Tipping the Balance: Manipulating the mechanical environment by reverse dynamization can accelerate bone healing Kevin Tetsworth, Vaida Glatt Journal of Limb Lengthening & Reconstruction 2019 5(1):1-3

Foot deformities and gait deviations in children with arthrogryposis Lucio Perotti, Chris Church, Celina Santiago, Nancy Lennon, John Henley, Kristen Nicholson, Jose Salazar-Torres, Maureen Donohoe, Kathryn Fazio, Freeman Miller, Louise Reid Nichols Journal of Limb Lengthening & Reconstruction 2019 5(1):4-10 Objectives: Arthrogryposis multiplex congenita is a congenital condition characterized by joint contractures with resulting foot deformities and gait deviations. The aim of this study was to describe gait deviations and foot deformities in children with arthrogryposis objectively and quantitatively with detailed gait analysis, including multisegment foot kinematics and foot pressure analysis. Materials and Methods: Children with arthrogryposis were evaluated retrospectively. Their data were compared to data from typically developing children. Comprehensive data presented include results of a full gait analysis with multisegment or single-segment foot kinematics, kinetics, pedobarograph, physical examination, and radiographic measurements. Children were grouped by age, orthotic use, and history of surgical intervention. Results: Forty-two children with arthrogryposis (2–20 years old) were reviewed. Physical examination and kinematic data showed that children walked with a crouched gait; exhibited stiffness in the hips, knees, and ankles; and showed limitations in their gross motor functioning. Power generation was low at the ankle and was high at the hip. Multisegment foot kinematics revealed stiffness in hindfoot plantar flexion and residual forefoot adduction. Foot pressure showed reduced heel impulse, excessive midfoot contact, and overall varus foot position. Categorization by age revealed greater stiffness at the hips and knees in older children. Children with knee–ankle–foot orthosis showed the most stiffness. Conclusions: Three-dimensional motion analysis and plantar pressure measurements are able to quantify the empirical observations of children with arthrogryposis walking with a crouched, stiff gait and having foot deformities. The use of these technologies in conjunction with clinical examination and functional tests is, therefore, recommended to monitor treatment efficacy and natural progression of gait deviations and joint deformities in arthrogryposis.

Use of hexapod frame to gradually correct congenital and acquired forearm deformity Lauren Elisabeth Wessel, Hayley A Sacks, Duretti Teferi Fufa, Austin T Fragomen, S Robert Rozbruch Journal of Limb Lengthening & Reconstruction 2019 5(1):11-16 Introduction: Forearm deformity affects patients with Multiple Hereditary Exostosis (MHE), Ollier's disease, and other various congenital deformities as well as those with physeal growth arrest secondary to trauma. Acute correction of such deformities is complicated by risk of neurovascular compromise and as such, techniques that allow for gradual deformity correction are of great interest in this clinical setting. We hypothesized that the use of hexapod frame would allow for reliable correction without neurovascular compromise. Methods: This retrospective, case series reviewed all patients who underwent osteoplasty of the radius and ulna between January 1, 2008, and December 31, 2017, among two surgeons. Patient demographics, comorbidities, radiographic parameters, external fixation index (EFI), and complications were recorded from chart review. Six patients presented with a diagnosis of MHE, two patients with a diagnosis of Ollier's disease, one with short stature homeobox (SHOX) deletion, and one with physeal growth arrest. Results: Of the ten patients identified, the rate of lengthening proceeded between 0.5 and 1 mm/day with an average EFI of 3.7 months/cm for the radius and 7.4 months/cm for the ulna. Average radius and ulna lengthening were 1.5 cm and 2.7 cm, respectively. Average radial bow preoperatively was 1.7 cm with a location of the maximal radial bow at an average of 61% from the radial tuberosity. Radial bow was corrected to 0.6 cm on average with a location of the maximal radial bow at an average of 64%. Neither patients exhibited nerve deficit nor neurapraxia at the conclusion of treatment. One fracture occurred after frame removal, which was treated with open reduction and internal fixation. Conclusion: Hexapod frames can be used to safely correct forearm deformities without neurovascular compromise.

A technique for hip arthrodesis using a multiplanar external fixator and transarticular screws Joshua N Speirs, Djuro Petkovic, John E Herzenberg, Scott C Nelson Journal of Limb Lengthening & Reconstruction 2019 5(1):17-21 Background: To determine the clinical and radiographic results of hip arthrodesis using external with minimal internal fixation. Methods: A consecutive series of ten patients underwent hip arthrodesis using combined multi planar external fixation and transarticular screws. Operative parameters and radiographic and clinical results were retrospectively analyzed for each patient. Results: Mean estimated blood loss was 490 mL. At an average follow-up of 47.5 months, Harris Hip Score averaged 83.4. Mean postoperative measurements included anatomic axis hip adduction of 9°, hip flexion 22.2°, and leg length discrepancy 20.3 mm. Average adduction drift of 8.3° was noted after fixator removal. There were no nonunions. Conclusion: The described technique for hip arthrodesis reliably fused the hip in a favorable position requiring a less invasive approach with lower blood loss. Additional advantages include multiplanar stability, potential for hip position adjustment postoperatively and preservation of hip abductors; in case of future hip replacement. Level of Evidence: This was a Level IV, case series.

