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Year : 2015  |  Volume : 1  |  Issue : 5  |  Page : 1-117

Proceedings of ILLRS Congress Miami 2015 Combined Meeting Of ILLRS, LLRS And ASAMI-BR

Date of Web Publication5-Nov-2015

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How to cite this article:
. Proceedings of ILLRS Congress Miami 2015 Combined Meeting Of ILLRS, LLRS And ASAMI-BR. J Limb Lengthen Reconstr 2015;1, Suppl S1:1-117

How to cite this URL:
. Proceedings of ILLRS Congress Miami 2015 Combined Meeting Of ILLRS, LLRS And ASAMI-BR. J Limb Lengthen Reconstr [serial online] 2015 [cited 2019 Jan 20];1, Suppl S1:1-117. Available from: http://www.jlimblengthrecon.org/text.asp?2015/1/5/1/169104

#1: Is subtalar fixation in superankle reconstruction able to hold foot and ankle correction in fibular hemimelia? Preliminary results

Monica Paschoal Nogueira (Brazil),
Tatiana Guershman, Fernando Farcetta.

Question: Is subtalar fixation in superankle reconstruction able to hold foot and ankle correction in fibular hemimelia? Preliminary results.

Method: Ten children undergoing 12 superankle procedures consisting on fibular anlage ressection, peroneal and achillis tendon lengthenings, and supramaleolar, or subtalar or both supramaleolar osteotomies, (fixed with 2 plantar kirshner wires ) and after that application of circular external fixator baby Ilizarov type for 5 cm lengthening and valgus and procurvatum diaphyseal correction. Foot and ankle correction after external fixator removal was evaluated.

Results: In 5 patients, supramaleolar fixation was removed after 6 weeks, during deformity correction, and all of them had lost subtalar correction when evaluated after external fixator removal. In the other 5 patients, the Kirshner wires were maintained until the end of lengthening and deformity correction. They were removed together with the external fixator. Foot and ankle correction were maintained in those feet.

Conclusion: Subtalar and ankle fixation should be maintained until the end of lengthening and deformity correction to avoid loss of correction, mainly in the subtalar joint.

#2: Ankle Reconstruction Procedures in Tibial Hemimelia

Yehia Rady
(Egypt), Mohamed Y. Rady

Question: TibialHemimelia is a longitudinal deficiency of the tibia which could be either complete or partial. Its prevalence is estimated to be one per million live births; and 30% of the available cases are thought to be affected bilaterally. TibialHemimelia may present as an isolated anomaly or be associated with variety of skeletal or extra skeletal malformations. Tibial Hemimelia treatment strategy should be directed to reconstruct weight-bearing bone with a controlled knee function, reconstruct articulation between the leg bone and the foot, equalize the limb length discrepancy, and correct any foot deformity. The aim of this work is to reconstruct articulation between the leg bone and the foot at different types of Tibial Hemimelia patients.

Methods: This work material included 31 cases with different types of Tibial Hemimelia, 18 boys and 13 girls. Respectively, 13, ten, and eight cases were affected on the left side, right side, and bilaterally. The used procedures were selected separately according to each type. For example, apply traditional surgical techniques to centralize the fibula at ankle, reconstruct deficient ligaments, . etc. In addition, specific Ilizarov techniques were used to centralize the fibula, correct foot deformities, and overcome limb length discrepancy that might be occurring.

Results & Conclusion: The results obtained were satisfactory in all of the cases. Accepted range of dorsi and planter flexion at the calcaneo-fibular articulation was achieved with no varus or valgus range. The main existed complication, other than those associated with the use of Ilizarov apparatus, was infection in one case that was resolved with the appropriate treatment. The achieved results are encouraging.

#3: Hip Subluxation and Dislocation under Femoral Lengthening predisposing factors

Micha Langendoerfer (Germany),
Jessica Masullo , Thomas Wirth

Question: Hip subluxation and dislocation are rare but serious complications possibly encountered under femoral lengthening in patients with Congenital Short Femur. The question was to identify predisposing risk factors and additional risk signs during the lengthening process.

Methods: We report on 3 cases of hip subluxation and dislocation, which occurred in a 15 year period from 1999 to 2014 in a collective of 43 patients with femoral lengthenings due to Congenital Short Femur. Various devices such as monolateral and circular frames as well as intramedullary lengthening devices were used. Retrospectively the cases were analyzed regarding predisposing factors such as acetabular dysplasia and configuration of the proximal femur and overall prospective length discrepancy. Also the amount of actual bone lengthening, development of contractures and compromising incidents such as trauma were taken into account.

Results & Conclusions: In all cases of hip (sub-) luxation the acetabular dysplasia was very moderate with an average AC angle of Varus deformity of the proximal femur seems to be a strong predisposing factor, seemingly more important than preexisting acetabular dysplasia. In addition there is a strong correlation of joint contractures under femoral lengthening, acetabular dysplasia and the risk of hip dislocation. Nevertheless even with the knowledge about these risk factors and close monitoring during the actual lengthening process, secondary hip dislocations may happen also at later stages in the treatment or may be triggered by trauma.

#4: Treatment of Congenital Coxa Vara Using Ilizarov External Fixator

Yehia Rady (Egypt)
, Mohamed Y Rady

Question : Fixation by plate and screws is unreliable in the treatment of Congenital Coxa Vara, as it does not hold the proximal fragment well and hip spica plaster cast is usually needed. Toggling of the screws at the holes of the plate, in addition to the persistent pull of the short contracted glutei allow partial or complete recurrence of the deformity. In addition, Pauwels Y shaped and other types of osteotomies must be planned preoperatively by drawing the appropriate lines on a tracing of the A-P radiograph, which is difficult to be applied intraoperatively. The greater trochanter needs to be pulled down with bone hook, and after correction the position is held by tension band wiring and hip spica for 6 weeks. Delayed treatment result in deformities and pseudoarthrosis that cannot corrected by the traditional techniques. The objective of this work is to evaluate treatment of congenital coxa vara by oblique sub-trochanteric osteotomy and Ilizarov frame fixation.

Method : The material included 26 patients with infantile coxa vara, 16 boys and 10 girls. Their age is ranged from 5 to 16 years with an average of 6.54 years. The right side was affected in 11 cases, the left side was affected in nine, and six patients suffered the disease bilaterally. The ratio of unilateral to bilateral cases was 2.5:1. The main indication for surgery is neck-shaft angle measures 90 or less and an epiphyseal-Hilgenreiner angle measure is 60 or more.

Results : The results were satisfactory in 24 cases. One patient needed bone graft due to the delayed union at the site of the osteotomy, another one needed bone lengthening; these two cases suffered limited range of hip movements.

Conclusion : Treatment of infantile coxa vara by subtrochanteric osteotomy and Ilizarov external fixation allows correction of severe angle deformities and continuous angle adjustment until the complete union is achieved. So, there was no need for another surgical interference. These results encourage us to advocate this method of treatment in congenital Coxa-Vara at any age.

#5: Prevention of recurrence of tibia and ankle deformities after bone lengthening in children with type II fibular hemimelia

Dmitry Popov (Russia),
Arnold Popkov, Anna Aranovich

Question: This study was aimed to evaluate development of the tibia after Ilizarov lengthening and deformity correction depending on performing or not the simultaneous resection of fibular anlage in children with fibular aplasia type II, who did not undergo early surgery.

Methods: The study analyzes results of reconstructive treatment in 38 children at the age over 4 years. Two groups of children are compared: bifocal tibial lengthening with the Ilizarov device (group I) and bifocal lengthening associated with resection of the fibular anlage (group II). The results were estimated in 12 months and in long term exceeding 3 years.

Results: Radiological data of measurement of the aLDTA show surgical correction of deformities achieved in both groups. During the further limb growth a tendency to normalization of the aLDTA is observed only in the group II. Quick relapse of the angular deformities of the tibial shaft in the first group occurs mainly during further growth of the limb regardless to the complete correction while treatment. On the other hand there were no recurrence of diaphyseal deformities in the group II.

Conclusion: In children with congenital fibular deficiency of type II at the age of 4 years old the bone lengthening and deformity correction should be associated with fibular anlage resection. That approach improves conditions for distal tibia development and prevents or decreases significantly the recurrence of deformities of the tibia and ankle joint in long term follow up.

#6: Management of Fibular Hemielia (congenital Absence of Fibula) Using Ilizarov Method in Sulaimani

Omer Ali Rafiq Barawi (Iraq)

Fibular hemimelia is the most common congenital deficiency of the long bones, which is characterized by a wide spectrum of manifestation ranging from mild limb length inequality to sever shortening with foot and ankle deformities and associated anomalies.

Method: to preserve the limb from amputation, achievement equals limb length, and a functional plantigrade foot and ankle.

Patients and Methods: This is a prospective study done on 40 limbs in 32 patients with fibular hemimelia, during the periods of March 2010-Janiuary 2014. Male to female ratio is 24:8, their age ranged from 2-16 years. Reconstruction of ankle and foot done and equalization of the limb using Ilizarov frame.

Results: The results assessed using Association for the Study of Applications of Methods of Ilizarov, ASAMI scoring system. The final results were; Failure rate: 2 limbs (5%), Poor: 2 limbs (5%), Fair: 2 limbs (5%), Good: 8 limbs (20%), Excellent: 26 limbs (65%)

Conclusion: The Ilizarov method is an attractive alternative method of amputation for selected fibular hemimelic patients having three or more toes who are refusing amputation.

#7: What is the role in rehabilitation in young children undergoing limb lengthening? preliminary results in fibular hemimelia

Monica Nogueira (Brazil),
Sandra Prado, Cristina Reuter, Rodrigo Mota.

Question: What is the role in rehabilitation in young children undergoing limb lengthening? preliminar results in fibular hemimelia.

Method: Ten children undergoing 12 limb lengthening procedures after reconstruction of the ankle (Paley superankle approach) were treated in an intensive Physical therapy protocol including 1 hour a day, 2 days a week program for 3 months. A program based on the approach of fascial manipulation treats limb lengthening as an acute fibromyalgiauntil active lengthening ends. A combination of techniques, including fascial manipulation therapy, pool therapy, proprioception and specific exercises prevent contractures or actively treat them before they get rigid. A painless approach is important, to avoid inflamatory changes in soft tissue and allow for limb lengthening in children with less distress.

Results: Patients reffered important improvement of both confort and range of motion after therapy, and could sleep well, and even bowel function was improved. Temperature of the limb was changed after fascial manipulation, and muscles were palpable softer and more relaxed after each session. Knee contractures were avoided in all but one patient, that had a anterior subluxation of the knee, treated by surgery. Patients cooperated with the protocol, and had a good personal relation with therapist and family. Psychological support is also improved, once families have more time in treatment being oriented and heard. After 100 days lengthening, limb lengthening were resumed and patients could have a most relaxed protocol, 2 or 3 times a week, until able to walk and move around with no difficulties.

Conclusion: Fascial approach rehabilitation in limb lengthening in young children based on treating the lengthening myofascial syndrome or acute fibromyalgia should be recommended, for its effectiveness, and could be confortable and relaxing for patients. Reducing distress is crucial for this first lengthening, specially because they are small children and very often have more procedures to go through in future.

#8: Limb Reconstruction Procedures in Tibial Hemimelia

Mofakhkhrul Bari (Bangladesh)

How to treat- 1. Reconstruct weight bearing bone with controlled knee bone function 2. To equalize the LLD 3. To correct any ankle and foot deformity and make the foot plantigrade

Methods: 12 cases of different tibial hemimelia, 8 boys and 4 girls were treated from 1995 to 2013 at NITOR and Bari-Ilizarov Orthopaedic Centre. In 9 cases the right side was affected, the left side in 2 cases and bilateral affection in 1 case. The procedure that was used is the surgical technique (Brown procedure) to centralize the fibula at the knee and ankle with stabilization by Ilizarov technique. Sometimes reconstruction of knee extensor mechanism and deficient ligament reconstruction in ankle is needed. Ilizarov technique is absolutely needed to correct the knee, ankle and foot deformities and to overcome the LLD.

Results: The results that we obtained were very much satisfactory in all cases. Complications are a fact of life that every orthopaedic surgeon has to face. In my series 1 refracture was observed and that was treated by reapplication of Ilizarov and union was achieved.

Conclusion: Ilizarov technique is a reliable and adaptable technique by which we can correct deformity and gain limb length simultaneously by intelligent meticulous followup.

#9: Fibular Hemimelia

Mofakhkhrul Bari (Bangladesh)

How to treat- 1. Reconstruct weight bearing bone with controlled knee bone function 2. To equalize the LLD 3. To correct any ankle and foot deformity and make the foot plantigrade

Methods: 18 patients (12 males and 6 females) treated because of type II Aichterman -Kalamchi fibular hemimelia. 12 segments were lengthened (8 tibia, 4 femur). The tibia was lengthened twice in six patients, simultaneous tibia and femoral lengthening in 4 cases. The age at surgery ranged from 2-15 years (mean 8 years); mean shortening was 7.5 cm (ranged from 3-15 cm). Valgus deviation in 12 patients, in 2 of them combined with rotational deformity. Ilizarov frame used for tibial lengthening in 10 segments. Hind foot stabilization was done in all the patients. Femoral lengthening was done in 4 patients.

Results: Lengthening achieved from 3-9 cm. Axial deviation (valgu8, detorsion 4) was corrected in 8 patients.

Conclusion: Treatment of fibular hemimelia is very difficult, particularly lengthening and it is technically demanding, required multiple surgeries and entails a lengthy procedure with many complications anticipated.

#10: Lengthening for Congenital Femoral Deficiency in adult: A case report

Narutaka Katoh (Japan),
Nobuyuki Takenaka, Motoyuki Takaki, Shota Harada, Yoshinobu Watanabe, Takashi Matsushita

Question: Congenital femoral deficiency is still difficult disease to treat. Lot of cases was chosen amputation.

Methods: We introduce one case of congenital femoral deficiency in adult treated using the Ilizarov method.

Case: 21 y. o. female. She had right femoral deficiency (leg length discrepancy 220 mm, with pseudoarthrosis) and scoliosis (operated in childhood)

Results: We lengthened her femur 198 mm for 12 months, maturation period was 10 months. Pseudoarthrosis of distal femur was remained as knee function.

Conclusion: The Ilizarov method was very useful for lengthening of congenital femoral deficiency, and kept her knee function by remaining pseudoarthrosis.

#11: The outcomes of femur lengthening using orthofix fixator.

Rim Boussetta (Tunisia),
Rafil Elafram, Haythem Rjeb, Sami Bouchoucha, Walid Saied, Mohamed Nabil Nessib

Question: Congenital short femur is a very rare and complex defect ranging from simple hypoplasia to total absence of the femur. Lengthening the femur with an external fixator is commonly practiced for a wide variety of pathologies. We studied the advantages and complications of femur lengthening using orthofix fixator.

Methods: We present a retrospective review of a series of 13 consecutive lengthening in 13 patients with congenital short femur using the Orthofix technique performed between 1999 and 2013.

Results: The mean follow up was 13 years (from 2 to 15 years). The mean residual inequality was 2 centimeters. The patients had the fixator for a mean period of 05 months (lengthening-consolidation index 01 centimeters per 01 month) 04 patients had femoral fracture after the removal of the fixator. They were treated by plate, cast or pining. The functional results were satisfactory with good knee range motion.

Conclusion: Lengthening the femur with an external fixator is commonly practiced for a wide variety of pathologies. The main complication of this technique is the femur fracture after the removal of the fixator.

#12: Outcome of limb lengthening in fibular hemimelia Versus amputation

Rim Boussetta (Tunisia),
Rafik Elafram, Haythem Rjeb, Sami Bouchoucha, Walid Saied, Mohamed Nabil Nessib

Question: The decision to recommend either reconstructive or ablative surgery to the parents of children with fibular hemimelia is difficult and debatable in the orthopaedic literature.

Methods: We retrospectively reviewed the cases of eight patients (eight limbs). Five of these children were treated by Ilizarov method and three patients were amputed. The hemimilia were type IA and II. We used the previsionnel inequality as a guide to decide on the treatment option.

Results: All patients who had limb lengthening were ambulatory and mobile with acceptable leg lengths and limb alignment at the time of last follow-up. They all have ankle realignment. The mean follow up was 15 years (from 8 to 20 years). All of them were satisfied with the outcome. Knee stiffness and septic complications were the main problem through and after the lengthening. The patients who underwent amputation had orthesis and were satisfactory with less complication.

Conclusion: We conclude that limb reconstruction in children with less severe forms of fibular hemimelia is a good option.

#13: Avascular necrosis of the capital femoral epiphysis of the long (normal) leg in patients with congenital femoral deficiency: A report of three cases

hn G. Birch (USA), Timothy Brown, Lane Wimberly

Question: Does Avascular Necrosis Occur in the Long (Normal) Capital Femoral Epiphysis of Patients with Contralateral (Short Leg) Congenital Femoral Deficiency?

Methods: During routine longitudinal evaluation of patients with congenital femoral deficiency in our limb deficiency clinic, we incidentally noted avascular necrosis in the capital femoral epiphysis (i.e., Perths-like) changes in the long (i. e. normal) leg in three patients. We then carefully reviewed in detail the case history, clinical course, radiographs, and (when available) MRI of these three patients.

