients and as good in one patient. One patient treated with the Ilizarov external fixator had poor radial head reduction. Conclusion Ulnar lengthening with distraction osteogenesis is an effective treatment for HMO Masada IIb deformities. The optimum site for ulnar osteotomy appears to be at the proximal one-third to one-fourth of the ulna.

The Axial Load-Share Ratio in Vivo as a Supplemental Assessment for the External Fixator Safe Removal

Background: Timing the fixator removal is vital for a successful external fixation treatment. The purpose of this study was to determine the effectiveness of axial load-share ratio in vivo as a supplemental decision support tool for the safe removal of an Ilizarov external fixator.Methods: This prospective observational study consists of 83 patients undergoing tibial or femoral lengthening with Ilizarov circular external fixation in our institution, from January 2011 to October 2019. In group Ⅰ (38 patients), the external fixator was removed based on the surgeon’s clinical experience and radiographs from January 2011 to June 2015. In group Ⅱ (45 patients), from July 2015 to October 2019, the supplemental axial load-share (LS) ratio test was accomplished without the knowledge of the clinical results by another medical team. The test was performed by electronically measuring forces in the fixator rods and in a ground force plate. When the LS ratio < 10% was consistent with the conclusion (dense bone formation was achieved in the distraction zone) drawn from the corresponding routine radiographs by the treating surgeon, the external fixator was removed.Results: There was no statistical significance in demographic data between the two groups (P>0.05). In group Ⅰ, 4 of the 38 patients suffered refracture (the refracture rate was 10.5%) after fixator removal, and bone union was finally achieved with further intervention by intramedullary nail. In group Ⅱ, 36 patients terminated the external fixation after the first mechanical test, and another 9 patients terminated the external fixation at the subsequent test. None of the 45 patients in group Ⅱ suffered refracture (the refracture rate was 0%). There was statistical significance in the refracture rate between the two groups (P<0.05).Conclusions: Adequate assessment of bone regenerate is crucial before removing an external fixator to prevent deformation or refracture. The axial load-share ratio in vivo is a practically quantitative method to supplement radiography and clinical experience for the assessment of regenerate healing, and the axial load-share ratio dropped below 10% is a safe limit for the Ilizarov external fixator removal.

Distal Intra Articular Tibial Fracture Treated by Ilizarov with Ligamentotaxis

Background The thin soft tissue and muscles envelope that surrounds the distal tibia makes treatment of these fractures difficult. These fractures are often referred to as ―pilon‖ fractures or ―plafond‖ fractures‖. If the articular surface of the tibia is involved; in such cases an anatomic realignment of the involved articular fracture in conjunction with a stable fixation is crucial. Objectives The aim of this paper is to conduct a systematic review of literature about functional and radiological outcomes in patients with distal intra articular tibial fracture treated by external fixator with ligamentotaxis. Materials and Methods We performed this systematic review and meta-analysis in accordance to the recommendations of the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. MOOSE is a reporting checklist for Authors, Editors, and Reviewers of Meta-analyses of interventional and observational studies. According to International committee of medical journal association (ICJME), reviewers must report their findings according to each of the items listed in those checklists Results Over all, five studies reported the time to union. The overall effect estimates showed that the time to union after Ilizarov external fixator was 12.83 weeks. Three studies reported the rate of union. The overall effect estimates showed that the rate of union after Ilizarov external fixator was 88.4%. Over all, eight studies reported the good-excellent AOFS score. The overall effect estimates showed that the rate of good-excellent AOFS score after Ilizarov external fixator was 69.4%. Nine studies reported the rate of malunion. The overall effect estimates showed that the rate of malunion after Ilizarov external fixator was 10.2%. Over all, seven studies reported the rate of delayed union. The overall effect estimates showed that the rate of delayed union after Ilizarov external fixator was 6.3%. All studies reported the rate of pin infection. The overall effect estimates showed that the rate of pin infection after Ilizarov external fixator was 33.7%. Ten studies reported the rate of major infection. The overall effect estimates showed that the rate of major infection after Ilizarov external fixator was 3.4. Conclusion External fixation and ligamentotaxis by either ilizarov or any external fixator is a good and easy method for fixation of distal intraarticulat tibial fracture with few serious complications. due to easy to apply it, less rate of infection, no risk of bleeding since no opening the fracture site, good aligment of the joint, no streaping of the periosteomy that lead to later on good and rapid healing of the fracture.