Posttraumatic distal radius growth arrest treatment by ilizarov distraction osteogenesis Mahmoud A El-Rosasy, Abdullah A Nada, Mohamed Romeih Journal of Limb Lengthening & Reconstruction 2019 5(1):22-26 Background: Posttraumatic distal radius growth arrest is a challenging orthopedic condition, due to a combination of several deformity components including shortening, angulation and joint line malorientation. It can drastically affect both the function and the shape of the wrist and forearm. However, little has been written about this problem. Patients and Methods: In this retrospective study, seven adolescent patients were operated in our department. All had posttraumatic distal radius growth arrest that resulted in shortening with or without angular deformity. The management consisted of distal radius metaphyseal osteotomy and distraction osteogenesis using Ilizarov frame. The patients' ages ranged from 12 to 15 years. The mean shortening of the radius was 2.2 cm. Correction was assessed radiologically (radial length, joint orientation line) and clinically by Mayo Wrist Score. Results: The mean external fixation time was 2.4 months (range from 2 to 3 months). The mean total treatment time was 12.3 weeks (range from 12 to 16 weeks). The mean bone healing index was 1.13 months/cm. The Mayo Wrist Score mean was 85.7 (range: 75–95) points. According to the Mayo Wrist Score, results were excellent in three patients, good in three patients, satisfactory in one patient with no unsatisfactory results. Superficial pin tract infection occurred in all cases and was managed without further sequelae. Conclusion: Distraction osteogenesis, by Ilizarov external fixator, addresses the sequelae of posttraumatic distal radius growth arrest by restoring the normal anatomy in a controlled biological manner, without further grafting procedures through a minimally invasive approach.

The “Sleeper” plate: A technical note Muayad Kadhim, Ahmed I Hammouda, John E Herzenberg Journal of Limb Lengthening & Reconstruction 2019 5(1):27-32 Context: A tension band plate (TBP) for guided growth of angular deformity is typically removed after the deformity is corrected to prevent overcorrection. After TBP removal, rebound deformity may occur, necessitating reinsertion of a new TBP. Aims: This study aims to describe a minimally invasive technique for partial removal of TBP to deactivate the TBP when correction is achieved. The technique also allows minimally invasive reactivation of the construct when desired. Settings and Design: This is retrospective case series study. Subjects and Methods: The surgery consists of removing the metaphyseal screw only and keeping the plate and the epiphyseal screw. The procedure is done through a 1-cm incision with fluoroscopy. The metaphyseal edge of the plate is elevated off the bone to break the seal between it and the bone, to prevent tethering. Bone wax is injected in the empty plate hole to prevent bone ingrowth, as this could also cause re-tethering. In case of a subsequent rebound deformity, the metaphyseal screw may be re-inserted percutaneously to reactivate (“wake-up”) the “sleeper plate”. Statistical Analysis Used: Descriptive analysis. Results: The sleeper plate technique was done in eight patients (three males and five females). Four patients had genu valgum and four had genu varum. Mean age at surgery was 11 years (7–14 years). Metaphyseal screw removal was done in a mean period of 14 months (range from 7.4 to 22 months) after the index procedure. Rebound of the deformity happened in three patients and required plate reactivation by reinsertion of the metaphyseal screw. Conclusion: The sleeper plate technique is a minimally invasive procedure and can be an alternative to the removal of the whole TBP construct if the patient is skeletally immature with a risk of deformity rebound. Level of Evidence: IV

Hexapod orthogonal periarticular slack-wire stabilization technique: Surgical tip for accurate orthogonal metaphyseal frame mounting Henry Sean Pretorius, Ryno Du Plessis, Nando Ferreira Journal of Limb Lengthening & Reconstruction 2019 5(1):33-36 Introduction: The use of hexapod circular external fixators in the treatment of various orthopedic conditions has become more common in recent years. One of the principle mounting requirements is that the fixator is orthogonally aligned to the mechanical axis of the limb. This creates the optimal mechanical environment for bone formation as any forces exerted on the fixator are transmitted as axial forces to the limb while eliminating unwanted motions such as rotation and shear. We describe a method to reliably obtain orthogonal mounting of periarticular rings during hexapod circular external fixator application. The technique is fast, accurate, and uses components readily available on all hexapod external fixator systems. Methods: The “hexapod orthogonal periarticular slack-wire stabilization (HOPSS) technique” uses a untensioned/slack wire as the second fixation element following the transverse reference wire. A wire fixation bolt is attached to the ring, and a second wire (slack wire) is placed through the wire fixation bolt to allow insertion in an antero–posterior direction. The wire is advanced through the near cortex and onto the far cortex after which the wire fixation bolt can be tightened and a final image intensifier check can be done. The technique can be used for the application rings to the metaphysis of long bones. Discussion: Orthogonal mounting for Ilizarov all-wire frames has been a crucial part of the surgical technique and has long been accepted as it promotes axial micromotion that supports callus formation and union and eliminated parasitic motion at the bone ends. The described technique uses readily available instruments and components to assist with perfect orthogonal mounting. Conclusions: The hexapod orthogonal periarticular slack-wire technique is a simple method for obtaining more accurate orthogonal mounting. It is quick and effective and does not require any additional equipment.