Results: There were two males and one female. All had congenital femoral deficiency involving the right leg, with the left being apparently normal. Patient 1 (male) developed Perths-like changes in the contralateral left leg. MRI demonstrated typical appearance of avascular necrosis of the capital epiphysis. Because of his young age and lack of symptoms or hip motion restriction, he has been treated expectantly to date. Patient 2 (male) has peculiar facies, foot abnormalities, but evaluation including genetic, did not identify any specific diagnosis, other than the congenital femoral deficiency. On our initial evaluation at age four, it was event that radiographs taken at age three revealed unrecognized Perths-like changes in the left hip. He, was asymptomatic, without restriction of motion in the left hip, and has been treated expectantly to date. Patient 3 (female) was treated with a Pavlik harness as an infant. At age 6 she underwent reconstructive surgery for right hip dysplasia, including 8 weeks in a 1 spica cast. Shortly after elective implant removal from the right upper femur, she complained of left leg pain, and was subsequently noted to have Perths-like changes in the capital epiphysis. She had approximately 6 months of hip discomfort, but with resolution of symptoms and improved motion, her family declined treatment. She has postoperative radiographic changes in the right hip, consistent with a much milder avascular necrosis.

Conclusion: We presume that the occurrence of avascular necrosis of the capital femoral epiphysis in these patients represents a higher than expected rate compared to the at-risk general population estimates of Perths disease (approximately 1:750 males, 1:3000 females) This in turn may be an indication that patients with congenital femoral deficiency may have an altered proximal femoral vascular anatomy putting them at increased risk for avascular necrosis, or other coagulopathy increasing the risk for avascular necrosis of the femoral capital epiphysis.

#14: Complete, congenital fibular deficiency can be treated by early planned series of moderate lengthening

Badelon, Olivier (France)

26 years ago, the author had an initial experience with the technique of callotasis in young children, which suggested a potential expansion of indications for lengthening.

Methods: Five patients with unilateral involvement have been treated since 1989. The femorotibial inequality was 54.8 (35-80) mm at one year of age, with a discrepancy of 19.4% (13-30). The calculated shortening at maturity was 15.6 (10-24) cm, not including the foot. A posterolateral release of the foot was performed before walking age in 3 patients, with an osteotomy of the distal tibia in 2 and an arthrodesis of the ankle in one. The lengthening was begun at 2 years of age (1.6-2.8) for the tibia, and at 4 years of age (3.5-4.4) for the femur. There were 5.6 lengthening (3-7) per child: 21 of the tibia and 7 of the femur, with an angular correction of 10 to 40 degrees without bone resection. The callotasis technique was used with an external fixator of Ilizarov in 2 and an Orthofix in 26, without weight-bearing. Lengthening per bone segment ranged from 15 to 40 mm (12- 20%). The interval between each was 9-23 months. All the children had an epiphysiodesis of the contralateral knee by 12 years of age (10- 13).

Results: No articular disturbances were observed. Complications occurred only in the lengthened bone: 7 bowings, 5 fractures and one chronic infection in the hole of a pin. A genu valgum of 20 was treated by a simple osteotomy of the upper tibia in one. During childhood they had a normal lifestyle without any effect on schooling. At the end of the surgical program the femorotibial inequality was 3 mm (+5/-10) with a limb discrepancy of 38 mm (-15/-45) because of the foot. They had a genu valgum of 9 degrees (5/12). The foot was in a lateral position in 3 but functional in all. All of them had normal shoes with a compensation of 12 mm (8/20). As of today the patients averaged 23 years of age (23-25.6). They have no bad memories of their past treatment. They are very happy to have their leg safe and no prosthesis.

Conclusion: It is possible to propose a conservative treatment if the lengthening program begins before 3 years of age when the predicted femorotibial inequality at skeletal maturity is less than 25 cm, and if the foot is or will be functional after surgical release.

This step-by-step lengthening program should be considered in young children. It is safer than the attempted greater lengthening in older children.

#15: Foot correction with distraction method in the type II - Fibular hemimelia in chldren

Alexander Kirienko (Italy)

The study aimed to demonstrate the possibilities of Ilizarov distraction method for the simultaneous limb lengthening and the correction of complex foot and ankle deformities in fibular type II hemimelia in children who did not undergo early surgery. With the distraction method all elements of deformity of the foot can be controlled and corrected. Some mobile foot may be treated with closed method, but the patients with foot bone fusion and severe dislocation should be treated with osteotomy correction or arthrodesis.

Methods: 36 very complex foot deformities were treated in children at the age over 5 years. To 6 of them simultaneously with femur and tibia lengthening and deformity correction in different level were performed closed method of correction of valgus equinus foot. To the other 26 patients were performed open surgery with the V, Y or L shape osteotomy to separate talar-calcaneal, talar navicular orcalcaneal-cuboidfusion. The range of age of the patients in the beginning of treatment was 5 to 12, the mean age was 7,2. The staged procedure were performed for all of those patients. In 4 the cases with dislocation of the ankle joint were performed arthrodesis.

Results: The mean treatment time for one step surgery was 5,1 months. The follow up period was from 12 month to 20 years. We had complication in our 22 patients including pin tract infection in ten, wire breakage in seven, 2 patients had claw toe. No nerve or vascular damage was seen. In all cases a plantigrade position of the foot was achieved. The mean final lengthening was 14,6 cm (range: 6-25). The lengthening index was 0.78 mo/cm. Successful result was obtained in 34 patients and poor in 2 due to partial recurrent deformity of the foot in later age.

Conclusion: The Ilizarov technique for bone lengthening and correction deformity of the tibia and simultaneous correction of the complex valgus equnus foot shown satisfactory results in the treatment of all types of congenital fibular hemimelia and should be considered an valid alternative to amputation, as measureable functional improvement may be achieved. The severity of this disease coupled with the difficulty in predicting long-term results, demands attention to technical issues and requires good communication between the surgeon, patient, and family.

#16: Congenital pseudarthrosis of the leg: Familial case report

Lettreuch Abdel Raouf (Algeria)
, Saighi Bouaouina Abdeltif, Aissia Ahmed, Cherifi Hayat

Question : familial congenital bone observation: possibility of two clinical forms? Congenital pseudarthrosis of the leg is relative rare affection; this uncommon type of pseudarthrosis is one of the most difficult conditions to treat the frequency of the neurofibromatosis is estimated between 1/4000 and 1/5000 births. Research family history is important, it is positive in 60% of the cases, bone manifestation of NF1 neurofibromatosis correspond to primitive dystrophic bone lesions, scoliosis was the first skeletal change next skeletal change in literature are abnormalities of growth and sub periosteal bone cystes Mac Carrol and Ducroquet reported in 1937 the presence of congenital pseudarthrosis of tibia in neurofibromatosis, Beber, Green , Rudo were described the presence of congenital bowing and relationship with neurofibromatosis. The familial neurofibromatosis exists but the existence of two different forms in the same family has not been reported in the literature.

Method : it is the story of two brothers aged 20 and 10 who have a one congenital curvature followed from birth with a conservative treatment to bone maturation and the other with a leg fracture nonunion follows at walking age needed six times surgeries to achieve consolidation.

Results : Its about a child 18 months old who consult for antero-lateral deformation of the left leg, the curvature had an angle of 20 classified type 1 according to Crawford classification, conservative treatment with bracing has been recommended with clinical and radiological regular supervision every 3 months. The curvature worsens at the age of 5-6 years then stabilizes around the age of 8-9 years, leg protection was continued until bone maturity age (16-17) . At last follow up the child was well, with tolerated curvature without function impact The second case is about his brother who broke his leg at 1 year old who had a antero-lateral congenital curvature, progressing to non-union type 4 classified according to Crawford, consolidation was observed after 6 surgeries (resection of bone and grafting, Ilizarov technique Masquelet technique, nailing transplant and finally a thickening graft) The child is aged 10 years with 4 years of follow up, with a shortening of 1 cm and half. Both children have continued their school with lighter disturbance to the youngest because of frequent hospitalizations.

Conclusion : The existence of two forms of clinical familial different bone manifestations of neurofibromatosis in the leg seems rare in literature, management of congenital curvature of the legs also rarely found in the literature especial with a conservative treatment up bone maturation, the fracture occurred in young brother and his expensive treatments for 6 years with several surgical procedures lets us conclude the importance protected congenital curvature of the fracture by various processes to avoid heavy treatment of nonunion sometimes need several years.

#17: Management of Congenital Pseudarthrosis of the Tibia at Sheffield Childrens Hospital

Chrishan Mariathas (UK),
Stephen Giles, Stanley Jones, Sanjeev Madan, James Fernandes

Question: Congenital Tibial Pseudarthrosis (CPT) is a rare spectrum of disorders ranging from bowing of the tibia to congenital fracture. Its management is challenging and a number of treatments have been described such as bone grafting, intra medullary rodding, free fibular grafting, circular framesand amputation. As a tertiary referral centre, our unit has managed a relatively large group of patients with CPT, and this study aims to assess the effect on outcome following changes to practice instigated in 1999, as well as the outcomes of different treatment modalities.

Methods: A retrospective review of CPT cases treated at our unit was conducted involving case note and radiograph review. Rate of re-fracture, time to weight bearing, time to union and complications were recorded, as well as measurements of residual deformity. Questionnaires were used to assess functional outcome.

Results: Fifty-one cases of CPT were identified from 1984 to present day. Of these, revision rates, time to union and re-fracture rates were better in the patients with external fixation as well as the group of patients treated from 1999 onwards. No amputations were carried out post 1999. Infection rates were higher in frame patients, but osteomyelitis was rare and occurred equally in internally and externally stabilised patients. Ultimately only 5 patients underwent amputation, but all of these were prior to 1999. Functional outcome was very poorly reported.

Conclusion: The outcomes assessed compared favorably with those in the wider literature. Internally fixed patients tended to be younger primarily treated cases, while externally fixed tended to be older, requiring rescue surgery. Improved outcome following changes to clinical care from 1999 has led to the authors advocating the standardized treatment described from this time.

#18: Do age and modality of treatment affect union; refracture rates in congenital pseudarthrosis of tibia

Miliind M Chaudhary (India),
Gairik Ghosh

Question: Does the age at starting treatment and the modality of treatment have an effect on union and refracture rates in Cpngenital Pseudarthrosis of Tibia?

Methods: We analysed the results of treatment of 54 patients with congenital pseudarthrosis of tibia performed by a single surgeon over 25 years. 15 children were treated at age 5 years or lesser. 23 were treated between ages of 6 and 12 and 16 were treated above the ages of 12.

Monofocal compression was used in 11 cases, Bifocal compression distraction was used in 14 with proximal lengthening, IM Rodding with Iliac crest bone grafting and Bifocal simultaneous compression distraction were used in 23 patients, Bone Transport was done only in 3, Monofocal distraction was performed in one case of hypertrophic pseudarthrosis, All of the above were performed with Ilizarov fixator. All had a foot frame applied. 2 were treated with IM Rodding and bone grafting only. We also looked at Refracture rates based on age and modality of treatment.

Results: 46 patients have united. 13 of the 16 at or below age 5 united 20 of the 23 between ages of 6 & 12 united 13 of 16 above ages of 12 united. 10 or 11 treated with Monofocal compression united 12 or 14 treated with Bifocal united 21 of 24 treated with IM Rod, Bone grafting and Bifocal treatment united 1 of 3 in Bone transport, 1 of 1 in Monofocal distraction and 1 of 2 in IM Rod and Bone grafting united. 5 of 11 treated with Monofocal Compression had a refracture. 3 of 14 treated with Bofocal Compression distraction osteosynthesis had a refracture. only 1 of 25 treated with IM rod, BG and Bifocal had a refracture.

Conclusion: Contrary to recommendations by some authors, young children when treated with Ilizarov exfix below ages of 5 years can have high rates of union. Union rates are not affected by age at starting treatment or by the modality of treatment. However refracture rates are higher in monofocal compression method (which could not ensure a broad area of union due to absence of bone grafting) and refracture rates are significantly lower with addition of IM rods and Iliac crest Bone grafting. 4 patients each at ages of 5 and less & 12 and more had a refracture and one of age group 6 to 12 had a refracture.

#19: Treatment of tibial congenital pseudarthrosis by Masquelet technique.

Rim Boussetta (Tunisia),
Rafik Elafram, Ismail Jerbi, Sami Bouchoucha, Walid Saied, Mohamed Nabil Nessib

Question: Of all the diseases in children, congenital pseudarthrosis of the tibia is probably one of the most difficult to treat. Even today, failure to obtain bone union is frequent and the functional prognosis is mediocre because of residual deformities, joint stiffness and remaining length inequalities.

Methods: We retrospectively reviewed the cases of four patients who had congenital tibial pseudarthrosis treated in our department

Results: Good clinical and radiological results were obtained after a mean follow-up of 10 years. The mean pathological bone defect was 8 centimeters. All the patients were treated with excision of the bone defect, Masquelet technique and iliac bone graft. The X rays showed a total consolidation of the tibia.

Conclusion: CPT is still a disease whose physiopathology has not been completely clarified. The key elements of this review are the necessity of stable fixation, which is essential for bone union, and restoration of anatomical alignment. Union of fibular pseudarthrosis and radical resection of the diseased bone and surrounding tissue are certainly important elements

#20: The use of external fixation in the treatment of hip dislocation in infants and children.

Nuno Craveiro-Lopes (Portugal),
Carolina Escalda, Manuel Leo

Question: The use of external fixation for the treatment of hip dislocation in infants and children can bring additional advantages to traditional methods. The authors present two cases difficult to solve with traditional methods, in which it was necessary to use methods of external fixation for treatment of dislocation of the hip in an infant and a child.

The first case is an 11 months old child with bilateral hip dislocation in which successful conservative treatment was done from birth. He undergone two surgical attempts, first with adductor tenotomy reduction and spica cast immobilization, and then open reduction with loss of reduction during immobilization cast. To achieve a more stable reduction, we used a mini - AO external fixator with threaded pins applied in the supra-acetabular zone and femur. It is important to note that parents, who have had previous experience with two spica casts, preferred the external fixator, finding it much more convenient and comfortable for the placement and hygiene care of the child. The fixator was kept for two months, being removed with sedation on an outpatient basis, while maintaining good stability of the hips. The second case was a 4 year old child with poli-malformative syndrome, including knee dislocations, clubfoot, neurological disorders, and high dislocation of the right hip with femoral head necrosis. We opted for an arthroscopic approach to clean the pulvinar and recession of round ligament, release capsule and everted the limbus and them, making a percutaneous acetabular osteotomy we applied an Ilizarov device to reduce the hip by artrodiastase and to progressively lower the acetabular roof. After two months, the Ilizarov apparatus was removed and a spica cast was applied for two months and then a free hips plaster for another two months, after which the patient began physical therapy and joint mobility exercises.

The first patient started walking at 14 months, with full ranges of motion and without pain. At 5 years old, his hips were with full and symetric range of motion and were stable, although with some dysplasia. The observation of the second patient carried out 6 months after surgery showed a reduced and stable hip with an acetabular angle of 29 and acceptable mobility. At one year after surgery the patient had full range of motion and was walking independently

Conclusion: Among the most evident advantages of the use of external fixation, in these difficult to treat cases by conventional methods, we found the minimally invasive approach, the possibility of gradual correction, the absence of blood loss, the improved stability of the reduction, the absence of implanted material and the shorter post-operative hospital stay in ward.

#21: Pelvic support osteotomy in unstable hip

Ram Avtar Agrawal, (India),
Rajat Agrawal

Question: Unstable Hip in young patients is a challenging problem in Orthopaedics. Earlier, hip arthrodesis was an option with many disadvantages; total hip in young patients is being explored. Between these two options is there any option without disadvantages of arthrodesis and early hip replacement?

Methods: Between September 2003 and August 2012, 22 patients were treated with pelvic support Osteotomy. 12 were old septic arthritis, 6 were old Perthes and 4 were old CDH. First, the pelvis is supported by a osteotomy in the proximal one-third of the femur. This consists of medial angulation of the diaphysis that places the proximal end of the femur in maximal adduction in relation to the pelvis and the distal two-thirds of the femur in relative abduction. Second, an additional corticotomy is made in the distal metaphyseal area of the femur. Through this corticotomy the limb may be progressively lengthened eliminating the leg length inequality. Finally, by producing a gradual varus (lateral) angulation through this distal corticotomy, the mechanical axis was normalized through the hip, knee and ankle joints. Results: 19 out of 22 cases had significant clinical improvement. Trendelenburg sign became negative and lurch was reduced to minimum. Pain was relieved and patients were able to squat.

Conclusion: For unstable hip in young patients, hip arthrodesis has many disadvantages; hip replacement in very young patients is still not treatment of choice. Between these two options, Pelvis support Osteotomy is a very good alternative. With Pelvic support Osteotomy stability of the hip is regained and it relieves pain and maintains function without creating a non-biological interface.

#22: The Ilizarov hip reconstruction as salvage for the adolescent problem hip; short-term functional outcomes.

Timothy Nu
nn (Ethiopia), James Fernandes, Sanjeev Madan

Question: What are the functional, radiographic and gait changes following Ilizarov Hip Reconstruction that are performed for a variety of severe hip pathologies in teenagers?

Methods: We conducted a case review of 25 patients who hadundergone an IHR over a period of 10 years for a variety of underlying hippathologies, all with severe avascular necrosis of the femoral head.

