Anil Bhave

Femoral lengthening over an intramedullary nail : A matched-case comparison with Ilizarov femoral lengthening

Twenty-nine patients (thirty-two femora) had femoral lengthening over an intramedullary nail, with the nail and the external fixator applied concomitantly at the time of the femoral osteotomy. After gradual distraction at a rate of one millimeter per day, the nail was locked and the fixator was removed. The mean age was twenty-six years (range, ten to fifty-three years), and the mean amount of lengthening was 5.8 centimeters (range, two to thirteen centimeters). For comparison, thirty-one patients (thirty-two limbs) who had had standard Ilizarov femoral lengthening were matched with the group that had had lengthening over an intramedullary nail; the matching was performed on the basis of the amount of lengthening, the age of the patient, the etiology of the indication for lengthening, and the level of difficulty of the procedure. Lengthening over an intramedullary nail reduced the average duration of external fixation by almost one-half. The radiographic consolidation index (the number of months needed for radiographic consolidation for each centimeter of lengthening) for the limbs that had had lengthening over an intramedullary nail was reduced significantly (p < 0.001) compared with that for the matched-case group. The range of motion of the knee returned to normal a mean of 2.2 times faster in the group that had had lengthening over an intramedullary nail. There were six refractures of the distraction bone in the matched-case group. In the group that had had lengthening over an intramedullary nail, one nail and one proximal locking screw failed. The over-all rate of complications was 1.4 per cent in the group that had had lengthening over an intramedullary nail compared with 1.9 per cent in the matched-case group. With the numbers of patients available for study, we could not detect a significant difference between the groups with respect to the operative time (p = 0.124); however, the cost of treatment and the estimated blood loss were higher in the group that had had lengthening over an intramedullary nail. On the basis of clinical and radiographic criteria, there were twenty-three excellent, seven good, and two fair results in the group that had had lengthening over an intramedullary nail compared with twenty-six excellent, four good, and two fair results in the matched-case group (p = 0.37). The advantages of lengthening over an intramedullary nail include a decrease in the duration of external fixation, protection against refracture, and earlier rehabilitation.

Multiplier method for predicting limb-length discrepancy.

Background: In patients with a congenital or developmental limb-length discrepancy, the short limb grows at a rate proportional to that of the normal, long limb. This is the basis of predicting limb-length discrepancy with existing methods, which are complicated and require multiple data points. The purpose of our study was to derive a simple arithmetic formula that can easily and accurately predict limb-length discrepancy at skeletal maturity. Methods: Using available databases, we divided the femoral and tibial lengths at skeletal maturity by the femoral and tibial lengths at each age for each percentile group. The resultant number was called the multiplier. Using the multiplier, we derived formulae to predict the limb-length discrepancy and the amount of growth remaining. We verified the accuracy of these formulae by evaluating two groups of patients with congenital shortening who were managed with epiphysiodesis or limb-lengthening. We also calculated and compared the multipliers for other databases according to radiographic, clinical, and anthropological lower-limb measurements. Results: The multipliers for the femur and tibia were equivalent in all percentile groups, varying only by age and gender. Because congenital limb-length discrepancy increases at a rate proportional to growth, the discrepancy at maturity can be calculated as the current discrepancy times the multiplier for the current age and the gender. This calculation can be performed with use of a single measurement of limb-length discrepancy. For progressive developmental (noncongenital) discrepancies, the discrepancy at skeletal maturity can be calculated as the current discrepancy plus the growth inhibition times the amount of growth remaining. The timing of the epiphysiodesis can also be calculated with the multiplier. The predictions made with use of the multiplier method correlated well with those made with use of the Moseley method as well as with the actual limb-length discrepancy in both the limb-lengthening and epiphysiodesis groups. The multipliers derived from the radiographic, clinical, and anthropological measurements of femora and tibiae were all similar to each other despite differences in race, ethnicity, and generation. Conclusions: The multiplier method allows for a quick calculation of the predicted limb-length discrepancy at skeletal maturity, without the need to plot graphs, and is based on as few as one or two measurements. This method is independent of percentile groups and is the same for the prediction of femoral, tibial, and total-limb lengths. The multiplier values are also independent of generation, height, socioeconomic class, ethnicity, and race. We verified the accuracy of this method clinically by evaluating patients who had been managed with limb-lengthening or epiphysiodesis. The method was also comparable with or more accurate than the Moseley method of limb-length prediction.