Modified Osteotomy for Treatment of Forearm Deformities (Masada IIb) in Hereditary Multiple Osteochondromas: A Retrospective Review

Purpose: Approximately 30% of patients with hereditary multiple osteochondromas (HMO) have forearm deformity and dysfunction. The aim of this retrospective study was to review our experience with the surgical treatment of children with HMO and Masada IIb forearm deformities.Methods: Data of eight children treated for HMO Masada IIb forearm deformity at our hospital between 2015 and 2019 were collected from the hospital records and retrospectively reviewed. All patients underwent ulnar lengthening by distraction osteogenesis using either the Orthofix or Ilizarov external fixator. Range of movements at the elbow and wrist joints, and forearm supination/pronation, before and after the operation were recorded. Radiographs were evaluated by the Fogel method, and wrist joint function by the Krimmer method.Results: Follow-up radiographs showed significant improvement in relative ulnar shortening after treatment (pre-operative 9.23 ± 5.21 mm; post-operative 0.33 ± 4.13 mm). Changes in radial articular angle (pre-operative 33.55° ± 3.88° to 32.78° ± 6.57°) and carpal slip (pre-operative 45.00% ± 19.09%; post-operative 43.13% ± 16.68%) were not significant. Elbow flexion and extension, wrist flexion and extension, ulnar and radial deviation at wrist, and forearm rotation were significantly improved after surgery. Wrist function was graded as excellent in seven patients and as good in one patient. One patient treated with the Ilizarov external fixator had poor radial head reduction.Conclusion: Ulnar lengthening with distraction osteogenesis is an effective treatment for HMO Masada IIb deformities. The optimum site for ulnar osteotomy appears to be at the proximal one-third to one-fourth of the ulna.

Lengthening and deformity correction in vascularized fibular autograft for a patient with Ewing sarcoma

We report the case of a pediatric patient with Ewing’s sarcoma of the tibia treated with vascularized fibular autograft where the resulting limb deformity and leg length discrepancy (LLD) were corrected using Ilizarov external fixator. A 14-year-old girl presented to our outpatient clinic with a deformity of the right proximal and distal tibia and an 11.7 cm of LLD after tumor reconstruction surgery. Deformity correction and limb lengthening were simultaneously performed using double corticotomy on the right proximal and distal tibia. One year postoperatively, the union of the right proximal tibia had progressed, but nonunion was observed at the right distal corticotomy site. To address this, osteosynthesis with tricortical iliac bone allograft was performed after the removal of the Ilizarov external fixator. After 6 months, the union of the distal tibia was confirmed, and the varus deformity of proximal and distal tibia improved. The LLD was also decreased, but the left lower limb was still longer by 3 cm. This report shows that vascularized fibular autografts can potentially be used for the gradual correction of LLD and deformities. However, for the treatment of multiple deformities in bones previously reconstructed with vascularized fibular graft, the possibility of impaired bone forming potential of the fibular graft should be considered.

Open tibial fracture with severe soft tissue injury and bone loss managed with ipsilateral fibular transport and its complications: a case report

<p class="abstract">Massive segmental bone defects of tibia present as a challenging task to manage specially when associated with extensive soft tissue injury. A 30 year old male presented to Paras HMRI hospital, Patna, post road traffic accident with Gustilo Anderson 3B comminuted open tibia shaft fracture and with an external fixator in situ with a grossly inflamed and infected wound. Initially patient was managed with serial wound debridement and skin grafting was done early to obtain adequate soft tissue coverage. The patient then underwent application of Ilizarov external fixator with plan of one level fibular osteotomy for ipsilateral fibular transport. With good outcome of the procedure clinically and radiologically, Ilizarov fixator was removed after time duration of about 1.3 years and limb was immobilized in plaster of Paris (POP) cast which was removed after 8 weeks. Within 1 month of removal of POP cast the patient presented to hospital again with complaints of pain and instability when his leg was run over by his child’s bicycle while playing. Diagnosed as fracture of proximal (transported) fibula he was managed then with locking plates; one of which was used as an internal fixator and the other as external fixator which was outside the body and acted as a support to the operated limb. After about 1 year the external locking plate was removed and patient was able to bear weight on his extremities. Despite various modalities to treat massive tibial gap, fibular transport procedure with Ilizarov external fixator seems to be the most viable option.</p>

Simultaneous septic arthrodesis of the tibiotalar and subtalar joints with the Ilizarov external fixator—an analysis of 13 patients

Purpose Treatment of joint destruction of the tibiotalar and subtalar joints caused by acute or chronic infections in compromised hosts is a challenging problem. In these cases, simultaneous septic arthrodesis with the use of the Ilizarov external fixator represents a possible alternative to amputation. This case series presents the results and complications of patients with acute or chronic infection of the tibiotalar and subtalar joints. Methods Between 2005 and 2015, 13 patients with acute or chronic infections were treated by simultaneous single-stage debridement/arthrodesis of the tibiotalar and subtalar joints. In seven patients, there was a florid infection with fistula formation and soft tissue defects, and in six patients, there was chronic osteomyelitis with closed soft tissue. In addition to the demographic data, the time spent in the fixator, the major and minor complications and the endpoint of consolidation were reviewed. Results The mean time spent in the fixator was 18 (min 15, max 26) weeks. The mean follow-up time for nine patients was 100 (min 3, max 341) weeks. Complete osseous consolidation of both the tibiotalar and subtalar joints was achieved in 10 patients (77%). In three (23%) patients, there was complete consolidation of one of the joints and partial consolidation of the other joint. Conclusion The Ilizarov external fixator allows for simultaneous arthrodesis of the tibiotalar and subtalar joints in septic joint destruction. However, the healing rates are below the rates reported in the literature for isolated tibiotalar or tibiocalcaneal arthrodesis in comparable clinical situations.