Results: The median age at surgery was 15 years. Thepre-operative diagnoses were slipped upper femoral epiphysis (10), hipsepsis (6), developmental dysplasia of the hip (6) and perthes (3). Atfinal follow up the lower-extremity length discrepancy had improved from a mean of 5.6 cm apparent shortening to 2.3 cm. Trendelenberg sign remained in 7 cases. Improvements in range of hip movements and gait parameters wereobserved. One patient had conversion to a total hip replacement, 4 patientsrequired re-do IHR due to remodeling of the osteotomies.

The early results of IHR are encouraging but the on-going treatment for patients to equalise limb lengths, treat the effectsof remodelling and maintain adequate knee range of motion must beemphasised.

#23: Proximal Femoral Osteotomy in Perthes Disease Using Monolateral External Fixator

Ishani Pinak
in Shah (India) , Kwang-Won Park; Han-Ju Kim; Suh-Woo Chay; Somshekhar Dayal; Hae-Ryond Song

Question : External fixation methods have been described for proximal femoral osteotomy for various etiologies, none dedicated to a single disease entity.

Method : Our study introduces a technique of proximal femoral osteotomy and fixation with a monolateral external fixator system in Legg-Calve-Perthes disease.

Results : Mean angular correction of varus in group A was 20 degree (10-49 degree) and mean medial displacement was 29% (10-49%). Angular correction of valgus in group B was 21 degree (14-33 degree) and lateral displacement was 47% (38-58%). Mean fixation time was 14.6 weeks (10-20 weeks). Complications occurred in 7 hips (50%); pin tract infection in 3, hipabduction contracture in 1, non-union in 2, re-fracture in 1. All resolvedwith intervention and healed uneventfully.

Conclusion : Our surgical technique provides precise correction and stable fixation with minimal intervention. Therefore, the monolateral external fixator is an ideal fixation device for correction of proximal femoral deformities.

#24: Management of sequelae of hip septic arthritis in children

Mikhail Teplenky (Russia)

Difficulties with surgical correction of a condition following septic coxitis are caused by evident deformity and low adaptation potential of articular components. Review results of reconstructive treatment using the Ilizarov external fixation applied for sequelae of septic coxitis.

Methods: Treatment results of 32 children aged from 3 to 10 years treated for sequelae of septic coxitis were reviewed. In the majority of cases the patients suffered septic arthritis in the first months of life. In 4 cases, the pathology of the joint was due to hematogenous (4) and postoperative osteomyelitis (1). The hips were grouped according to Hunka as follows: type IIa-3, type IIb-6, type III-2, type Iva-7, type IVb-10 , type V-4. Transtrochanteric osteotomy only was performed for 6 types II and III patients, and femur and pelvis were osteotomised in 5 cases. Cervical stump was reduced into acetabulum, proximal femur formation and pelvic osteotomy were produced for dislocated femur (type IV). Trochanteric arthroplasty was performed for 4 types IV B and V patients younger than 6 year. Additional surgery due to recurrence of dislocation, deformation produced in 5 cases. Superficial inflammation of the soft tissues of 1 degree is diagnosed in 4 cases. Cases of inflammation of 2-3 degrees, as well as acute osteomyelitis are not revealed.

Results: Results were followed from 1 to 8 years. Functional outcomes were assessed using Colton, types II and III showed 7 good and 4 fair results; types IV-V, 8 good, 10 fair and 3 poor outcomes. Radiological assessment of deformity types II and III showed 6 good and 5 fair results according to Kruczynski grading system. In patients with 4-5 type deformity results are regarded as good in 10 cases, satisfactory in 9, unsatisfactory 2. Congruence of articulating surfaces according to Coleman was as follows, type I, 7, type III, 18 and type IV, 7.

Conclusion: The usage of the technique is practical enough even with evident destruction of the proximal femur. The approach can be alternative to trochanteric arthroplasty and pelvic support osteotomy in patients older 6 year.

#25: Comparison of Joint Distraction and Non-distraction Usingan Ilizarov Fixator in the Treatment of Ankle Fractures

Nobusuke Shibata (Japan),
Koji Nozaka; Shin Yamada; Hidetomo Saito; Hiroaki Kijima; Yoichi Shimada

Question : The purpose of this retrospective study was to compare the effects of distraction and non-distraction of the joint during treatment with Ilizarov external fixator in older patients with ankle fractures.

: Forty-three patients 60 years old with ankle fracture were selected. Patient treatment included either joint distraction (n = 15) or non-distraction (n = 28). The mean age of the patients was 68.4 years in the distraction group and 70.2 years in the non-distraction group.

: The mean range of motion in the sagittal plane was 45.3 for the distraction group and 38.9 for the non-distraction group. The mean AOFAS score of the distraction group was 94.2 (range, 72-100), which was significantly higher.

: Older patients with periarticular ankle fractures whose joints were distracted during treatment had higher AOFAS scores than those treated without joint distraction.

#26: Hexapod Circular External Fixation in Treatment of Displaced and Comminuted Tibial Shaft Fractures

Haim Shtarker (Israel)
, Pavel Nudelman, Michael Assaf, Mikhail Samchukov

Question : Several treatment options are currently exist for tibial shaft fractures ranging from closed reduction and plaster cast immobilization to open reduction followed by internal fixation. Unfortunately, majority of those methods have limitations when used for stabilization of unstable displaced or comminuted fractures. The purpose of this study was to review the initial experience with novel hexapod circular external fixator in treatment of displaced or comminuted tibial shaft fractures.

Method : Charts and radiographs of the 15 patients with displaced or comminuted tibial shaft fractures treated with the TL-Hex circular external fixation since December 2012 were retrospectively reviewed. Average age of the patients was 25.5 years (ranging from 8 to 88 years of age). Four patients were under age 14 and the other 11 patients were adults. There were 13 males and 2 females. Five patients suffered from the open tibial fractures while the other 10 patients had displaced closed fractures of the tibial shaft. All patients underwent application of TL-Hex circular external fixator followed by fracture reduction and stabilization. Adjacent knee and ankle joints were left mobile. Near anatomic reduction was achieved intra-operatively under C-arm imaging using the rapid adjustment mode of the struts. This was followed by fine-tuning of bone segment position using the gradual adjustment mode of the struts. In all cases, partial weight bearing was permitted immediately postoperatively while the full weight bearing was allowed to all patient during the first two weeks after surgery. Radiographic control of fracture healing was done every two weeks. After appearance of progressive callus formation, frame dynamization was performed. Usually, two weeks after dynamization, external fixation device was removed under sedation.

Results : Complete anatomical reduction of fracture was achieved in all cases. Superior frame stability and reduced rate of superficial pin tract infection was noticed in the majority of patients. No major complications were observed. Frame fixation time was the same as that when using other standard circular frames. Unique key design features of the novel hexapod circular external fixator rings (tabs location on the side, two-strut attachment with a single set screw, etc.) and struts (metal-plastic interface at the claw-type universaljoints, independent acute and gradual length adjustment with a single length adjustment scale, lockable pull-and-turn adjustment knob, etc.) allow to maintain Ilizarov principles of stable bone fragment fixation using combination of crossing wires and half pins.

Conclusion : Patients with mid-shaft tibial fractures can be successfully treated using the novel hexapod circular external fixation device. The frame is characterized by simplicity of assembly and application considerably shortening the surgery time as well as significantly improved stability allowing immediate weight bearing and maintenance of joint range of motion.

#27: Radiological analysis of bicondylar tibial plateau fractures treated with circular external fixator

Giovanni Lovisetti (Italy),
Rohaman Tasarib, Lorenzo Bettella.

Question: Experiences with percutaneous reduction and stabilization through external fixation reported a very low incidence of infection and soft tissue complications, but these methods have been considered ensuring a low grade of quality of reduction. Both in external and internal fixation various parameters have been utilized in the literature to define the quality of reduction of bicondylar proximal tibia fractures, in many instances with a questionable degree of accuracy. Our aim has been to evaluate the efficacy of external fixation in achieving a satisfying reduction employing a standardized complete radiologic protocol.

Method: We analyzed the radiologic outcomes of 20 bicondylar proximal tibia fractures treated with circular external fixation and minimally invasive articular approaches with a mean follow up of 37.3 months ( 6-144). According AO/ASIF fractures were classified as follows 41C1: 1; 41C21:3, 41C22:1; 41C23: 3; 41C31: 11; 41C33: 1. According Honkonen Jaervinen classification has been: Type 5: 6; Type 6: 8; Type 7 6. We utilized strict radiologic parameters, obtained from long standing x rays of both legs and x rays focused on the articular lines. Loss of regularity of articular surfaces (steps, gaps), alignment of the articular lines on both planes with regard to tibial axis, translations and mechanical axis deviations have been recorded.

Results: Complete reduction of articular surfaces has been achieved in 11 cases (55%). In the remaining patients the mean articular step has been 4 mm (3-5). 11 Condylar widenings (4.2 mm mean, Range 3-7) have been observed . Mean MPTA has been 87.4 (83-91) and PPTA 79.4 (74-90) degrees. We observed no translations in 18/20 patients (90%) with 2 patients with a 5 mm translation on the sagittal plane, of which one had also a 10 mm translation in the frontal plane.

Conclusion: Our results compared favourably with the literature of both internal and external fixation of these lesions, although the frequent use of scoring systems limits the availability of precise data for comparison. In fact the results in terms of alignment and absence of translations have been also superior to those of internal fixation. Articular surface regularity however, associated a 55% of excellent reductions to a 40% of fair reductions and a 5% of poor reductions.

#28: Hybrid External Fixation via a Minimally Invasive Method for Tibial Pilon Fractures Technical Note

Ahmet Murat Bibi (Turkey)
, Ersin Kuyucu, Ferhat Say, Adnan Kara, Mehmet Erdil, Semih Ayanolu

Question: Tibial pilon fractures constitute 1% of all lower extremity fractures and are one of the most difficult fracture types to manage. We aimed to present the clinical and radiological outcomes of patients with tibial pilon fractures who were treated with hybrid external fixators. Shanz screws were applied synchronously and used as joysticks for fracture reduction.

Methods: The study group included 42 patients (29 males, 13 females) with tibial pilon fractures that were classified as 43 C according to the AO/Orthopedic Trauma Association (OTA) classification system. Prior to the reduction of the tibial pilon fracture, open reduction and internal fixation through a longitudinal incision over the lateral malleolus were applied in patients with concomitant lateral malleolus fractures. Schanz screws were positioned into the major fracture fragments as determined on axial computerized tomography sections in the anteroposterior plane and perpendicular to the medial and lateral fracture fragments. After confirming optimal anatomical reduction with fluoroscopy, Schanz screws fixated to two separate motors were synchronously passed through the fracture fragments. An external fixator was applied after the fracture was stabilized with Schanz screws.

Results: The mean age of the population was 37.7 years old (range, 22-47 years old), and the mean follow-up interval was 21.4 months (range, 12-44 months). Fracture healing was observed in all patients, and the mean fracture healing time was 17 weeks (range, 12-32 weeks) [Figure 3]. The mean lateral distal tibial angle was 89 degrees (range, 84-92 degrees). Joint surface irregularity was not observed in any patient. All of the patients had 0-15 degrees of ankle dorsiflexion. None of the patients had restricted ankle plantar flexion. According to the AOFAS scoring system, the clinical evaluation was excellent in 26 patients, good in 14 patients and fair in 2 patients

Conclusion: Nonunion and malunion were not observed in any of the patients, and good alignment was achieved. Permanent hybrid external fixator applied using Schanz screws via a mini open technique is a fast, easily applied alternative with low morbidity and satisfying results.

#29: Hybrid external fixation via a minimally invasive methodfor tibial pilon fractures technical note

Ahmet Murat Blbl (Turkey),
Ersin Kuyucu, Ferhat Say, Adnan Kara, Mehmet Erdil, Semih Ayanolu

Question: Tibial pilon fractures constitute 1% of all lower extremity fractures and are one of the most difficult fracture types to manage. We aimed to present the clinical and radiological outcomes of patients with tibial pilon fractures who were treated with hybrid external fixators. Shanz screws were applied synchronously and used as joysticks for fracture reduction.

Methods: The study group included 42 patients (29 males, 13 females) with tibial pilon fractures that were classified as 43 C according to the AO/Orthopedic Trauma Association (OTA) classification system. Prior to the reduction of the tibial pilon fracture, open reduction and internal fixation through a longitudinal incision over the lateral malleolus were applied in patients with concomitant lateral malleolus fractures. Schanz screws were positioned into the major fracture fragments as determined on axial computerized tomography sections in the anteroposterior plane and perpendicular to the medial and lateral fracture fragments. After confirming optimal anatomical reduction with fluoroscopy, Schanz screws fixated to two separate motors were synchronously passed through the fracture fragments. An external fixator was applied after the fracture was stabilized with Schanz screws.

Results: The mean age of the population was 37.7 years old (range, 22-47 years old), and the mean follow-up interval was 21.4 months (range, 12-44 months). Fracture healing was observed in all patients, and the mean fracture healing time was 17 weeks (range, 12-32 weeks) [Figure 3]. The mean lateral distal tibial angle was 89 degrees (range, 84-92 degrees). Joint surface irregularity was not observed in any patient. All of the patients had 0-15 degrees of ankle dorsiflexion. None of the patients had restricted ankle plantar flexion. According to the AOFAS scoring system, theclinical evaluation was excellent in 26 patients, good in 14 patients and fair in 2 patients.

Conclusion: Nonunion and malunion were not observed in any of the patients, and good alignment was achieved. Permanent hybrid external fixator applied using Schanz screws via a mini open technique is a fast, easily applied alternative with low morbidity and satisfying results.

#30: Fixator-Assisted Antegrade Closed Interlocked Nailing in Fractures above Total Knee Arthroplasty

Alexander Cheinokov (Russia
), Igor Shugol, Jakhangir Karimov

Question: Conventional treatment modalities in distal femoral fractures above a total knee arthroplasty have been focused on locked plating and retrograde closed interlocked nailing. Capacities of antegrade nailing seem to be underestimated. Aim of our study was to develop a technique of antegrade closed nailing for the target injury.

Methods: Fixator-assisted closed antegrade nailing was used in 17 consecutive patients (age 41-82) with fractures of the distal femur above knee prosthesis (Rorabeck type II) and 3 patients with periprosthetic deformations of the distal femur after percutaneous osteotomy for correction. The use of a small wire simplified Ilizarov frame allowed to obtain and maintain reduction until nail was locked. Locking was done in frontal plane with 3-4 screws 6 mm. Option of insertion of 3 locking screws, which locked each other in the oval hole, was introduced.

Results: Mean operative time was 78,34,6 minutes. In most cases union was reached to 12-16 weeks. Uneventful fracture healing occurred in 19/20 cases. Complications included non-union with distal screw cut-out and valgus angulation in 1/20 case - exchange retrograde nailing was performed with a tibial nail allowed to insert oblique locking screws.

Conclusion: Fixator-assisted antegrade interlocked nailing appears to be least invasive surgical option. It provides rapid recovery and high union rate. Using of fixator-assisted technique for reduction provides alignment with good spatial control. Antegrade nails with multiplanar distal locking screws could be useful to provide better purchase in the osteoporotic metaphyseal fragment.

#31: Long-term Follow-up of an Infant with Severe Lower Limb Trauma

Tomomi Tsumuraya (Japan),
Yasuda Tomohiro, yukoIrie, Shu Obara

Question: Leg and foot length discrepancies resulting from severe lower limb trauma in infants have been rarely reported and thus remain largely unknown. We report the case of a 6-year-old girl who, while waiting for the school bus with her mother, was hit and injured by a motorcycle that had crashed into the bus queue. She sustained severe trauma of the left foot, with an open fracture of the tibia and right femur.

the patient received long-term follow-up observation and treatment for 16 years; we report this follow-up with a literature review. On getting injured, she was transported to the emergency and critical care center of our hospital and underwent an emergency surgery (lavage and debridement) on the same day for the open fracture of the right femur (Gustilo 3B), open fracture of the right tibia (Gustilo 3B), open fracture dislocation of the left talar calcaneal joint, fracture of the left ischium. Following the surgery, right calcaneal traction was placed, and a plaster cast was fixated from the lower left leg to the foot. Once the soft tissue had stabilized, external skeletal fixation was performed for the right femoral fracture, and pinning for the right tibial fracture was performed using a K-wire. Further, skin grafting was performed to treat the skin damage on the right femur and left ankle. The subsequent progress was uneventful, and after removal of the external skeletal fixation and K-wire, a cast was fixated.

Results : Six months following the injury, bone union was achieved; the patient could then bear her full weight on the right side and was discharged with patella tendon-bearing brace for the left side. After hospital discharge, growth disturbance of the left leg and malunion of the talus and calcaneus were observed, with a gradual increase in the leg length discrepancy. Therefore, 13 years after the injury, leg length correction was performed using a ring-type external skeletal fixator. At present, approximately 16 years after the injury, leg and foot length discrepancies are 9 mm and 20 mm, respectively.

#32: Role of external fixation in complex acute and post-traumatic disorders in the inferior limb: Reconstruction versus amputation

Tartaglia Nicola (Italy)
, Corina Gianfranco, Mori Claudio, Noviello Chiara

Question: Complex open fractures or post-traumatic conditions (aseptic and infected non union) of the inferior limb are a big challenge for the orthopedic surgeon who often need to choose if a reconstruction procedure is possible rather than an amputation. The external fixation using the Ilizarov methods of bone resection and lengthening helps to stabilize fracture and to rebuild bone, muscle and skin defect. The surgical procedure starts with a surgical toilette of damaged soft tissue and necrotic bone followed by bone resection and lengthening with external fixation (circular, monolateral or hybrid) according to Ilizarov techniques (proximal osteotomy with progressive lengthening 1 mm for each day).