Periprosthetic joint infection

Periprosthetic joint infections are a devastating complication after arthroplasty and are associated with substantial patient morbidity. More than 25% of revisions are attributed to these infections, which are expected to increase. The increased prevalence of obesity, diabetes, and other comorbidities are some of the reasons for this increase. Recognition of the challenge of surgical site infections in general, and periprosthetic joint infections particularly, has prompted implementation of enhanced prevention measures preoperatively (glycaemic control, skin decontamination, decolonisation, etc), intraoperatively (ultraclean operative environment, blood conservation, etc), and postoperatively (refined anticoagulation, improved wound dressings, etc). Additionally, indications for surgical management have been refined. In this Review, we assess risk factors, preventive measures, diagnoses, clinical features, and treatment options for prosthetic joint infection. An international consensus meeting about such infections identified the best practices and further research needs. Orthopaedics could benefit from enhanced preventive, diagnostic, and treatment methods.

Improvement in gait parameters after lengthening for the treatment of limb-length discrepancy.

BACKGROUND Patients who have limb-length discrepancy demonstrate an altered gait pattern or a limp. The purpose of this prospective study was to compare the objective gait parameters for the shorter lower limb with those for the longer lower limb before and after lengthening and to compare these data with those for a group of twenty subjects who had no limb-length discrepancy. METHODS Eighteen patients had equalization of limb length to within one centimeter. We analyzed the stance time, the second peak of the vertical ground-reaction-force vector, and the rate of loading with use of two force-plates arranged in a series. RESULTS The difference in the mean stance times between the shorter and longer limbs before lengthening was 12 percent, whereas that after lengthening was 2.4 percent; the difference between the values before and after lengthening was significant (p<0.001). The difference in the stance times between the limbs of the patients who did not have limb-length discrepancy was 2 percent. Preoperatively, the mean second peak was 104 percent of body weight for the shorter limb compared with 116 percent for the longer limb; this difference was significant (p<0.001). After lengthening, the mean second peak for the shorter limb increased to 113 percent of body weight. The difference in the means for the second peak before and after lengthening was significant (p<0.001). With the numbers available, no significant difference was detected in the means for the second peak between the shorter and longer limbs after lengthening (p = 0.12). CONCLUSIONS This study shows that lengthening of the shorter limb of patients who have limb-length discrepancy can normalize symmetry of quantifiable stance parameters and eliminate a limp.

Nerve lesions associated with limb-lengthening.

BACKGROUND Nerve injury is one of the most serious complications associated with limb-lengthening. We examined the risk, assessment, and treatment of nerve lesions associated with limb-lengthening. METHODS We retrospectively studied the records on 814 limb-lengthening procedures. Nerve lesions were defined by clinical signs and symptoms of motor function impairment, sensory alterations, referred pain in the distribution of an affected nerve, and/or positive results of quantitative sensory testing with use of a pressure specified sensory device. RESULTS Seventy-six (9.3%) of the limbs had a nerve lesion. Eighty-four percent of the nerve lesions occurred during gradual distraction, and 16% occurred immediately following surgery. The pressure specified sensory device showed 100% sensitivity and 86% specificity in the detection of nerve injuries. The patients in whom the lesion was diagnosed with this method, or with this method as well as with nerve conduction studies, had significantly faster recovery than did those diagnosed on the basis of clinical symptoms or nerve conduction studies alone (p = 0.02). Patients undergoing double-level tibial lengthening and those with skeletal dysplasia were at higher risk for nerve lesions (77% and 48%, respectively). Nerve decompression was performed in fifty-three cases (70%). The time between the diagnosis and the surgical decompression was strongly associated with the time to recovery (p = 0.0005). Complete clinical recovery was achieved in seventy-four of the seventy-six cases. CONCLUSIONS Early detection based on signs and symptoms or testing with a pressure specified sensory device improves the prognosis for nerve injury that occurs during limb-lengthening. Of the methods that we used to identify neurologic compromise, testing with the pressure specified sensory device was the most sensitive. Aggressive early treatment (slowing the rate of lengthening and/or performing decompression) allows continued lengthening without incurring permanent nerve injury. When indicated, decompression of the affected nerve should be performed as soon as possible, thereby improving the chances of and shortening the time to complete recovery.