Fibular osteotomy strategies and techniques: A survey of the limb lengthening and reconstruction society membership David Johnson, Satbir Singh, Mikhail Samchukov, Alexander Cherkashin, Christopher A Iobst Journal of Limb Lengthening & Reconstruction 2019 5(1):37-40 Context: Fibular osteotomy is a necessary element of most tibial procedures, but there is no consensus on the ideal location, orientation, or technique for the procedure. Aims: We surveyed limb reconstruction surgeons to learn how often a fibular osteotomy was performed, details of surgical technique, and varying intraoperative parameters. Settings and Design: A cross-sectional survey was sent to all members of the Limb Lengthening and Reconstruction Society – North America, as well as experienced international limb reconstruction surgeons. Subjects and Methods: The survey contained 12 questions regarding fibular osteotomies in the setting of limb reconstruction surgery. Responses were not specific to any particular procedure. Data were collected on how often a fibular osteotomy was performed, details of surgical technique, and varying intraoperative parameters. Statistical Analysis Used: Statistical tests employed include Kruskal–Wallis, Mann–Whitney U, Chi-square, and Fisher's exact tests where appropriate. Results: A total of 149 surveys were returned. Most surgeons perform fibular osteotomy at the junction of middle and distal thirds or in middle third, 36.9% and 31.5%, respectively. The least common location for osteotomy was in the proximal third of fibula (4%). The most common method for creating fibular osteotomy was with an oscillating saw (48.3%), followed by drilling holes and using an osteotome (45.0%). The average reported time for the completion of osteotomy was 13 ± 7.2 min, with shortest average time reported for surgeons who perform osteotomy in the distal third (11.3 ± 6.4 min) and longest for those at proximal third (14.6 ± 10.3 min). The most common closure technique was that of layered closure (97%). Conclusions: Most surgeons perform a transverse osteotomy occurring at the junction of the middle and distal thirds of the fibula. The osteotomy is most commonly performed at the beginning of the case using either an oscillating saw or multiple drill holes and osteotome. Continued research is needed to determine the specific indications for performing a fibular osteotomy, if the anatomic location of the fibula osteotomy is important, and when a segment of the fibula should be removed.

Reconstruction of massive tibial defects after resection of adamantinoma with double-level distraction osteogenesis Eugenia Schwarzkopf, Molly Friel Klima, Abraham Trabulsy, Daniel Eduardo Prince Journal of Limb Lengthening & Reconstruction 2019 5(1):41-46 Adamantinoma is an extremely rare disease that typically involves large portions of the tibial cortex requiring extensive resections, for which a myriad of complex reconstructions have been performed with varying success. Techniques of bone regeneration utilizing internal or external methods are used to manage bone defects in trauma, infection and congenital deformities, but less commonly used for oncological osseous defects. We present four cases of patients diagnosed between 2015 – 2018 with tibial adamantinoma in a background of osteofibrous dysplasia who underwent distraction osteogenesis reconstruction via a double level cable bone transport. In all cases wide resection of the adamantinoma was performed to achieve negative surgical margins and the defect reconstructed by double level bone transport using Ilizarov cables guiding distraction osteogenesis. Bone transport occurred at a combined mean rate of 2 mm per day: 1mm proximally and 1mm distally. Full weight-bearing and ambulation were encouraged immediately. The mean age at time of surgery was 18 years (14 – 25) and the mean size of tibial defect was 23 cm (17.5 – 26). The mean time in external fixation was 8.5 months (6 – 12 months), yielding a mean External-Fixation Index (EFI) of 0.44 month/cm (0.3 – 0.69). The average MSTS score at mean follow time of 20 months (13-27 months) is 28 (26 – 30). At last follow up all patients are infection free and without evidence of disease. Despite typical complications of prolonged external fixation, all four patients have excellent results with an average MSTS score of 28. The mean EFI of 0.44 month/cm is well below the standard EFI of 1 month/cm, suggesting this subset of patients may require less external fixation time than previously considered. The case series supports the hypothesis that double level D.

A unique case of a genu valgum deformity manifested in Hallermann–Streiff syndrome Abdulmuhsen N Alshammari, Aliaa F Khaja, Mohammed A Alabdullatif, Thamer S Alhussainan Journal of Limb Lengthening & Reconstruction 2019 5(1):47-50 Hallermann–Streiff syndrome (HSS) is a relatively rare genetic disorder causing mainly dysmorphic craniofacial features. Very few cases are reported in the literature, none of which reported lower limb skeletal deformity. The main objective of this paper is to report a skeletal manifestation of HSS and the outcomes of its surgical treatment. A patient with HSS was evaluated, treated with corrective surgery, and followed up at the authors' hospital. The standard guidelines for genu valgum correction by guided growth method were applied on both limbs using an 8-plate system at the distal femurs. Subjective and objective satisfaction was achieved with the return of functional status. The surgical treatment was successful, and the patient went back to the potential functional level without significant impairment.