From 2005 to 2013 we have treated 27 patients with leg open fractures or post-traumatic conditions with huge bone, muscle and skin loss. 22 were males and 5 were females: medium age 47 years.

At minimum follow-up of 2 years, functional results have been excellent in 20 cases, sufficient in 6, insufficient in 1 (leg amputation). Medium healing time (patient with external fixator) has been 7 months. We had no cases of deep infections in the resection site or in the proximal osteotomy site; however we had 4 cases of superficial pin tract and screws infections. No cases of non-union, chronic osteomyelitis or residual axis deformity were observed; in 6 cases we observed ankle stiffness. While lengthening process was gradually restoring the bone defect, we observed also a progressive recover of skin and soft tissue defect: in fact the association of a free skin flap procedure was necessary only in one case.

Authors believe that external fixation according to Ilizarov technique of bone resection and lengthening is a treatment option to save a limb from amputation in complex inferior limb fractures or post-traumatic conditions. A good evaluation of patient psychology needs to be assessed to propose this long term treatment. However if patients are motivated enough in most cases surgeon can reconstruct the limb offering a good quality of function. The key of success lies in a careful plan of the case, the choice of the most stable implant, doing a good and extensive debridement, working in collaboration of dedicated plastic surgeons, use of associated therapy (IV specific antibiotics, OTI therapy and VAC therapy), a strict outpatient clinic follow up, a strong psychological support for these patients. Long term treatment need to be balanced with the need of patient to come back to work as soon as possible since also an amputation is not a surgery without complications and in some cases a patient amputated wouldn't be taken back to work in certain type of jobs.

#33: Treatment of severe infected military injuries usinghexapod circular external fixation

Haim Shtarker (Israel)
, Pavel Nudelman; Michael Assaf, Mikhail Samchukov

Question : During the last 3 years, hundreds of severely injured children and adults, not the military citizens but casualties of a Civil War, were admitted to our hospital from the neighboring country Syria. Although they were treated according to the most advanced principles of the military trauma management, majority of them unfortunately already appeared with severe bone infection due to lack of appropriate initial care and late transfer to the hospital after injury. Hexapod-type of circular external fixation was used in the most complicated cases with severe infection and bone loss. The purpose of this study was to review different aspects of hexapod fixation in treatment of severe military injuries using several illustrative cases.

Method : Charts and radiographs of the 5 patients with severe military injuries treated with the hexapod-type circular external fixation were retrospectively reviewed. Immediately after admission, patients were transferred to OR for careful surgical debridement, taking cultures, massive washing of surrounding tissues and temporary unilateral external fixation. In cases of poly-trauma, treatment was provided according to damage control principles. Broad-spectrum antibiotic treatment was initiated. Depending on wound condition, additional second, third, fourth and even fifth debridement in OR was done. After wound was considered as clean, different methods of soft tissue coverage were applied including vacuum device, muscular and skin flaps, limb shortening and cross leg flaps. Usually, unilateral external fixator was converged to the circular hexapod frame at that stage followed by osteotomy and initiation of bone transport. In some cases, however, the osteotomy for bone transport was delayed until soft tissue healing. Bone transport for defect substitution was consisted of two stages. First, the created transport segment was gradually transferred through the defect areas using either the transport hexapod ring sliding along the threaded roads or by using modified cable system assembled on the hexapod rings. At the time of docking, threaded rods or cable were removed and replaced by the six hexapod struts for precise positioning of contacting bone segments followed by compression. Intravenous antibiotic treatment was continued for 1.5 to 2.0 months until normalization of CRP and clinical appearance.

Results : Despite attempts to follow all patients during and after the treatment, it was challenging and sometime impossible task. Some of the patients returned to their country during the treatment with the device attached. In cases available for follow up, healing and continuity of bone and soft tissue were recorded. No cases with recurrent infection were noted. Bone regenerate appeared in good quality in all cases and anatomical restoration at the docking was achieved.

Conclusion : Hexapod circular external fixation can be recommended for treatment of severe military trauma. The novel hexapod fixator utilized in our cases provides superior stability due to slotted ball-and-socket universal hinges. Due to strut attachment on the outer surface of the rings, switching from ring based or cable-based bone transport to hexapod configuration at the docking site was very simple and not time consuming. Devise was tolerated by all patients and they were able to manage either bone transport or docking site compression away from the hospital and without the medical aid.

#34: Fracture reduction; limb reconstruction using a novel hexapod circular

external fixator: Initial experience in Israel Haim Shtarker (Israel),
Pavel Nudelman, Mochael Assaf, Mikhail Samchukov

Question: Temporary frame instability, complexity of strut adjustment, and lack of preoperative planning are well-known limitations of the existing hexapod-type external fixators. The purpose of this study was to review the initial experience with novel hexapod circular external fixator in fracture reduction and limb reconstruction.

Charts and radiographs of the 35 patients treated with the TL-Hex circular external fixation since December 2012 were retrospectively reviewed. All patients were divided into 2 groups: fracture group (25 patients) and limb reconstruction group (10 patients). Fracture group consisted of 19 patients with tibial fractures (including 1 patient with bilateral fracture) treated either with standard TL-Hex frame (16 segments) or TL-Trauma (TL-Hex rings with rapid adjust struts) assembly (4 segments), 3 patients with femoral fractures (including 1 patient with bilateral fracture), 1 patient with combined femoral/tibial fracture, and 2 patients with cable bone transport for segmental tibial bone loss. Second group combined 4 patients with tibialvarus (including 2 patients with bilateral deformity), 1 patient with bilateral malrotation syndrome, 1 patient with distal femoral valgus, 2 patients with humeral lengthening, 1 patient with neglected clubfoot, and 1 patient with ankle arthrodesis for arthritis.

External fixator required significantly less time for pre-assembly, intraoperative strut removal or re-attachment and was user-friendly in postoperative strut length adjustment. All patients in fracture group achieved desirable reduction and healing while limb lengthening or/and re-alignment was accomplished in all patients in limb reconstruction group. Comparison of deformity parameters with final limb alignment demonstrated high precision of the TL-Hex software in either preoperative or postoperative planning modes. Superior frame stability and reduced rate of superficial pin tract infection was noticed in the majority of patients. No major complications were observed except one case of nonunion after proximal tibial osteotomy. In this case, frame was re-applied to the extremity and the union was achieved.

The novel hexapod circular external fixator can be successfully applied in treatment of patients with fractures and limb reconstructions.

#35: Complex Tibial Condyle Fractures Treated by Ilizarov External Fixation - A Prospective Study

Harshad M. Shah (India)
, Sandeep Reddy R, Ashok Kumar P, Naresh Shetty, Yashwantha Kumar, Dinesh Kumar Golla

Question : Can the treatment of complex tibial condylar fractures be treated with Ilizarov External Fixator successfully?

Method : We treated 43 complex tibial condyle fractures with Ilizarov External Fixator some of them combined with minimal percutaneous fixation with cancellous cannulated screws and bone grafting. Complications have been minimum and comparable to other reports.

Results : All the tibial condyle fractures united. After one year, there were 9 excellent, 23 good, 11 fair results as per Holl and Luck Grading; the mean Lysholm score was 82.16. Complications of pin tract infections, varus malunions, (2/43), extensor lag (5/43), infection (2/43), foot drop (1/43), have been minimal and comparable to published reports and treated successfully where possible.

Conclusion : Ilizarov External Fixation method of treatment for tibial condyle fractures is very good with predictable results. In these high-energy traumatic fractures, this method gives better results with less complication.

#36: Taylor Spatial Frame (TSF) for primary and definitive fixation of femoral fractures in patients with multiple traumatic injuries.

Sala Francesco (Italy),
Bove Federico, Alati Salvatore, Capitani Paolo, Agus Maria Alice, Scita Valentina

Question : To evaluate the Taylor spatial frame (TSF) for primary and definitive fixationof femoral fractures in patients with multiple traumatic injuries.

Methods : Retrospective study. Setting: Level I trauma center. Patients: Consecutive series of 28 patients, 29 femoral fractures, treated between 2005 and 2014. Twenty-five fractures (86%) were open. Injury Severity Score 16 for all patients. Intervention: Twenty-six fractures (90%) underwent definitive fixation with the TSF and 3 were treated primarily within 48 hours of injury. In 13 cases (45%), fractures were acutely reduced with the TSF fixed to bone and the struts in sliding mode without further adjustment, and in 16 cases (65%), the total residual deformity correction program was undertaken. Main Outcome Measure: Clinical and radiological.

Results : Complete union was obtained in 24 fractures (83%) without additional surgery at an average of 29 weeks. Five non-unions occurred, of which one with infection. Results based on Association for the Study and Application of the Method of Ilizarov criteria: 60% excellent, 15% good, 8% fair, and 17% poor for bone outcomes and 30% excellent, 40% good, 18% fair, and 12% poor for functional outcomes. Eighty-two percent of patients returned to preinjury work activities.

Conclusion : Primary and definitive fixation with the TSF is effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of primary defect caused by bone loss, easy and accurate application, convertibility and versatility compared with a monolateral fixator, and improved union rate and range of motion for lower extremity long-bone fractures in patients with multiple traumatic injuries.

#37: Different Courses of Bone Healing in Femoral Non Unions Assessed with an Instrumented Internal Plate Fixator

Klaus Seide (Germany)
, Birgitt Kowald, Matthias Muench, Majed Aljudaibi, Maximilian Faschingbauer, Christian Jrgens

Question : Monitoring of non union healing is a difficult problem for the patient and the surgeon. Typically, successive radiographs are performed and an emerging calcification is evaluated. Often, CT scans are necessary. An electronic telemetric system had been developed to assess bone healing mechanically. So the question arose, what useful information the electronic measurements could provide to quantitatively evaluate the courses of healing in non unions.

Method : The system consists of a telemetry module which is applied to an angularly-stable (locked) plate fixator, an external reader device, a sensor for measuring externally applied load and a notebook computer with processing software. By correlation between externally applied load and load measured in the implant, the elasticity of the osteosynthesis is calculated. The elasticity decreases with ongoing consolidation of a fracture or non-union and is an appropriate parameter for the course of bone healing.

Results : Clinical application was performed in 55 patients suffering non unions of the femur. 46 cases were finished. In 45 out of 46 consolidation was achieved. Four different types of healing curves could be distinguished. There were patients showing a fast decrease in elasticity resulting in a healing in 12 weeks. Others showed a slow decrease over several months, finally consolidating. A different type of healing showed high elasticity values for a considerably long time, then suddenly showing consolidation. A fourth type was related to the non healing situation, the measured elasticity remained on a constant high level. An important observation was, that relevant mechanical stability occurred, before it could be radiographically seen. Higher measured initial mechanical stability of the osteosynthesis, e. g., because of cortical support opposite to the plate, correlated significantly with a better healing course.

Conclusion : The electronically instrumented implant offers quantitative data to learn and understand the course of healing of non unions. Clinically, it proved to be very valuable for the assessment of bone healing in such difficult healing situations. Especially, the measurements were helpful in the decision to avoid revision surgery, e. g., bone grafting. Incorporating microelectronics in orthopedic implants will be an important development direction.

#38: Anesthetic requirements for removal of external fixation

Anton M. Kurtz (USA),
Osama Elattar, Spencer S. Liu, Philip J. Wagner, Austin T. Fragomen, S. Robert Rozbruch

Question: It has been suggested that removal of external fixation may be satisfactorily performed in the office rather than under anesthesia in the operating room. Modern hydroxyapatite-coated half-pins make a far stronger bond to the patients bone than earlier uncoated pins, with a concomitant increase in pain when they are removed. Additionally, the authors have preferred to use the trip to the operating room to remove the fixator and perform a thorough debridement of pin sites and release of subcutaneous adhesions. We therefore sought to document: (1) the anesthetic requirements, (2) the composition of the frame, (3) the time required, (4) and the adequacy of anesthesia for a series of patients requiring removal of an external fixator.

Methods: We prospectively recorded data on 53 external fixator removal procedures (CPT 20694). The surgeon and the anesthesiologist independently recorded data. Patient demographics and preoperative pain medications; sedative and analgesic doses; airway management and anesthetic technique; frame location, size, and composition; removal time; and a gradeof anesthetic adequacy were recorded.

Results: (1) Midazolam and propofol were used in 87% and 94% of cases, respectively. An average of 5 mg of midazolam (range 2-10 mg), and 219 mg of propofol (range 25-675 mg) were administered when those drugs were used. Fentanyl and ketamine were used in 75% and 7.5% of cases, respectively. An average of 100 mcg of fentanyl (range 50-200 mcg), and 35 mg of ketamine (range 20-50 mg) were given when those agents were used. Thirty-six patients (68%) required active management of the airway, mostly in the form of a chin lift/jaw thrust maneuver. (2) Most frames were removed from the lower extremity, concentrated on the tibia and ankle/foot. Frames were composed of an average of 2 rings, 3 half-pins, 2 olive wires, and 2 smooth wires. 38 patients (72%) had 2 ring frames, 11 patients (21%) had frames with 3-5 rings/arches, and 4 patients (7%) had monolateral frames removed. (3) Time for removal of the fixator, and debridement of the pin sites, exclusive of postoperative radiography, casting or bracing, averaged 13.4 minutes (SD 5.6 minutes, range 7-40 minutes). (4) Anesthesia was graded as good to excellent in 91% and unsatisfactory to poor in 9% of cases.

Conclusion: Removal of external fixation is a painful procedure that requires IV sedation and analgesia to achieve patient comfort, safe removal, and thorough debridement of pin sites and soft tissue adhesions. The medication dosages and airway management techniques required to achieve these aims make clear the fact that removal of external fixation is best performed in the operating room.

#39: Is the PRECICE nail better than the intramedullary skeletal kinetic distractor (ISKD)? - A cohort study

Dong Hoon Lee (Korea),
Keun Jung Ryu, Hyun Woo Kim, Jin Ho Hwang

Question : Although fully implantable intramedullary lengthening nails were developed and gaining more popularity, comparative study on their functions and complications have not fully been documented. We aimed to compare implant-related or non-implant-related complications between the two intramedullary lengthening devices; ISKD and PRECICE.

Method : This is a retrospective study with prospectively collected data from two cohorts. From March 2010 to June 2014, we evaluated 110 segments of bones undergoing femoral or tibial lengthening, which met pre-specified inclusion criteria. All patients underwent lower limb lengthening either for stature lengthening or for limb length discrepancy with two intramedullary lengthening devices (ISKD and PRECICE). The author switched the lengthening nail from ISKD to PRECICE on the middle of the study period, and the two groups (ISKD group vs PRECICE group) were compared on (1) accuracy of distraction, (2) pain in three circumstances (rest, physiotherapy, distraction motion), (3) implant-related complications and (4) non-implant-related complications encountered. The mean age was 28.88 years in ISKD group and 297 years in PRECICE group with no significant difference. Femur to tibia ratio was 26:9 in the ISKD group and 65:10 in the PRECICE group with no significant difference. Final length gain and consolidation showed no significant differences.

Results : Accuracy of distraction showed significant difference with more accurate distraction rate control in PRECICE nails. Pain VAS during rest and physiotherapy showed no significant differences. But, pain VAS during distraction motion showed significant difference with lesser pain in PRECICE group (5.72.6 in ISKD group vs 3.51.5 in PRECICE group). Overall, implant-related and non-implant-related complications showed no significant differences. However, they showed significant differences on the type of implant-related problems and obstacles. For implant-related problems, runaway nail (17%) and difficult-to-distract nail (34%) were only in ISKD, whereas bent nail (13%), nail with broken rotation coupling (19%), and nail with running back phenomenon (1%) were only in PRECICE. For implant-related obstacles, non-distracting nail (9%) was only in ISKD, whereas nail with failure of lengthening/shortening mechanism (8%) and broken nail (1%) were dominant (vs 3% in ISKD) or existed only in PRECICE.

Conclusion : The PRECICE nail showed lesser pain during distraction and predictable distraction rate control than the ISKD nail. Overall complication rates showed no significant difference. The major implant-related complications were related with the distraction rate control in the ISKD, whereas they were related with mechanical strength of the nail in the PRECICE.

#40: Reduction of number of hexapod strut changes using smart phone software iStrut

Konstantin Mikheev (Russia),
Petr Vvedenskiy, Mikhail Samchukov, Alexander Cherkashin

Question: Due to oblique strut orientation relative to the axis of bone segments, postoperative management of hexapod-type of external fixators often required strut exchanges. The number of strut exchanges is influenced by numerous parameters including ring size, ring separation distance, degree of bone segment angular/rotational correction, as well as the total amount of bone lengthening. In some cases with severe multi-planar deformities and significant limb lengthening, up to 5-6 struts should be replaced during the treatment. Strut exchange is a time-consuming process that required temporary ring stabilization followed by strut replacement. Although some of the novel hexapod frame struts have an independent rapid and gradual adjustments significantly increasing the total amount of strut shortening/lengthening, the placement of those strut in the not optimal rapid/gradual length configuration will still require strut length configuration re-adjustment and/or strut exchange. This is more evident when ring first method is used for frame application. Therefore, the purpose of this study was to develop a software program that will allow to optimize the strut length and reduce the number strut exchanges.