Treatment of Malunion and Nonunion at the Site of an Ankle Fusion with the Ilizarov Apparatus

BACKGROUND Malunion and nonunion of an ankle fusion site are associated with pain, osteomyelitis, limb-length discrepancy, and deformity. The Ilizarov reconstruction has been used to treat these challenging problems. METHODS We reviewed the results in twenty-one ankles that had undergone a revision of a failed fusion, with simultaneous treatment of coexisting pathologic conditions, with use of the Ilizarov technique. Eight patients had undergone ankle fusion only, eleven had undergone ankle and subtalar fusion, and two had undergone pantalar fusion. Eighteen patients with an average limb-length discrepancy of 4 cm underwent limb lengthening simultaneously with the revision surgery. The average patient age was forty years. Indications for treatment were malunion (eleven patients), aseptic nonunion (eight patients), and infected nonunion (two patients). Clinical, subjective, objective, gait, and radiographic analyses were performed after an average duration of follow-up of 83.4 months. RESULTS Solid union was achieved in all ankles. The functional result was excellent for fifteen patients, good for three, fair for two, and poor for one. The bone result was excellent for ten ankles, good for nine, fair for one, and poor for one. All eighteen patients who underwent gait analysis had a heel-to-toe progression gait, and twelve achieved normal walking velocity with their shoes on. A plantigrade foot was achieved in each case, and only two patients had >5 degrees of residual deformity. During the Ilizarov treatment, forty-one minor complications (treated conservatively) and twenty major complications (treated surgically) occurred. After removal of the circular frame, seven other complications, which required four additional operations, occurred. CONCLUSIONS In patients with a failed ankle fusion, infection, limb-length discrepancy, and foot deformity can be addressed simultaneously with use of the Ilizarov apparatus to achieve a solid union and a plantigrade foot, usually with a clinically satisfactory result.

Functional problems and treatment solutions after total hip and knee joint arthroplasty

A lthough most patients who undergo total hip or knee joint arthroplasty have an excellent clinical result with routine postoperative interventions, substantial dysfunction develops in 15% to 20% of patients for various reasons1. These patients do not respond to standard physical therapy modalities and need a very aggressive regimen of management that may include both invasive and noninvasive therapeutic options. The purpose of this study was to identify these patients with functional limitations and to assess the results of treatment with a customized regimen. We defined soft-tissue problems as those not directly related to the implant. Implant-related problems due to malalignment or loosening were ruled out radiographically or by specialized testing by two of the authors (M.M. and G.E.). We identified several functional problems following total hip arthroplasty and total knee arthroplasty that were related to muscle weakness, muscle tightness, limb-length differences, and nerve problems (Table I). View this table: TABLE I Problems Following Total Hip and Knee Arthroplasty After identification of the problems, management was initiated with either noninvasive treatment such as physical therapy, customized bracing, electrical stimulation, or iontophoresis or with invasive treatment such as injections of Botox (botulinum toxin type A; Allergan, Irvine, California), intraarticular injections, nerve blocks, or muscle-lengthening procedures. For patients exhibiting joint stiffness, a lack of extension, or a lack of flexion (<90°) following total knee arthroplasty, we developed a special customized protocol utilizing a customized hinged cast and adjunctive physical therapy. We identified problems with the soft-tissue envelope that were directly related to the joint in the majority of patients. In addition, some patients had problems affecting an adjacent joint that resulted in poor gait and function, such as malalignment of the knee joint in a patient who had had a total hip arthroplasty or malalignment of the foot in a patient who had had …

Surgical treatment and customized rehabilitation for stiff knee arthroplasties.

