Surgical Treatment of Leg Length Discrepancy and Knee Flexion Contracture Associated with a Congenital Absence of Quadriceps

We report the case of an 18-year-old male with congenital absence of quadriceps and hypoplasia of the patella who presented with a significant leg length discrepancy (LLD) and knee flexion contracture. Surgical management was aimed toward lengthening the limb, stabilizing the joint, and correcting the knee flexion contracture. Correction of a significant congenital LLD and knee flexion contracture poses challenges due to long-standing altered biomechanics. These are rare conditions for which no accepted surgical algorithms exist. It is essential to anticipate the biomechanical consequences of limb lengthening and flexion contracture correction that might arise and plan comprehensive interventions accordingly.

The PRECICE nail system: The initial Kuwaiti experience

Objectives: The PRECICE system is an implantable limb lengthening intramedullary nail with remotely magnetically controlled distractors indicated for limb length discrepancy (LLD) and short stature treatment. This study reports the initial experience of the Kuwaiti deformity correction unit in utilizing the PRECICE system. Methods: Ten patients (four females and six males) were included in this study. All cases were operated using the PRECICE nail system (five antegrade femoral nails, three retrograde femoral nails, and two tibial nails). All surgeries were performed during January 2019 to February 2020. Results: The mean age of participants was 20 years (12–33 years), with a 21.6 kg/m2 mean body mass index (17–28). LLD etiologies (mean LLD = 39 mm) were congenital (n = 2), developmental (n = 2), post-traumatic non-union (n = 1), post-traumatic malunion (n = 1), post-traumatic physeal arrest (n = 1), and post-deformity correction and lengthening of the contralateral side with circular frame (n = 3). The mean distraction rate was 0.97 mm/day (range: 0.75–1.2 mm/day). Mean lengthening was 39 mm (range: 20–60 mm). Healing was confirmed at 76 days on average (range: 50–120 days). All patients reached full consolidation to regenerate bone, normal alignment, and normal joint orientation. Antegrade femur lengthening was done in five patients. One patient with a previous knee fixed flexion deformity of 25° improved to a 5° lag of extension. No complications were observed during the lengthening procedures. All the patients were followed up for a minimum of 12 months. Conclusion: The PRECICE nail system was successful in lengthening cases with different etiologies, achieving target lengths without complications. All the patients had reported excellent functional outcomes.

Staged correction of varus knee and lateral thrust in an achondroplastic (ACH) juvenile patient who underwent limb lengthening with IM nails: tips for proper timing and prioritisation of procedures

We present the case of a fifteen-year-old achondroplastic (ACH) woman who requested to have her femurs lengthened by intramedullary nails. She had undergone bilateral tibial lengthening at the age of eleven and presented with a varus deformity of the right lower limb, lateral thrust of the right knee and valgus deformity of the left lower limb. We performed deformity analyses based on mechanical axis measurements, and we came with a staged surgical plan. In ACH adolescences, correction of bony deformity needs to encounter continuous fibula growth dynamics. Lateral knee thrust was corrected by gradual distal translation of the fibula head via an Ilizarov frame and the amount of translation we decided clinically. Tibial lengthening and valgus osteotomy of the distal femur accentuate lateral collateral ligament (LCL) complex laxity. In patients with ACH, tibial lengthening and valgus osteotomy of the distal femur—if needed—should precede LCL complex tightening, and femoral lengthening should follow.

Psychosocial Implications of Limb Lengthening and Reconstruction Orthopedic Surgery: A Literature Review

A fervent interest in improving patient care, quality of life, and outcomes in adolescent patients undergoing limb Lengthening/ Reconstruction Surgeries (LLRS) has guided the exploration of how psychosocial markers in adolescence may be viewed as crucial to achieving enhanced healthcare delivery. This systematic literature review stems from a retrospective pilot study which investigated the importance of psychosocial aspects in the care of children, adolescents, and young adults who have undergone multiple LLRS. It was determined that such patients value psychosocial support given by their surgeons and caregivers, further promoting psychosocial maturation [1]. Currently, prospective investigation is in the process of being explored as yet another outgrowth of this seminal pilot study. Specifically, the current review seeks to explore the literature relevant to aspects of psychosocial development fundamental to enhancing outcomes of a chronic, orthopedic medical condition. The dearth of studies applying a biosocial lens to this subspecialized field of orthopedic surgery and care supports the need for such expanded investigation.

Computed Tomography in Limb Salvage and Deformity Correction—3D Assessment, Indications, Radiation Exposure, and Safety Considerations

Computed tomography (CT) is an essential tool in orthopedic surgery but is known to be a method with that entails radiation exposure. CT increases the risk of developing fatal cancer, which should not be underestimated. However, patients with bone defects and/or deformities must frequently undergo numerous investigations during their treatment. CT is used for surgical planning, evaluating callus maturation, alignment measurement, length measurement, torsion measurement, and angiography. This study explores the indications in CT scans for limb lengthening and deformity correction and estimates the effective radiation dose. These results should help avoid unnecessary radiation exposure by narrowing the examination field and by providing explicit scanning indications. For this study, 19 posttraumatic patients were included after the bone reconstruction of 21 lower limbs. All patients underwent CT examinations during or after treatment with an external ring fixator. The mean effective dose was 3.27 mSv, with a mean cancer risk of 1:117,014. The effective dose depended on the location and indication of measurement, with a mean dose of 0.04 mSv at the ankle up to 6.8 mSv (or higher) for vascular depictions. CT evaluation, with or without 3D reconstruction, is a crucial tool in complex bone reconstruction and deformity treatments. Therefore, strict indications are necessary to reduce radiation exposure—especially in young patients—without compromising the management of their patients.