Methods: To provide the efficient and reliable mean for strut length configuration optimization, the iStrut program was developed as an application for the iPhone and iPad. The program requires to enter the following specific parameters: existing struts size, existing rapid adjustment length and existing gradual adjustment length according to the strut scale, as well as direction of strut length adjustment (lengthening or shortening). The program will run the strut length optimization module and provide optimized strut size and rapid/gradual strut lengths. The struts can be adjusted immediately resulting in the most efficient daily strut adjustment prescription with minimal amount of strut length modifications and strut exchanges.

Results: The program was tested for different types of deformity correction and limb lengthening experimentally and then validated by several different surgeons in clinical practice. In all cases, iStrut program allowed to select the most optimal sizes and configurations of struts.

Conclusion: Application iStrut allows to select the most optimal strut sizes and their acute/gradual length configuration immediately after the surgery directly in the OR. This will significantly reduce the number of strut length modifications and strut exchanges during the deformity correction and limb lengthening using the hexapod frame. Saved in the application optimized strut length configurations can be entered into the hexapod software at surgeons convenience at the later time.

#41: Use of a novel hexapod frame system for femoral and tibial deformity correction: Safety and initial experience

Daniel Marsland (UK),
Amir Qureshi

Question: Is the Orthofix circular fixation system safe and reliable to use for complex deformity correction.

Methods: We maintained an accurate audit trail of patients treated using this novel fixator.

Results: The University Hospital Southampton is the largest user of Orthofix in the UK. We have successfully treated femoral and tibial deformities including sagittal, coronal, axial and rotational deformities using a new hexapod system that utilizes six struts interconnecting circular components secured to the bone with fine wires and hydroxyapatite coated half pins. There have been no cases of non union or amputation.

Conclusion: Successful use of a hexapod system relies on adequate hardware stability and also software which allows controlled and reliable correction in all six planes. Illustrative cases of our initial experience using the Orthofix system will be presented, including postoperative management in the out patient department and usability of programming software.

#42: Classification of standard hexapod frame configurations

Mikhail Samchukov (USA)
, Alexander Cherkashin, Franz Birkholtz

Question : Despite the widespread use of the hexapod systems for fracture reduction and long bone deformity correction, there is no consensus in the literature regarding the common classification of hexapod frame configurations as well as a standardized method of bone segment fixation applicable to different hexapod frames. Moreover, various individual modifications of standard frame assemblies and mounting as well as lack of unique nomenclature in frame description increase the number of potential frame assemblies applicable for the same anatomical region for the treatment of the same pathology. Therefore, the purpose of this study was to develop a unique classification of hexapod frame configurations based on the most common standard hexapod frame assemblies.

Method : Various hexapod frame configurations and segmental stabilization modules described in the literature were analysed and grouped according to the type of deformity and the application site in relation to the limb anatomy. The foot and ankle area, for example, was divided into four interrelated biomechanical segments including 1) tibia, 2) hindfoot (calcaneus & talus), 3) midfoot (confined between the Chopart and Lisfranc joints), and 4) forefoot. Accordingly, each component of foot and ankle deformity was presented by two segments and described as malposition of one segment relative to another. This was followed by combining different frame assemblies into specific groups based on the 1) number of correction levels, 2) strut set orientation relating to limb axis for each level of correction, and 3) type of frame stocking in the double-level and triple-level frames resulting in classification of standard hexapod frame configurations.

Results : Classification of standard hexapod frame configurations is presented in Figure 1. Depending on the number of correction levels, all hexapod configurations are combined into three groups including single-level, double level, or triple-level frames. For each level of correction, hexapod module is further defined as vertical (parallel to the femoral/tibial axis) or horizontal (parallel to the hindfoot/forefoot axis) and categorized as 6V or 6H frames, respectively. Finally, double-level hexapods are characterized respectively to type of frame stocking as vertically inline (6VX6V), horizontally inline (6HX6H), orthogonally inline (6VX6H), or vertical parallel (6V + 6V) frames. Description of the rarely used triple-level hexapods is based on the combination of single and double-level frames. For example, single-level vertical frame connected to double-level horizontally inline frame is categorized as 6VX (6HX6H) hexapod. Therefore, there are seven standard hexapod frame configurations utilized for fracture reduction and deformity corrections including 1) single-level vertical (6V), 2) single-level horizontal (6H), 3) double-level vertically inline (6VX6V), 4) double-level horizontally inline (6H × 6H), 5) double-level orthogonally inline (6VX6H), 6) double-level parallel vertical (6V + 6V), and 7) triple-level 6VX (6HX6H) hexapod frames.

Conclusion : Developed classification allows to combine all different frame assemblies into seven standard hexapod frame configurations irrespective of which external fixator is used. Using unique nomenclature in description of stabilization modules and frame assemblies, the classification can be further expanded utilizing more specific configuration for rare applications of the hexapod-type fixation devices.

#43: Comparative conformational instability of different hexapod frames

Mikhail Samchukov (USA)
, Barbara Chiaramonti, Sergey Leonchuk, William Pierce, Alexander Cherkashin

Question : Despite numerous advantages in fracture reduction and correction of multi-planar deformities, hexapod frame instability due to strut joints free play, more evident in the latency and consolidation periods, is well-known limitation. The purpose of this biomechanical study was to analyse whether the type of the universal joint utilized in struts structure affects the overall conformational instability of the hexapod frame. We hypothesized that hexapods with cardan-type universal joint of the struts allow more frame instability than hexapods with ball-and-socket universal joints and the magnitude of the hexapod frame instability is inversely proportional to the angle between the rings and struts as well as separation distance between the rings.

Method : Four hexapod external fixators were utilized in the study including two frames with the cardan-type universal joint (Taylor Spatial Frame, Smith & Nephew Orthopaedics, Memphis, TN and Ortho-SUV, S. H. PITKAR, India) and two frames with ball-and-socket universal joint (PoliHex, Litos, Hamburg, Germany and TL-Hex Ring Fixation System, Orthofix, Verona, Italy). The mechanical testing was performed by using a universal testing machine (MTS 858, Minneapolis, MN) applying a 5-N load to detect the free play while avoiding the frame deformation. The study was divided into three phases: 1) maximal axial free play of the individual struts, 2) comparative free play evaluation of the standard hexapod frame assembly (two 155-160 mm diameter rings interconnected by 6 long struts according to the manufacture specifications at the 180 mm ring separation resulting in 70 of ring-to-strut angle) in axial compression, torsion, AP translation and ML translation, and 3) influence of ring-to-strut angle ranging from 70 to 10 (and related ring separation distance ranging from 180 mm to 20 mm) on the maximal axial free play. Each frame configuration was tested three times per loading mode and the average values were evaluated to compare linear or angular displacements of the dynamic ring. The groups were compared statistically using one-way ANOVA test.

Results : PoliHex and TL-Hex hexapod struts with ball-and-socket universal joints demonstrated statistically significant.

Conclusion : Type of the universal joint utilized in the struts structure affects the overall conformational instability of the hexapod frame. The hexapod frames with cardan-type universal joint of the struts have more instability than hexapods with ball-and-socket universal joints. The magnitude of frame instability in the hexapods with the cardan joints is inversely proportional to the angle between the rings and struts as well as distance between the rings. Hexapod frames with ball-and-socket universal joints have superior frame stability independent on ring-to-strut angle and ring separation distance.

#44: How Accurate are 6-Achses Corrections with Hexapod Fixator Systems?

Klaus Seide (Germany)
, HinrichHeuer, Matthias Muench, Ulf-Joachim Gerlach

Question : Different hexapod based external fixators are increasingly used to treat bone deformities and fractures. As they are based on a robot kinematics typically positioning very precisely in technical applications, the question arises, whether these high accuracy is found in the hexapod fixators and its applications as well.

Method : The study consisted of two parts. First, the literature was searched for studies concerning the accuracy of corrections with hexapod based fixators. Second, a measuring system was built to evaluate the accuracy of the kinematics and software in a laboratory model. An infrared tracking system was applied to measure multiple positioning maneuvers, detecting 3-dimensional positions of reflective balls mounted in an L-arrangement at the fixator, simulating bone directions and its projections (simulating radiographs).

Results : In the clinical literature, for different hexapod systems on the market, median values from 1 mm to 3 mm remaining translational deformity and 1 to 3 remaining angulation deformity with maximum values from 3 mm to 14 mm and 3 and 30, respectively, have been reported. Values exceeding 5 remaining have only occurred rarely. In the biomechanical literature, the resulting accuracy in experiments with sawbones or bovine bones showed mean correction errors between 0.3 mm and 1.3 mm and 1.8 and 2.3. In purely technical set ups of the hexapod kinematics itself, using coordinate-measuring machines, accuracy is reported with values ranging from 0.4 mm to 2 mm for translations and 0.4 to 0.7 for angulations. However, exact descriptions of applied methods are lacking in these reports. For the system investigated in this study, median absolute differences of target movement and measured movement were below 0.3 mm and 0.2 with quartiles ranging from -0.5 mm to 0.5 mm and -1.0 to 0.9, respectively. So, the accuracy of the investigated hexapod system was high with errors smaller than clinically detectable.

Conclusion : Compared with the results of the present study of the pure mechanics, a considerably higher variance of positioning results in clinical studies was found. This can be explained by additional influencing factors in clinical usage. These include quality of radiographs, accuracy of correction planning, mounting of the fixator to the bone, stiffness of the ring-bone connection, soft tissue/callus-tension as well as muscular traction during corrections. The experimental setup was found to be precise and reliable. So, it can provide the basis for a comparison of clinically established or newly developed hexapod based fixator systems regarding both their mechanical and software accuracy.

#45: The FITBONE-system - A concept for limb lengthening and deformity correction

Rainer Baumgart (Germany)

The Fitbone-System is a fully implantable device based on an external computerized control unit and a wireless energy transmission to a motorized distraction nail. The system is not only a lengthening device but also a multifunctional correction tool for posttraumatic and congenital deformities and bone defects. Which results can be expected?

Methods: In our Center meanwhile about 1400 implantations of the Fitbone-System were done. 46% of our patients were posttraumatic cases, 35% congenital cases and 15% bilateral cases due to dwarfism or cosmetic reasons. Bone transport was performed in 2,7% of the cases and combined with lengthening in another 1,3%.

Results: 391 cases, which were treated between November 2010 and December 2013 with the last version of the Fitbone-System (Series 4) were evaluated after removal of the implant. In all cases long standing radiographs (LSR) were performed before and after treatment for quality control. The mean lengthening amount was 38 mm (20-85) at the femur and 33 mm (20-60) at the tibia. In 28 cases bone transport was performed. 96% of the lengthenings and 99% of the bone transports were finished sucessfully (+/- 5 mm). The mechanical axis was within the pysiological range (+/- 5 mm at the knee joint level) in 91% of the lengthening group. 4% of the patients had a slight varus and 6% had a slight valgus of less than 5. There was no clinical relevant torsion deviation. The range of motion of the knee and the ankle joint was reduced temporarely, especially when femur and tibia were lengthened simultaneouly but recovered in all cases exept two at the time of follow up. Technical problems during the time of early development could be diminished completely. In our study there were only 2 implant related failure due to the high technical standard which was reached meanwhile.

Conclusion: Considering the developed operation technology made for the Fitbone-device, axis deformities and deviations of torsion are able to be acutely corrected intraoperative while lengthening can be precisely performed computer controlled postoperatively. The Fitbone-System is an efficient, safe, comfortable and reliable tool for exact corrections of all geometric parameters of the lower leg. The operative technique is sophisticated but justified by the precise outcome and the excellent cosmetic result

#46: The reverse planning method (RPM)

Rainer Baumgart (Germany)

Preoperative planning is essential to any surgical correction of lower limb deformity. Adequate patient assessment requires clinical examination and long standing anteroposterior radiographs of both legs and in addition a lateral radiograph of the affected bone to allow accurate exact geometrical analysis of malalignment. CT scans are useful to quantify both the limb length and the torsion of hip and ankle joint. Planning strategies for deformity corrections with external fixators are established, well known and accurate for the femur and tibia but not suitable for internal devices. Thus, the planning for lengthening of the femur or tibia with or without deformity correction using intramedullary nails requires completely different planning strategies.

Methods: The RPM (published in OOT, 2009) presents a step-by-step deformity correction and lengthening planning method to achieve desirable anatomic relationships at the completion of correction using straight or Herzog intramedullary nails in the femur and the tibia. For the femur, preoperative planning for antegrade and retrograde insertion of the nail are described separately. Since the planning starts with the final result of the projected correction and works backwards to the preoperative deformity, the surgical planning is termed the Reverse Planning Method (RPM).

Results: The RPM was used in our Center successfully since 10 years in more than 1500 cases. Assuming that reaming will be done in a preplanned way to accommodate a straight nail (since currently-available implantable nails for lengthening are straight), and not along the path of least resistance. Technically, such reaming requires the use of rigid, straight reamers; flexible reamers commonly used for intramedullary reaming are not useful. The fully implantable motorized lengthening nail, which was used in our Center was specifically designed for lengthening using these strategies. The RPM takes all deformities including the lateral shift while lengthening close to the anatomical axis at the femur into account. In essence, the method plans the proper orientation of all joints relative to the mechanical axis at the end of all corrections including the lengthening procedure. The RPM may also be used when deformities of the femur and tibia co-exist. In such cas es, the femoral and tibia planning are combined, using the mechanical axis and normal knee axis as the foundation for planning. Although the method may be used for deformities of the proximal femur and distal tibia, the RPM is most effective for the correction of diaphyseal deformities and those located near the knee joint.

Conclusion: Compared with external fixation, where ideal lengthening occurs along the mechanical axis, intramedullary lengthening occurs along the nail axis, which more typically approaches that of the anatomic axis in the femur. These fact and more important all deformities and joint orientations are taken in consideration by the method. The described RPM may be used for preoperative surgical planning when any straight intramedullary lengthening nail will be used, or when lengthening with or without deformity correction will be accomplished with external fixators in combination with straight intramedullary nails (lengthening over nail).

#47: The Tube-II-System - A patent-registered system for the implantation of intramedullary nails

Rainer Baumgart (Germany)

Implantations of intramedullary nails can be done through small incisions in a minimal invasive way. The " Tube-II-System" is a patent-registered medical device (1) not only for soft tissue protection but also for protecting the bone and directing the way of reaming. The system is specially adapted to the fully implantable distraction nail (Fitbone) using the Reverse Planning Method (RPM). What is the advantage?

Methods: The system is principally structured in soft ssue protection tubes and working tubes, both with different diameters and length (S, M, L, XL) which can be adapted to the specific situation. The inner and the outer diameter are labeled on the outside. Special instruments are available to place and to remove the tubes. To place the thin walled soft tissue protection tubes, first a 3 mm K-wire has to be inserted at the planned entry point of the bone. Over the wire a cannulated cone acting as a dilatator of the soft tissue can be pushed forward. Its outer diameter is the same as the inner diameter of the soft tissue protection tube which can now be placed over the cone a-traumatically. The tube stay in place until the whole procedure is finished what means, that all changes of instruments take place without any contact to the soft tissue. To protect the entry point of the reamer and to direct the way of reaming, the soft tissue protection tube can also be impacted into the bone. Corrections close to the initial entry point of the K-wire can be done by eccentrically cones very accurate. Corresponding to each soft tissue protection tube a working tube is available adapted to the diameter and the length reducing the inner canal according to the instrument which has to be used. For reaming the diaphysis, the metaphysis has to be protected not to lose the preformed pathway representing the correction of the axis. The system offers thin walled working tubes which can protect the bone canal from the entry point all the way to the osteotomy. If passing the osteotomy side with the tube the position of both fragments can be stabilized to each other.

Results: The Tube-II-System was used in our Center successfully since 10 years in more than 1500 cases. For both, ante-and retrograde nailing, only small skin incisions.

Conclusion: The Tube-II-System is an imperative device for minimal invasive nailing techniques. When using flexible reamers in trauma cases soft tissue protection tubes are adequate and the impaction into the bone is optional. In case of axis corrections using the RPM the impaction into the bone and the use of working tubes is mandatory to ream the bone fragments 3-dimentional in the pre-planned way.

#49: Guiding Clinical Judgment in Surgery for Limb Length Discrepancy: The Relationship between Height and Income

Eric J. Peng (USA),
Raymond W. Liu.

Question: Treatment for a child with limb length discrepancy is generally based on weighing the benefits of lower morbidity with epiphyseodesis versus avoiding surgery on the healthy leg, the ability to correct associated deformities and greater ultimate height with limb lengthening. Although commonly ignored when balancing risks and benefits, mature height can affect patients socioeconomically. Though studies have noted an association between increased height and increased income as an adult, this relationship has not been rigorously investigated.

Method: Data from the National Longitudinal Survey of Youth 1979 (NLSY79) was analyzed for an association between adult height and income. NLSY79 is a longitudinal study of a nationally representative sample of 12,686 people who were 14-22 years old when first surveyed in 1979. Surveys were conducted annually from 1979 to 1994, and every other year from 1994 to 2010. Average yearly income at each inch of height was calculated for both men and women. Data was excluded if less than 30 subjects were available at any given height and if subjects filled out income data fewer than 14 out of the 24 times surveyed.

