Dror Paley

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.

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.

The load applied to the foot in a patellar ligament-bearing cast

The purpose of this study was to determine whether a patellar ligament-bearing cast reduces the load applied to a foot in a cast. In a study of ten people who had no history of gait abnormalities, disease involving the motor system, or deformities of the lower extremities, we compared the load applied to the plantar aspect of a foot in a cast (as detected with F-Scan computer-monitored pedobarographic sensors) with the total load that an extremity in a cast receives relative to the ground (as detected with force-plates). Six trials were completed three times by each person. The trials consisted of walking (1) while wearing regular shoes; (2) with a patellar ligament-bearing cast on one leg; (3) with a patellar ligament-bearing cast and an overlying soft knee brace, locked in full extension, on the leg; (4) with only a below-the-knee cast on the leg; (5) with a below-the-knee cast and an overlying knee brace, locked in full extension, on the leg; and (6) with only a knee brace, locked in full extension, on the leg. The loads at peak heel-strike for all three trials were averaged and normalized to body weight. The load on the plantar aspect of the foot, as compared with the total load, was reduced a mean of 11 percent when the patellar ligament-bearing cast was worn alone, and it was reduced a mean of 26 percent when the patellar ligament-bearing cast was used with an overlying knee brace locked in full extension. This difference was significant (p = 0.007). With the numbers available, we could not detect a significant difference between the reduction in load when a patellar ligament-bearing cast was worn alone compared with that when a below-the-knee cast was worn alone or between the reduction when a below-the-knee cast was worn alone compared with that when a below-the-knee cast was used with a knee brace (p = 0.3). In conclusion, we could not demonstrate a significant reduction in the load on the foot when a patellar ligament-bearing cast was used in a traditional fashion; however, a significant (p = 0.007) reduction in load was found when a knee brace locked in full extension was worn in addition to the patellar ligament-bearing cast.

Pseudarthrosis following Slipped Capital Femoral Epiphysis: Treatment with Reduction with Use of Gradual Distraction. A Case Report*

Pseudarthrosis is a rare complication of slipped capital femoral epiphysis. Traumatic pseudarthrosis of the femoral neck is treated with bone-grafting, osteotomy, and open reduction with internal fixation or with osteotomy alone. Severe slips are treated with closed pinning, epiphyseodesis with bone-grafting, open reduction, or osteotomy. Open reduction is associated with a high risk of avascular necrosis. We are not aware of any guidelines for the treatment of pseudarthrosis following slipped capital femoral epiphysis. The purposes of this report are to present the case of a patient who had this rare condition and to discuss alternative methods of treatment. A twenty-seven-year-old man was seen because of progressive pain in the right hip and a limp. Chronic bilateral slipped capital femoral epiphysis had been diagnosed when the patient was fourteen years old, and it had been treated initially with in situ pinning with one pin in each hip. The pin in the right hip was removed because of trochanteric bursitis when the patient was fifteen years old, and the pin in the left hip was removed when he was sixteen and one-half years old. The pain in the right hip and the limp had developed when the patient was seventeen years old. Both of these symptoms became progressively worse; when the patient was first seen by us, he stated that the pain and limp limited his activities of daily living and interfered with his occupation as a housepainter. The patient was 171 centimeters tall and weighed 109 kilograms at the time of presentation. He walked with a lurch and had a delayed Trendelenburg sign (a positive Trendelenburg sign that is not immediate but that occurs within thirty seconds) on the right. The range of motion of the right hip was 70 degrees of flexion, full extension, 10 degrees of abduction, 15 degrees …

Surgical decompression of the peroneal nerve in the correction of lower limb deformities: A cadaveric study

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.

Joint Distraction for Special Conditions

Management of Perthes disease remains controversial despite extensive literature exploring this subject. Obtaining and maintaining hip range of motion are the only principles of treatment that are universally agreed upon. Containment of the femoral head within the acetabulum is thought to have a beneficial role, especially in patients with more than 50 % femoral head involvement. Methods used to achieve containment include abduction bracing, femoral or innominate osteotomies, and shelf procedures. However, these methods are contraindicated when the degree of femoral head collapse and deformation prevent spherical hip motion. Unloading of the hip was originally considered important in the treatment of Perthes disease. Various methods, such as complete bed rest and use of a Snyder sling, have been tried toward this end, but little evidence exists to show that these methods alter the natural history of the disease. The failure of unloading may be related to the misconception that non-weight bearing is equivalent to unloading. We now know that muscular forces on the non-weight-bearing hip can apply one to two times the body weight. To truly remove all compressive forces from the hip, the muscular forces must be neutralized. This can be accomplished by hip joint distraction with an external fixator. Distraction of the hip also can reduce subluxation of the femoral head relative to the acetabulum.

Combined Technique: Correction of Long Bone Deformities Using Fixator-Assisted Nailing

Deviation of the mechanical axis (MAD) results primarily in deformities of the long bones, which result in the development of secondary osteoarthritis of the hip, knee, and/or ankle joints. Orthopedic surgeons have utilized many different procedures to correct these deformities to prevent secondary osteoarthritis. However, these techniques generally result in low patient comfort and lack accuracy. A comprehensive technique termed “fixator-assisted nailing” (FAN) was developed by Dror Paley in 1993 and was first described by Paley et al. in 1997. Its goal was to combine the accuracy and minimal invasiveness of external fixation with the convenience of internal fixation. Internal fixation prevents the recurrence of the deformity and allows early mobilization of joints and quicker rehabilitation.

Percutaneous Z Tendon Achilles Lengthening

Achilles tendon lengthening is a delicate procedure whereby the risk of over lengthening (creating calcaneus), rupture, and weakening of the gastrocnemius-soleus muscle is devastating. The Silfverskiold test is clinically performed to differentiate gastrocnemius equinus from gastrocnemius-soleus equinus. Many surgical techniques have been developed to treat negative results of the Silfverskiold test. The authors prefer a gastrocnemius-soleus recession in order to preserve muscle strength. However, when a large amount of equinus deformity is present, an Achilles tendon lengthening is performed in order to achieve an adequate amount of length.1 The authors present a percutaneous technique for Achilles tendon lengthening.2