Treating patients who have arthrofibrotic or stiff knees after total knee arthroplasty can be difficult. Treatment with arthroscopic débridement, arthrolysis of adhesions with polyethylene spacer exchange, or complete revision arthroplasty often has led to less than optimal range of motion and functional outcomes. We used a combination of surgical arthrolysis and an intensive postoperative rehabilitation protocol, including functional bracing, to treat this condition. We then retrospectively reviewed 18 knees in 17 patients who had stiff knees after total knee arthroplasty with no other detectable clinical or radiographic abnormalities, at a mean followup of 30 months. Seventeen knees (94%) had gains in knee range of motion with a mean increased range of motion of 31°. Although 16 of 17 patients had clinical improvement and were satisfied with the procedure, only ⅔ of the patients (12 of 18 patients) had excellent or good Knee Society objective scores. This combined surgical and rehabilitation method can lead to an increased range of motion. All patients improved clinically, but good functional results were less predictable. The authors think treatment of these difficult knees should be aimed at soft tissue operative releases supplemented by an intensive rehabilitation protocol.Level of Evidence: Therapeutic study, level IV (prospective study). See Guidelines for Authors for a complete description of levels of evidence.

Functional problems and arthrofibrosis following total knee arthroplasty.

Improved surgical techniques and multidisciplinary rehabilitation protocols that involve coordination among surgeons, physical therapists, anesthesiologists, and social services personnel have led to excellent knee function and range of motion in a large percentage of patients following total knee arthroplasty. Nevertheless, there remains a small number of patients with persistent dysfunction that is difficult to treat1-4. Functional problems following total knee arthroplasty may be incapacitating as a result of persistent pain5, instability6, and a limited range of motion7. It has been shown recently that there is a direct correlation between a decreased range of motion following surgery and a lower perceived quality of life as evaluated with use of the Short Form-36 health survey questionnaire8. Continued dysfunction for any reason ultimately leads to decreased patient satisfaction. There is controversy about treatment methods for patients for whom initial rehabilitation efforts are unsuccessful following total knee arthroplasty. The reported efficacy of both noninvasive and invasive treatment modalities has been variable, with the percentage of patients obtaining improvement ranging from 0% to 90%3,9-12. Patients who have continued dysfunction despite initial rehabilitation efforts may require revision surgery. However, patients who have well-aligned, well-fixed prosthetic components will likely not benefit from a complete revision. Treatment of arthrofibrosis, scarring, soft-tissue contractures, and/or other soft-tissue dysfunction should involve less invasive treatment protocols before surgical options are considered. Nonoperative treatment modalities for restoring the range of motion include intensive rehabilitation protocols, static or dynamic splinting, injections, and application of serial casts13. Manipulation with the patient under anesthesia and invasive procedures, including arthroscopic debridement, open debridement with or without polyethylene exchange, and complete component revision, have been utilized when initial nonoperative rehabilitation efforts have failed. As a result of the …

Growth patterns after lengthening of congenitally short lower limbs in young children

The purpose of this study was to assess growth patterns after lengthening of the congenitally short femur or tibia in children younger than 6 years. Twenty such children underwent 28 bone segment lengthenings (13 femora and 15 tibiae) by distraction osteogenesis. Our results show that femoral lengthening in children younger than 6 years does not lead to growth inhibition, whereas isolated femoral lengthening may be associated with growth stimulation. Isolated tibial lengthening in children younger than 6 years does not lead to growth inhibition, whereas simultaneous femoral and tibial lengthening or two tibial lengthenings in close succession can lead to tibial growth inhibition.