Results: There were 6403 males (50.5%) and 6283 females (49.5%) in the study. Heights ranged from 59 to 76, and averaged 70.0 for men and 64.2 for women. Overall, each extra inch of height conferred an $816.68 increase in yearly income (3.5% of average annual income, r2 = 0.89). For men, each extra inch of height from 64 to 70 correlated with an increase in yearly income of $1,244.61 (4.6% of average annual income for men), while each extra inch of height from 70 to 76 correlated with an increase in yearly income of $479.62 (1.8% of average annual income for men). For women, each extra inch of height from 59 to 70 correlated with an increase in yearly income of $876.28 (4.8% of average annual income for women).

Conclusion: For men, height is positively correlated with income, with diminishing returns above 70. For women, height is positively correlated with income up to 70. The average 70 male earns $2,489.22 more per year than the average 68 male, and over the course of 50 years employment would earn $124,461 more lifetime income. This study describes the relationships between adult height and income, with increasing adult height associated with greater income. Clinicians may wish to consider this factor when discussing contralateral epiphyseodesis versus ipsilateral lengthening with families.

#50: Assessing Psychological Contributions to the Outcome of Limb Lengthening

Barry Nierenberg (USA),
Gillian Mayersohn, Evan Smith, Laura Tabio, Sophia Serpa, Meg Nicholl

Question: Are there potential psychological risk and/or protective factors associated with rehabilitation outcomes in limb lengthening and/or deformity correction patients?

Methods: During the study (start date: 7/1/15), 5 versions of the self-report, proxy and observational measurers will be administered; including (a) pediatric patient (ages 8-12), (b) adolescent patient (ages 13-18), (c) adult patient, (d) parent/caregiver and (e) PT staff observation. Patients and caregivers will be asked to complete a psychological self-report battery tailored to patient age. Surveys will be administered electronically through the use of electronic tablets at the Institute (except for the 4 th follow-up time point). Data will be collected at 4 time points including: (1) Pre-physical therapy, (2) 6-8 weeks into physical therapy, (3) at exit from physical therapy at the Institute and (4) 6-8 weeks after completing physical therapy at the Institute. All participants will receive a $15 Amazon. com gift card for each completed survey. Next, brief chart reviews will be conducted by the Co-Authors under the supervision of the Presenting Author to gather additional patient demographic information. Data collected will then be de-identified, encrypted and stored in a secure database to protect confidential patient information. Data will be analyzed through SPSS21 to identify potential risk and protective factors for successful rehabilitation outcomes.

Results: De-identified data will be analyzed through SPSS21 to identify potential risk and protective factors for successful rehabilitation outcomes. This will be accomplished through a series of analyses directed at identifying and exploring trends in the data. Specifically, Pearson correlations, ANOVA, MANOVA and ANCOVA will be the primary analyses employed. Additional statistical techniques may be employed if necessary and presented as preliminary data findings.

Conclusion: Based upon preliminary data findings, will be made with the objective of identifying psychological risk and protective factors associated with rehabilitation outcomes in limb lengthening and/or deformity correction patients. We expect to identify several of he risk and protective factors for successful rehabilitation outcomes and then apply these findings to the clinical setting.

#51: Can a check list protocol improve quality in limb lengthening follow up?

Monica Paschoal Nogueira (Brazil),
Aurora Segre, Tatiana Gureschman, Rita de Cassia Ferreira

Question: Can a check list protocol improve quality in limb lengthening follow up?

Method: A check list protocol was proposed to improve quality and try to evaluate objectively every aspect of limb lengthening every visit. It included, for each visit, (every one or two weeks) the following observations: sleep, apetite, humor, pain, presence of infection, antibiotic therapy, alignment, regenerate, lengthening rate, physical therapy status.

Results: 7 patients followed this protocol, and visits were recorded in these forms. They allowed for controlled monitoring of the limb lengthening process, and allowed for adequate standardize recording of each variable. Variables not often observed in regular orthopaedic visits were possible, and that was important to see the patient and lengthening process in a more global way.

Conclusion: A check list protocol in limb lengthening can help following the patients in limb lengthening in a more global way, with more details and no missing data. It is also usefull in teaching in limb lengthening.

#52: Can the rehabilitation in extensive limb lengthening be more effective and painless?

Monica Nogueira (Brazil),
Sandra Prado, Cristina Reuter, Rodrigo Mota

Question: Can the rehabilitation in extensive limb lengthening be more effective and painless?

Methods: Six patients undergoing 14 limb lengthening (10 cm each) procedures were treated in an intensive Physical therapy protocol including 2 hours a day, 5 days a week program for 3 months. A program based on the approach of fascial manipulation treats limb lengthening as an acute fibromyalgiauntil active lengthening ends. A combination of techniques, including fascial manipulation therapy, pool therapy, proprioception and specific exercises prevent contractures or actively treat them before they get rigid. A painless approach is important, to avoid inflamatory changes in soft tissue.

Results: Patients reffered important improvement of both comfort and range of motion after therapy, and could sleep well. Sometimes temperature of the limb was changed after fascial manipulation, and muscles were palpable softer and more relaxed after each session. Contractures were avoided in 13 patients with this protocol. From the 14 limbs lengthened 10 centimeter, just one patient had important contractures, and that was the eldest patient undergoing treatment, because she was not cooperative, and could not follow the intensity of protocol. Patients cooperated with the protocol and were tired but satisfied with the approach. After 100 days lengthening, limb lengthening were resumed and patients could have a most relaxed protocol, 2 or 3 times a week, until able to walk and move around with no difficulties.

Conclusion: Fascial approach rehabilitation in extensive limb lengthening based on treating the lengthening myofascial syndrome or acute fibromyalgia should be recommended, for its effectiveness, and could be confortable and relaxing for patients. That could be the end of the no pain no gain rehabilitation approach in limb lengthening, so feared by the patients.

#53: Mid - And Long-Term Outcomes of Patients Undergoing Femoral Lengthening Using the Ilizarov Technique

David A. Podeszwa (USA),
Jennifer Rodgers, Anthony Anderson, John G. Birch

Question: To evaluate the mid - And long-term clinical, radiographic, and functional outcomes of patients who underwent femoral lengthening using the Ilizarov technique.

Method: A single institution call-back evaluation of patients who underwent femoral lengthening utilizing the Ilizarov technique, with a minimum 5 year follow-up from their most recent lengthening. Sixty-six patients met the inclusion criteria with 23 agreeing to return for evaluation. Upon return, each patient completed an interview, physical exam, self-reported outcome scores (Satisfaction with Life Scales [SWLS], PRIME MD, Lysholm knee score [LKS], Hip Disability and Osteoarthritis Outcome Score [HOOS]) and radiographic evaluation (pelvis, hip, knee and lower extremity).

Results: Twenty three patients (12 females) who had femoral lengthening at an average age 13.4 years (range 9-17) returned an average 15 years (range 5- 26 years) post-operatively. Twelve patients underwent lengthening for congenital deficiencies and 11 for acquired deficiencies. The average initial limb length discrepancy was 7.9 cm (3-16.2). Thirty percent (n = 7) underwent 1 lengthening with each patient undergoing an average of 6.70 surgical procedures (range 2-14) and sustaining 3.74 complications (range 1-9). Limb length discrepancy (LLD) at final follow-up was 1.7 cm (0-7.5 cm). For the lengthened extremity at final evaluation (n = 20), 61% of patients knee flexion strength was clinically weaker than the contralateral side and 89% of patients had clinically weaker knee extension. Similarly, hip flexion strength was clinically weaker for 68% of patients and extension strength weaker for 58% of patients. 86% of patients had ≥ 90 hip flexion with 82% having ≥ 90 arc of motion. 86% of patients had ≥ 90 of knee flexion with 86% having ≥ 90 arc of motion. Eighteen patients (82%) had radiographically normal hip joints. The remaining 4 patients had previous septic destruction of the hip. The average Kellgren/Lawrence knee arthritis score was 1.86 (range 0-4). Twelve (55%) demonstrated knee joint space narrowing, osteophytes and sclerosis. The average LKS was fair (73.7, range 34-100) with 9 (41%) having a poor score. The average overall HOOS was 83.9 with only 4 patients scoring below 70 (range 30 -100) on the pain subscale. Sixteen patients (70%) were satisfied or extremely satisfied with life. Patients reported mild to moderate, if any, symptoms of somatization, depression and anxiety.

Conclusion: At an average 15 years after femoral lengthening utilizing Ilizarov technique, the majority of patients demonstrate deficits in hip and knee strength and range of motion compared to the contralateral side. However, most patients reported good hip and fair knee function, satisfaction with ADLs and good mental health.

#54: Femur lengthening: a comparison of internal lengthening with a remote controlled magnetic internal lengthening nail versus lengthening over a nail

Anton M. Kurtz (USA),
Jonathan R. Barclay, Joseph Nguyen , Austin T. Fragomen , S. Robert Rozbruch

Question: Lengthening over a nail (LON) has been shown to be superior to lengthening with a previous generation of mechanical internal lengthening nail in the femur. It is unclear, however, whether a newer generation of remote controlled magnet driven internal lengthening nail (MILN) has overcome the weaknesses of earlier technologies. We asked which technique (LON or MILN) better achieved: (1) the lengthening goals, (2) the distraction rate control, (3) optimal quality of the regenerate bone, and (4) fewer complications.

Methods: We conducted a retrospective comparison study between LON and MILN techniques. We reviewed the records and radiographs of 21 consecutive patients with 22 femoral LONs between 2005 and 2009, and 35 consecutive patients with 40 femoral lengthenings using a remote controlled magnetic internal lengthening nail between 2012 and 2014. Details such as limb length discrepancy (LLD), etiology, time to bony union, knee range of motion, regenerate quality, and any complications encountered were compiled. The minimum follow-up times for the LON and MILN cohorts were 13 months (mean, 27 months; range, 1338 months) and 10 months (mean 19.9 months; range, 10-31 months), respectively.

Results: (1) Patients treated with MILN had a significantly smaller post-treatment residual LLD (0.0 mm) than those treated with LON (3.6 mm) (p = 0.003). (2) Rate of distraction was closer to the goal of 1 mm/day and more tightly controlled for the MILN cohort (0.9 mm/day, SD 0.1 mm/day) than for the LON group (0.84 mm/day, SD 0.19 mm/day) (p = 0.044). (3) Regenerate quality (as measured with the modified Li score), and healing index (months/cm) were not significantly different between the cohorts. Time to union, however, was shorter in the MILN group (3.3 months) than in the LON group (4.5 months) (p = 0.001). (4) Knee flexion at the end of distraction was significantly greater for MILN patients (105 degrees) than for LON patients (88.8 degrees) (p = 0.033). The percentage of patients who experienced a complication was not different in the MILN group (15.8%) than in patients treated with LON (20%) (p = 0.724).

Conclusion: Femoral lengthening with the MILN is safe and well controlled, offering the limb lengthening surgeon greater accuracy in achieving lengthening goals, tighter distraction rate control, faster time to union, and greater knee mobility during treatment as compared to lengthening with the LON technique while maintaining an acceptable risk of complications and reliable healing.

#55: Including future arthroplasty in preoperative planning of limb lengthening - A Plea from the arthroplasty surgeon

Mark T. Dahl (USA),
Russell A. McGill

Question: To include future arthroplasty in the length and deformity correction planning process, and establish dialogue between the limb lengthening surgeon and arthroplasty surgeon. To describe factors important to successful knee arthroplasty in patients whose arthroplasty was performed after extensive limb lengthening. Discussion total knee arthroplasty following extensive limb length and/or deformity reconstruction has not been reported. Limb length and deformity correction surgeons may not perform arthroplasty, and may not consider the future arthroplasty consequences of the limb lengthening they are to perform. Preoperative consultation between the lengthening surgeon and the arthroplasty surgeon is desired. Internal or external fixation procedures preceding arthroplasty are known to pose a risk of deep infection resulting from residual bacterial contamination of pin or wire sites or prior operative reconstruction. Pin tract infection during external fixation for limb lengthening is common and may pose additional risk of arthroplasty infection. Presuming infection, contracture, deformity, and premature arthroplasty revision or failure is more likely if a limb lengthening or bone transport procedure was previously performed, the authors recommend future arthroplasty to be included in the initial lengthening preoperative plan.

This is a retrospective, consecutive case series of thirteen patients that underwent lengthening of the femur or tibia followed by a later total knee arthroplasty. The potential need for future arthroplasty was evident at the time of lengthening in each case, and steps taken to avoid future arthroplasty complications were recorded. The etiology of the knee arthrosis was post-traumatic malunion in eight, post-sarcoma excision with osteoarticular allograft collapse in one, post-radiation for soft tissue sarcoma in one, congenital knee dislocation in one, childhood traumatic knee dislocation in one, and neurofibromatosis in one. Three patients with post-traumatic malunions were specifically referred to the lengthening surgeon by the arthroplasty surgeon requesting correction of shortening and angular malunion before an arthroplasty. In these cases, the lengthening surgeon discussed the arthroplasty surgeon's intentions pre-lengthening. In addition to a standard history, physical examination, and radiographs, preoperative screening included: blood serology for inflammatory markers in all, knee aspiration and culture in five, bone biopsy/culture in three, bone densitometry in four, technetium bone scans in eleven, computerized tomography in eight, and magnetic residence scanning in ten. Seven patients had infectious disease consultation, and four patients had endocrinology consultation.

Patient Demographics:
Three patients originally presented with infected diaphyseal bone defects, with positive cultures for clostridium per fringes and methicillin resistant staphylococcus (MRSA) in one, MRSA in one, and methicillin sensitive staphylococcus in one. One patient with neurofibromatosis presented for length and deformity correction with knee instability, angular deformity, shortening, and severe arthrosis after multiple osteotomies had been performed. One patient presented at age 36 with a history of untreated knee dislocation at age of 4 and an 11 centimeter LLD. Two patients presented with knee fusions associated with their length and deformity problem. Risk assessment based on comorbidities is established when one knows an arthroplasty will be required. Potential comorbidities such as tobacco use, alcoholism, diabetes, steroid dependence, anti-inflammatory use, obesity, are all investigated and patients are informed of their potential role in the future arthroplasty. Preoperative treatments included: calcium and vitamin D supplementation in eight, bisphosphonate treatment in three, physical therapy in eight, smoking cessation in five, dietary consultation for weight loss in three, and dental evaluation in all. Pre-lengthening planning included: osteotomy level, internal or external fixation, pin site position, deciding on the use of pins or wires, strategies for osteopenia.

Lengthening achieved averaged 6.2 cm (range 3.5 cm to eighteen cm). Residual limb length discrepancy averaged 12 mm, (range zero to 3.2 cm). Mechanical axis alignment was within four degrees of neutral in all patients. All patients were able to ambulate independently. Twelve of thirteen patients retained their arthroplasty at one to twenty two years (average 4.2 years. Antibiotic bone cement was used in all. Partial constraint was used in 12 of the 14 knees. Knee range of motion averaged ninety-five degrees (range 30 degrees to 135 degrees). Three patients required knee manipulation under anesthesia. One patient developed aseptic loosening of the arthroplasty after 5 years, and was treated by revision arthroplasty. One knee arthrodesis converted to TKA required an additional open fibrolysis and quadriceplasty, and achieved 85 degrees of active motion. One congenital knee dislocation without quadriceps continuity pre-arthroplasty underwent a hamstring to patella tendon transfer but required a hinged knee brace due to persisting knee extensor weakness.

: Preoperative planning for limb lengthening procedures expected to be followed by total knee arthroplasty should include the following: investigation for potential comorbidities, consideration of arthroplasty type and requirements, discussion with a future arthroplasty surgeon, and identifying special considerations for the arthroplasty. Pre-lengthening planning should also consider arthroplasty consequences of: osteotomy level, internal or external fixation, pin site position, deciding on the use of pins or wires, and strategies for osteopenia.

#56: Treatment of post traumatic limb length discrepancy with motorized intramedullary lengthening nails

Ahmed I. Hammouda (Egypt),
Julio J. Jauregui, Martin G. Gesheff, Shawn C. Standard, Janet D. Conway, John E. Herzenberg

Question : Post-traumatic limb length discrepancy (LLD) may present secondary to fracture malunion, epiphyseal growth arrest, or bone overgrowth. Distraction osteogenesis using external fixation to correct LLD is associated with many complications. Recently, intramedullary (IM) lengthening systems have been introduced as an alternative to avoid the problems of external fixation. What is the safety and effectiveness of using IM lengthening systems to treat posttraumatic deformities?

Method : Medical records were retrospectively reviewed to identify patients who underwent treatment for posttraumatic LLD at our institution between December 2011 and December 2014 with IM lengthening nails. We identified 15 bone segments (11 femora and 4 tibiae) in 15 patients (11 males and 4 females) with a mean age of 35 years (range, 11-66 years). Average goal of lengthening was 3.9 cm (range, 1.8-6.0 cm).

Results : Mean follow-up after insertion was 1.6 years (range, 0.5-2.9 years). All patients achieved the lengthening goal. Regenerate consolidation with full weightbearing occurred at a mean of 162 days (range, 60-481 days). The mean femoral consolidation index was 36 days/cm (range, 16-96 days/cm), and the mean tibial consolidation index was 66 days/cm (range, 24-108 days/cm). Six limb segments (40%) had complications. Only one patient developed limited knee range of motion after femoral lengthening.

Conclusion : Intramedullary lengthening nails are a potential improvement over external fixation for treatment of posttraumatic injuries. Further studies will be needed to assess the effectiveness of lengthening nails used in conjunction with acute angular/rotational correction.

#57: Minimal invasive plate osteosynthesis using customized patient instrumentation in open wedge high tibial osteotomy; A preliminary report

Dong Hoon Lee (Korea),
Marty Trabish, Keun Jung Ryu, Hyun Woo Kim

Question : Open wedge high tibial osteotomy (OWHTO) is well-established technique to correct varus alignment, but has a potentiality for several complications. Authors introduced minimal invasive plate osteosynthesis (MIPO) technique using fixator assisted plating, but it need amount of radiation exposure during surgery. We developed a customized patient instruments based on the fixator assisted plating in OWHTO. We aimed to (1) describe how to perform customized patient instrumentation in OWHTO, (2) analyze the accuracy of hinge location of the osteotomy, (3) analyze the accuracy of the frontal, sagittal and rotational alignment, and (4) report its complications.

Method : We analyzed 25 segments from 14 patients who underwent OWHTO with customized patient instrumentation. All patients underwent long-standing radiograph and CT scan preoperatively. A virtual software suite (HTO-OP3D, Zapalign Inc, Seoul, Korea) was then utilized to determine an osteotomy site, hinge location and correction angle necessary to achieve the target alignment. Prerequisite to performing the necessary calculations a virtual standing pose for each patient specific bone models was created. Using the virtual pose, the following measurements and calculations were recorded: 1) native axis passing point through the center of the tibial plateau in full extension. 2) a new passing point target at the spine center. 3) hinge location within the prescribed anatomic safe zone (ASZ defined at 1 cm beneath the lateral articular margin and direct lateral, offset 1.5 mm from the cortical bone margin) 4) k-wire targets, fixator pin locations, plate locations were determined. A custom instrument with the corresponding references was then printed using compliant medical grade plastic. The surgical procedure was done using the instrument in combination with the fixator assisted plating. During the surgery, the distance of the hinge point from the joint line were recorded and compared with the preoperative plan. The coronal alignment was checked intraoperatively with a grid method to confirm the accuracy of the new technique. Femoro-tibial mechanical axis, posterior slope were analyzed withpreoperative and postoperative standing orthoradiography. Adverse events were recorded. Duration of follow-up was minimal 6 months (means 6.8, SD 1.4).

Results : The differences of hinge location of the lateral cortex were 00.3 mm. The differences of mechanical axis deviation between expected one by preoperative planning and the grid method during the surgery were 00.6 mm. The difference between preoperative and postoperative posterior tibial slope was 00.5 degrees. There was no adverse event from the customized zig. Unintended lateral cortical breakages (5 segments; 20%), hematoma (0 segments; 0%), superficial wound infection (0 segments; 0%), deep infection (0 segments; 0%), clinical deep vein thrombosis (0 segments; 0%), delayed union (0 segment; 0%), hardware failure (0%), postoperative stiffness (0%) and aseptic nonunion (0%).

Conclusion : Customized patient instrumentation provided accurate guidance for the osteotomy plane and correction angle. Fixator assisted technique using this customized zig enabled minimal invasive plate osteosynthesis. Further studies are necessary to compare its accuracy and the amount of intraoperative radiation exposure with the conventional techniques.

#58: Lower Limb Lengthening Using a Novel Magnetic Intramedullary Lengthening System, First 100 Patients

Julio J. Jauregui (USA)
, A Hammouda, M Gesheff, S. Standard, J Conway, J. Herzenberg

Question : Intramedullary (IM) lengthening nails are attractive alternatives to external fixators for limb lengthening. Four different devices are currently marketed. The most recent is a magnetic powered system. So far, only limited reports with small cohorts of patients have been published describing this new technology. We report here our first two years experience with this novel internal magnetically powered lengthening nail. The purpose of this study is to evaluate the effectiveness of the magnetic powered internal lengthening nail in terms of lengthening accuracy and complications observed.

Method : An IRB approved retrospective study of all patients who underwent IM lower limb lengthening was conducted between January 2012 and March 2014. A total of 100 segments (71 femurs/29 tibias) in 78 patients (42 males/36 females) were included. Mean age was 21 years (range, 7-69 years). Mean goal of lengthening was 4.9 cm (range, 1.8-6.7 cm). The patient etiology included congenital femoral deficiency (CFD) +/- fibular hemimelia (FH) (37 segments), post traumatic shortening (13 segments), achondroplasia (14 segments), skeletal dysplasia (9 segments), hypochondroplasia (6 segments), hemihypertrophy (4 segments), Olliers disease (3 segments), club foot with limb discrepancy (3 segments), limb shortening post septic arthritis (2 segments), and miscellaneous causes (9 segments).

Results : Mean follow-up time was 1.5 years (range, 0.6-2.9 years). Lengthening achieved was 4.8 cm (range, 1.8 to 6.7 cm). Four out of 100 segments (4%) did not achieve their desired lengthening. The mean femoral healing index was 30.5 days/cm (range, 11.2-66.8 days/cm) and the mean tibial healing index was 46.8 days/cm (range, 23.1-111.7 days/cm), P = 0.0001. There were 56 complications observed in 37 out of 100 segments (37%) (21 femurs and 16 tibias). The majority of complications (85.7%) were lengthening related rather than implant related. Mechanical rod failure occurred in 2 segments and required exchange by larger telescopic nails to resume lengthening. Another 4 segments required exchange (after they achieved the desired lengthening) with regular non-lengthening nails due to bent or broken rods as a result of weight bearing non-compliance. Complications were more common in tibial segments (16/29 = 55%) versus femoral segments (21/71 = 30%) (p = 0.02).

Conclusion : The magnetically powered IM lengthening system provides an attractive alternative to external fixators for lower limb lengthening. Most of the complications are related to the lengthening procedure rather than implant related. Further studies with longer follow up are recommended to confirm our results.

#59: Anterior plating after lengthening of the femur, surgical technique

Mauricio Zuluaga,
Andres Machado, Federico Persico, Byron Miranda, Esteban Gonzalez, Gabriel Fletscher

Question: How to reduce the infection rate with plating after lengthening technique of the femur, during a single surgical procedure.

Methods: We performed the plating after lengthening of the femur through an anterior approach with mipo in a pin free zone. The technique was done in a single surgical intervention without a previous antibiotic course. We followed 34 patients for 6 months after the plating. The infection rate and other complications were analyzed.

Results: 32 patients completed the treatment without complications. 1 patient had a superficial infection which was treated with oral antibiotic, another patient with loosening of the plate. In 20 patients a decreased range of motion of the knee was documented. This contracture improved after the frame removal and plating.

Conclusion: This technique of anterior plating of the femur after lengthening using mipo technique through a safe zone is a reliable, and easy procedure with low rates of complications, improving the comfort of the patients, and decreasing the external fixation index during the osteodistraction treatment.

#60: Assessing Effect of the Level of Osteotomy in Femoral Lengthening Using monolateral Fixator

Hae-Ryong Song (Korea),
Kwang-Won Park, Tae-Jin Lee.

Question: Femoral lengthening by distraction osteogenesis is an established procedure for correction of limb length discrepancy. However, very few studies have examined the effect of the level of osteotomy in femoral lengthening. We aimed to determine whether a different level of osteotomy in the femur affects radiographic outcome, clinical outcome, and complication incidence.

Method: Isolated femoral lengthening with monolateral fixator was performed in 51 patients (mean age; 13 years, range; 5-22 years). Patients were categorized into the following 3 groups according to the level of osteotomy; group A (proximal, 11 patients), group B (middle, 25 patients), and group C (distal, 15 patients). Pre-operative and post-operative radiographic parameters, clinical outcome, and surgery-related complications were analyzed.

Results: Radiographic outcomes are not significantly different for axial alignment indices, callus progression patterns, lengthening percentage, lengthening index, external fixation index, and maturation index between any of the groups (p > 0.05). One month after surgery, 43% of patients in group A, 46% in group B, and 80% in group C demonstrated limited knee range of motion (ROM) less than 80°. At 1 year after surgery, all patients in groups A and C demonstrated full knee ROM whereas 4 patients (30%) in group B demonstrated limited knee ROM up to 100°. Transient postoperative limited hip ROM during the first 3 months was observed only in group A. When analyzing postoperative complications, group C had the greatest complication rate of 9.3 per segment, most of which (53%) required surgical intervention.

Conclusion: Different levels of osteotomy in femoral lengthening do not show any significant difference in radiographic parameters. Clinically, distal osteotomy was associated with greater restriction of knee ROM and demonstrated the greatest number of complications requiring surgical intervention. Our study suggests that proximal and middle osteotomies are preferable to distal osteotomy in femoral lengthening.

#61: Strut-to-bone lengthening ratio in hexapod external fixators

Alexander Cherkash
in (USA), Christopher Iobst, Mikhail Samchukov

Question: The most commonly reported rate of limb lengthening is 1 mm a day. In the Ilizarov-type external fixators distraction/compression rods are parallel to the bone axis and each millimeter of their length adjustment produces an equal amount of the bone length change. In the hexapod frames struts are oblique to the bone adjustment axis. Therefore, each 1 mm of strut length adjustment does not correspond to the same amount of bone length change. The purpose of this study was to find a correlation between the rate of bone lengthening and strut length adjustment in a hexapod frame. Specifically, what is the rate of strut length adjustment necessary to achieve 1 mm of daily bone length increase?

Methods: The study was performed in two stages. Initially, a software simulation of the straight lengthening was performed using two commercially available hexapod frames. Strut-to-bone lengthening ratio was calculated for each hexapod frame for various ring sizes and ring separation distances. Calculated ratio between the strut and the bone length changes was then validated in several assembled limb lengthening configurations for both hexapod frames.

Results: Each strut in hexapod frame assembly is oriented at an angle to the axis of the reference bone segment, which is usually aligned with the common vector of distraction. Therefore, 1 mm of single strut adjustment produces less than 1 mm of bone length increase. When two or more struts are adjusted simultaneously however, the resulting amount of bone length increase is greater than those of the individual struts. Comparative analysis of the strut and bone rates of lengthening in those cases using both computer program simulation and assembled hexapod frame configurations demonstrated that 1 mm of length increase in each of the struts always produced more than 1 mm of bone lengthening. Although the resulting amount of bone length increase was influenced by various frame and mounting parameters (rings diameter, struts length, ring separation distance, etc.) but it was always more than 1 mm, ranging from 1.3 mm to 4.8 mm.

Conclusion: In any hexapod frame configuration for limb lengthening, 1 mm of struts lengthening produces more than 1 mm of bone length increase. The strut-to-bone lengthening ratio depends on numerous frame and mounting parameters and, therefore, fluctuates during the limb lengthening. To achieve 1 mm bone length increase struts should be adjusted to a lesser amount. When using hexapod frames with minimum struts adjustment rate of 1 mm, each adjustment may produce an acute overstretching of the newly forming tissues resulting in pathological forms of distraction regenerate and its delayed consolidation.

#62: Comparison between lengthening motorized nail and lengthening over nail in 53 segments.

Anna Isart-Torruella (Spain),
Merc Revert-Vinaixa, Jordi Tapiolas-Badiella, Ignacio Ginebreda-Marti

Question : Lengthening over nail and motorized nail have beendeveloped to minimize or eliminate the times of external fixation in thelimb. The aim of the study is to compare two methods.

Method : Retrospective and comparative study of 47 patients with limb length discrepancy for different problems. We reviewed 53 lengthening procedures in femurs and tibias. The procedures were performed between 2001-2014. We studied epidemiological data and x-rays before and after interventions (the discrepancy, the anatomic and mechanicalangles of femur and tibia), the maturation and consolidation index andcomplications during and after the treatment.

Results : There were 13 patient limb lengthening proceduresperformed as motorized nail (MN) and 34 patient limb lengthening over thenail (LON) procedures. Among the results, there were 4 women/9 men in the MNgroup and 10 women/24 men in the LON group. The average age of the patients was 22.2 years MN and 25.3 LON. There were 9 lengthening femurs and 6tibias as MN and 27 femurs and 11 tibiae as LON. We observed no difference inachieving the lengthening between the two procedures and no differencebetween angles preoperative and postoperative. There were 2 majorsincidences and 1 complication as MN. There was 1 minor incidence, 8 major incidences and 3 complications as LON.

Conclusion : However, there were similar results between twoprocedures, the motorized nail needed only one implant, (one operation lessthan LON), it avoids the external fixation and its complications, betterrecovery and the patient experienced fewer complications than the LON.

#63: Short above knee amputation stump lengthening: A casereport using motorized intramedullary lengthening

Mark T. Dahl (USA),
Russell A. McGilll, Elizabeth Weber, Jennifer Laine

Question: Describe a case report of short above knee amputation stump lengthening with a motorized intramedullary nail.

Method: A 31 year old Special Forces soldier sustained bilateral above knee amputations after stepping on an improvised explosive device (IED). The right femoral stump of 13.5 cm length was too short for an AKA fit without suspension. The left femoral stump of 36 cm was successfully fit. A percutaneous corticotomy was performed and a 5 cm stroke Fitbone stump lengthener was inserted into the femur retrograde. After a 5 day latency period, the patient lengthened with the remote control every 8 hours, achieving 5 centimeters of distraction at day 55. The distal locking bolt cut-out at reaching the maximal length due to weak bone at the distal stump tip, losing 3 cm of the length gained. The length was restored and an additional 3 cm was gained with the use of a circular fixator for 2 weeks. A new distal locking bolt was then inserted and the 8 cm lengthening site was allowed to corticalize. A second lengthening was performed 90 days later, after 3 cortices became evident on x-ray. The original lengthening nail was replaced with a 10 cm stroke nail and a second corticotomy performed just below the lesser trochanter. After a 5 day latency period, lengthening was initiate d, achieving 8 cm more length. The second lengthening was discontinued as the distal soft tissues became thin. A combined total of 16 cm of length was achieved. The patient achieved independent ambulation 380 days after initial lengthening treatment. No pain, skin irritation, or fitting issues exist at one year follow- up. The distal locking bolt cut-out resulted from insufficient bone purchase at the distal stump. The lengthening nail was 13.5 cm, as was the stump length, measuring from pirifomis to the distal end of the bone, but several mm of that bone was actually heterotopic bone and not native cortical bone, thus the screw cut-out. Future cases with such a situation would have better distal fixation secured with cerclage wires through the native cortical bone looped through the nail locking bolt hole. No signs of pin tract infection developed in the 15 day interval of fixator use. Hip flexion contracture of 45 degrees developed during the second lengthening, and was treated with fractional lengthening of the adductor longus and rectus femorus. Full hip extension, flexion, abduction, adduction and rotation were restored by 12 weeks post second lengthening.

Results: The total length gain was 16 cm, greater than doubling the original bone length. Consolidation time was short (healing index = 0.6 month/centimeter). The final outcome achieved an excellent prosthetic fitting and independent ambulation with bilateral above knee prosthesis.

Conclusion: Ideal prosthetic use after amputation requires four factors to be present: 1) Muscle power must be sufficient. 2) A longer stump provides better cantilever function and requires less energy expenditure. Additionally, a longer femoral stump can accommodate an above knee fitting instead of a pelvic weight bearing or suspension prosthesis. 3) The end soft tissue surface must be durable enough to distribute load within the prosthetic socket. 4) Joint motion must be sufficient to allow for the full gait cycle. Little literature exists on the benefits of short stump lengthening. All literature regarding this topic deals with fixator achieved length. Horesh et al. described a better and more stable prosthetic fitting after Ilizarov lengthening of an above knee amputation stump. Amputation stump lengthenings require much greater magnitude than are ordinarily attempted for limb length discrepancy. These large magnitudes put the hip joint at greater risk for contracture and the distal stump at risk for soft tissue thinning and even bone penetration through the distal soft tissue envelope.

#64: The residual limb lengthener for short amputation stumps

Stuart A. Gre
en (USA), Serge Kaska, Jean Claude D'Alleyrand, Mark Dahl

Question: How to elongate the stump of a very short amputated limb to improve function and increase ambulatory capacity

Methods: We have developed a telescoping internal limb lengthening device that works like the leg of a camera tripod: a tube within a tube allows a very short initial length and substantial elongation. It is motorized by a spinning magnet attached to a spindle within spindle. An external remote controller turns the internal magnet, which lengthens the device.

Results: Preliminary results in our first four patients will be presented. The device functions as contemplated. Increased functional capacity is evident as the patients can be converted from a ischial weight-bearing prosthesis to a quadrilateral socket, with better ambulatory speed and lower oxygen consumption during ambulation.

Conclusion: The Residual Limb Lengthener is an ideal device for elongated very short amputation stumps. A proper soft tissue envelope is essential for a successful outcome.

#65: Shortening methods in LLD treatment Phemisterepiphysiodesis vs. shortening osteotomy.

Pawe Koczewski (Poland),

Question: Introduction: Nowadays limb lengthening is the most common method in leg length discrepancy (LLD) treatment. Although shortening methods are still useful in selected cases with contraindication for lengthening procedures or as a complementary procedure in severe LLD. In treatment strategy planning may arise dilemma which method should be used: epiphysiodesis in growing period or shortening osteotomy after growth finishing. The aim of the study is to compare two shortening methods: (1) femoral, subtrochanteric osteotomy (SO) and (2) Phemisterepiphysiodesis, according to effectiveness, accuracy and risk of complication.

Methods: Two group of patients surgically treated because of LLD were evaluated: Group A - 18 cases treated with SO with plate fixation with mean age at surgery 17.8 years (12.2 to 24.3) and mean preoperative LLD 4.1 cm (2.5 to 7.0). Group B - 18 cases treated with Phemisterepiphysiodesis with mean age at surgery 12.8 years (9.4 to 14.9) and mean preoperative LLD 3.8 cm (2.0 to 9.0). Femoral resection in SO ranged from 2.5 cm to 5.0 cm (mean 3.7). Age of epiphysiodesis was determined according to LLD, skeletal age and Green-Anderson charts. Follow-up time ranged from 6 months to 19.5 years (mean 5 years). Results were classified according to Kemnitz and Campens classification: good final LLD 2 cm, overcorrection 1 cm or complication with permanent effect needing surgery.

Results: In group A good result was achieved in 15 cases, poor in 3. Complications were noted in 5 cases (28%). The most frequent complication was delayed union. Mean final LLD was 0.6 cm (0 to 3.0). Full equalization was achieved in 13 cases (72%). In group B good result was achieved in 8 cases, fair in 3 and poor in 7. Complications were noted in 6 cases (33%). The most frequent complication was epiphysiodesis failure (3), overcorrection (2) and axial deviation (1). Mean final LLD was 2.2 cm (0.4 to 7.5). Full equalization was achieved in 4 cases (22%).

Conclusions: 1. Phemisterepiphysiodesis have relatively low accuracy with high risk of under- or overcorrection. 2. Risk of complication in both methods is comparable. 3. Shortening subtrochanteric osteotomy with plate fixation in LLD treatment, having regard to limiting the amount of correction to 5-6 cm and risk of delayed union, is effective and predictable method.

#66: Technical implant failures in intramedullary bone lengthening

Gerald E
. Wozasek ( Austria), Thomas Tiefenbck, Lukas Zak

Question: The magnet-driven fully implantable and remotely controlled intramedullary nail is a novel technology, and literature regarding its safety, efficacy, reliability, patient satisfaction, and complication rates is limited. We noticed a number of weak points of this new implant, which have to be addressed by the manufacturer in the near future.

Methods: Ten patients for correction of post traumatic or congenital length discrepancy and deformity of lower extremities treated with a PRECICE nail were included in this prospective follow-up study. All patients were followed up routinely clinically and radiologically.

Results: In all patients limb-lengthening goal was reached. However in 2 cases mechanical failure with unintended shortening was seen one during the distraction period the other one 8 months later. Furthermore in the second case loosening of the interlocking bolts occurred. In the third case nail breakage with severe deformity happened 1.5 years after implantation.

Conclusion: Limb lengthening with fully implantable systems are promising to improve future treatment concepts in limb lengthening. The welding seam is a weak point of the first generation of the telescopic nail, which has been modified in the second generation of these implants. Further developments such as revision interlocking bolts and improvements of the lengthening mechanism will be necessary to secure uneventful lengthening and to prevent future legal liability aspects of this high tech implant.

#67: Evaluation of a Mobile Application for Multiplier Method Growth and Epiphysiodesis Predictions

Pablo Wagner (Chile),
Shawn C. Standard, John E. Herzenberg,

Question: The multiplier method (MM) is frequently used to predict limb length discrepancy and timing of epiphysiodesis. The traditional MM uses complex formulae and requires a calculator. A mobile application was developed in an attempt to simplify and streamline these calculations. How does the accuracy and speed of using the traditional pencil and paper technique compare with using a mobile application (MA)?

Methods: After attending a training lecture and a hands-on workshop in the MM and MA, 30 resident surgeons were asked to apply the traditional MM and the MA at different weeks of their rotations. They were randomized as to which method they applied first. Subjects performed calculations for five clinical exercises that involved congenital and developmental limb length discrepancies and timing of epiphysiodesis. The amount of time required to complete the exercises and the accuracy of the answers were evaluated for each subject.

Results: The subjects answered 60% of the questions correctly using the traditional MM and 80% correctly using the MA (p = 0.001). The average amount of time to complete the five exercises with the MM was 22 minutes and with the MA was 8 minutes.

Conclusion: Several reports state that the traditional MM is quick and easy to use. Nevertheless, even in the most experienced hands, performing the calculations in clinical practice can be time consuming. Errors may result from choosing the wrong formulae and from performing the calculations by hand. Our data show that using a mobile application is simpler, more accurate, and faster than the traditional multiplier method from a practical standpoint.

#68: Comparative hexapod frame free play evaluation using The mathematical modeling

Petr Vvedenskiy (Russia),
Konstantin Mikheev, Mikhail Samchukov, Alexander Cherkashin

Question: The stability of bone segment fixation within the external fixation device is one of the important parameters influencing the activity of distraction osteogenesis and, therefore, the final treatment outcome. It is well-known that all the existing hexapod-type external fixators have a certain degree of free play between the external supports due to numerous mobile connections in their struts. The purpose of this study was to investigate how does the free play between the rings of hexapod-type fixation devices depends on the frame configuration, specifically distance and angle between rings.

Methods: The mathematical modeling of the free play along the axis of the rings was performed using a specially developed computer program allowing creating the 3D virtual models of frames with regard to their real geometry. Four commercially available hexapod fixation devices were utilized including TSF (Smith & Nephew Orthopaedics, Memphis, TN), TL-Hex (Orthofix, Verona, Italy), Ortho-SUV (S. H. PITKAR, India), and PoliHex (Litos, Hamburg, Germany) frames. The ring sizes and their relative location (angle and separation distance) were entered into the program to simulate a specific device configuration. This was followed by entering the deformity parameters (angulation in two planes, length of the proximal and distal segments from the apex of deformity), mounting parameters (frame offset in two planes), and experimentally measured individual struts axial free play. Based on the data entered, the program calculated the total amount of rings free play !along the axis of the frame, which was passing through the centers of the rings. The study was divided into two series of testing. In the first series of experiments, the calculations of the free play values between parallel and symmetrically located rings were performed using 155 mm (TSF) and 160 mm (other frames) diameter rings with ring separated distance varied from 180 mm to 50 mm. In the second series of testing, the free play values were calculated between rings located at the different angles relative to each other ranging from 0 to 70.

Results: The obtained data revealed the following specific patterns. The axial free play values increased in respond to decrease of the distance between two rings as well as in response to increase of the angle between rings. Those patterns were similar to all four hexapod frames. In all testing modes, the TL-Hex hexapod demonstrated the minimal values of the free play with the minimal deviation of the free play values with changes in the ring separation distance and ring orientation angle. Overall, those free play values for the TL-Hex frame were 3 times less than those for the TSF, 4 times less than Orto-SUV frame free play, and 2 times less than the free play values for the PolyHex. Obtained theoretical free play values were validated experimentally using four mentioned above devices in the similar frame configurations.

Conclusion: The developed computer program can be useful for orthopedic surgeons as the tool of selecting the optimal hexapod frame configurations with the minimal amount of free play. The free play values obtained with mathematical modeling are reliable and can be implemented for different hexapod frames and in different configurations.

#69: Comparative analysis of the trajectory of bone segments movement in the hexapod frames

Petr Vvedenskiy (Russia),
Konstantin Mikheev, Mikhail Samchukov, Alexander Cherkashin

Question: One of the important parameters of limb lengthening and deformity correction influencing the activity of distraction osteogenesis is the rate and the rhythm of distraction allowing the bone segments to move incrementally resulting in production of the newly formed bone. With the classic Ilizarov-type of external fixators, this movement is achieved along the straight (or arched) line either by threaded/telescopic rods or pair of hinges and angular distractor. As result, those devices allowed a utilization of the Ilizarov distraction protocol with a one millimeter of daily distraction divided in four increments. Although modern hexapod-type of external fixators allowed simultaneous correction of multi-planar deformities in 3D space, the trajectory of bone segment movement due to adjustment of the six struts can be deviated from the straight (or arched) line. Therefore, the purpose of this investigation was to analyze the trajectory of bone segments movement using two hexapod frames. More specifically, what is the deviation of that trajectory from the straight line?

Methods: The mathematical modeling of bone segments movement was performed using a specially developed computer program allowing to reconstruct the trajectory of this movement in the hexapod frames. Two commercially available hexapod frames were included in the study including TSF (Smith & Nephew Orthopaedics, Memphis, TN) and TL-Hex (Orthofix, Verona, Italy). The intermediate points of movement trajectories were calculated for both frames based on the prescription tables created by the associated TSF and TL-Hex software. Importantly, two different approached were revealed in the prescribing of daily adjustment in those two hexapod frames. In the TSF prescription, the overall strut length adjustment (total number of clicks) is equally dividedthroughout the duration of deformity correction. This approach with the same amount of daily adjustment for the same strut is less confusing and more convenient for the patient. The algorithm, utilized in creating of TL-Hex prescription is different and producing daily amount of strut adjustment without such averaging. It proposes to change the length of the struts so as to ensure uniform motion of the bone segments along a predetermined trajectory at a predetermined movement speed. Thus, the amount of each strut daily lengthening is modified at the each next step of correction, resulting in different amount of their adjustment.

Results: Using those two approaches, the trajectory of bone segments movement were calculated for different types of deformity correction and lengthening. The analysis of trajectories modeled using the TL-Hex prescription algorithm revealed that bone segments are always moving along the straight line with equal amounts of movement per each increment. All the trajectories of bone segments movement modeled using the TSF prescription approach were curvilineal or spiral-shaped with significant deviations from the straight line during each increment of movement reaching more than 15 mm.

Conclusion: Prescription algorithm of the TL-Hex hexapod frame is more optimal for bone segments movement than that for the TSF. The implementation of the algorithm used in the TL-Hex software allows to move the bone segments during deformity correction and limb lengthening within the trajectory nearly close to the straight line.

#70: Mechanical behavior of Taylor Spatial Frame and Ilizarov external fixator

Leonidas Spyrou (Greece),
Alexis Kermanidis, Nikolaos Karamanis, Nikolaos Aravas, Konstantinos Malizos.

Question: What is the biomechanical behavior of a standard Taylor Spatial Frame and Ilizarov apparatus?

Method: Both fixators are studied experimentally and numerically. First, mechanical testing was conducted and used in order to validate the corresponding Finite Element (FE) models that were developed. The mechanical models were used next for a parametric evaluation of both fixators.

Results: The results focus on the axial mechanical behavior of both fixators, the deformed configurations upon loading, load distribution and prediction of callus formation.

Conclusion: The biomechanical analysis show that callus formation may present substantial differences between treatments with TSF frames and Ilizarov frames. The results suggest that TSF and Ilizarov frames may operate under different biomechanical principles.

#71: Application of computer-assisted frame in treatment of long-bone deformities in children and adults: experience of more then 500 cases

Leonid N. Solom
in (Russia), Victor A. Vilenskiy, Elena A. Tschepkina, Edgar V. Bukharev

Question: The question was to evaluate the efficiency of software-based Ortho-SUV Frame - OSF (www. ortho-suv. org) in treatment of long bone deformities in adults and children.

Method: We analyzed the results of long bone deformity correction performed in two centers: 342 adult cases were treated during period from 2006 till 2015 in one clinic (Group 1) and 162 children who received treatment in period from 2011 till 2015 in another clinic (group 2). Totally the frame was applied 605 times in 504 patients. In the 1 st group, 263 patients had acquired deformities (posttraumatic, including the consequences of osteomyelitis), 79 had congenital. In group 2, 137 patients had congenital deformities (including resulting different bone diseases), and only in 25 cases - posttraumatic. In group 1, according to the classification of long bone deformities (http://www. ortho-suv. org/images/stories/deform_class2. jpg) 38 cases had simple deformities (SD), 137 cases deformity of middle complicity (MD) and 167 cases - complex (CD). In group 2 SD were found in 24 cases, MD were found in 54 cases, and CD were found in 84 cases. The results are evalua! ted on the following parameters: a period of deformity correction (DCP), external fixation index (EFI), accuracy of deformity correction (AC), the number of complications. To assess the AC we used reference lines and angles.

Results: In group 1 OSF was applied in 342 cases (408 frames); in group 2 in 162 (197) cases. In group 1 DCP was 14,56,62 days for SD; 18,18,22 for MD and 3713,62 for CD. EFI for SD was 45,212,1 days/cm, for MD - 44,3214,22 and for CD - 47,5815,32. AC for deformities in frontal plane was 92,3% and for deformities in sagittal plane 94,6%. The reached MAD in varus (valgus) deformities were 4,2 + 3,1 (3,3 + 3,12). Reached mMPTA in varus (valgus) deformities was 87,4 + 4,32 (88,1 + 5,42); mLDTA 88,2 + 4,7 (87,2 + 4,26). In procurvatum (recurvatum) deformities reached PPTA was80,5 + 7,3 (82,15 + 6,5), ADTA 81,6 + 4,2 (79,2 + 6,2). In group 1 DCP was 11,28,4 days for SD; 14,67,42 for MD and 2015,3 for CD. EFI for SD was 30,216,2 days/cm, for MD - 33,613,4 and for CD - 36,214,1. AC for deformities in frontal plane was 92,5% and for deformities in sagittal plane 90,1%. The reached MAD in varus (valgus) deformities were 1,3 + 7,4 (2,2 + 6,5). Reached mMPTA in varus (valgus) deformities was 86,3 + 6,6 (90,4 + 7,2); mLDTA 91,1 + 5,8 (88,2 + 6,2). In procurvatum (recurvatum) deformities reached PPTA was 80,2 + 3,4 (81,3 + 2,4), ADTA 82,3 + 7,2 (80 + 6,6) The complications in group 1 (2) were the following (%): pin-tract infection 20 (16); joint contracture 12 (17); breakage of transosseous elements - 5 (3); non-union or atrophic regenerate formation 6 (3); chronic osteomyelitis recurrence 5 (0); secondary fractures and deformities 4 (6).

Conclusion: Application of OSF in long-bone deformity correction provides high accuracy and short terms of correction which is a prerequisite for its further use.

#72: MicroRNA-S03 promotes bone formation in distraction osteogenesis through targeting Smurf1

Yuxin Sun (Hong Kong),
Liangliang Xu, Jinfang Zhang, Xiaohua Pan, KM Chan, Gang Li

Question: Distraction osteogenesis (DO) is a unique technique to promote bone formation in clinical. However the underlying mechanism of DO is still unrevealed. Recently, microRNAs have been reported to play important roles in regulating osteogenesis. In this study, we aimed to confirm the hypothesis that some special microRNAs could regulate the bone formation during the process of DO

Methods: After successfully established the DO model of rats, a microRNA microarray was performed to compare the microRNAs expression levels between the bone samples derived from distraction area and contralateral side.

Results: Total 100 different microRNAs were found changed, with 74 microRNAs up-regulated and 26 down-regulated. Through screening, as one of the most highly expressed microRNAs, miR-503 was found gradually up regulated during osteogenic induction in mesenchymal stem cells of rats (rBMSCs). Besides, overexpression of miR-503 in rBMSCs could promote osteogenesis by up regulation Run × 2 and BMP2. Furthermore, luciferase report assay confirmed that Smurf1 was the direct target gene of miR-503. Finally, rBMSCs overexpression miR-503 was successfully constructed and locally injected into the distraction gap in DO animal. The results indicated that miR-503 overexpression therapy could promote mineralization in DO process in vivo.

Conclusion: In conclusion, miR-503 was found to regulate osteogenesis during the process of DO and overexpressing of miR-503 resulted in acceleration of mineralization of DO, which not only give clues to the underlying mechanism of DO but also provide potential therapeutic targets in clinical.

#73: The effect of HIV infection on the incidence and severity of circular external fixator pin track sepsis: A retrospective comparative study of 229 patients

Nando Ferreira (South Africa),
Leonard Charles Marais

Question: Does HIV infection pose an increased risk to the development and severity of pin site infection with the use of circular external fixators?

Methods: We performed a retrospective comparative analysis of all patients treated with circular external fixation between July 2008 and December 2012. Pin site infection rates and severity, as classified according to Checketts and Otterburn, was compared between HIV positive and HIV negative individuals.

Results: 229 patients were included. 40 patients were HIV positive. The overall incidence of pin site infection was 22.7%. HIV infection did not affect the incidence of pin site infection (p = 0.9). The severity of pin site infection was not influenced by HIV status (p = 0.9) or CD4 count (p = 0.2).

Conclusion: With the employment of meticulous pin insertion technique and an effective postoperative pin site care protocol, circular external fixation can be used safely in HIV-positive individuals.

#74: Postseptic LLD and axial deformity treatment using external fixation

Pawe Koczewski (Poland),
Milud Shadi

Question: Introduction Neonatal septic arthritis leads to severe shortening and axial deviation. This pathology is good indication for reconstruction using Ilizarov method with different types of external fixation. Aim: Evaluation of treatment results of postseptic deformities with Ilizarov method.

Methods: Material and method 102 segments (88 femur, 14 tibia) in 75 patients (42 boys, 33 girls) with mean age at surgery 13.6 (6.4 to 21.5) treated with external fixation between 1995-2010 were analyzed. The indication for surgery was LLD from 1.5 to 18 cm (mean 6.0) in 93 cases, combined with axial deformity (from 8 to 50, mean 18) in 47 of them and isolated axial deformity in 9 cases. The etiology of the deformity was septic arthritis of different localization: knee 83, hip 35, ankle 4. In 20 patients there was multifocal: hip and knee 17, ankle and knee 3. Isolated lengthening was performed in 46 cases, isolated axial correction in 9 cases, combined lengthening and axial correction in 47 segments. Double levelosteotomywas made in 4 cases.

Results: Results In 56 patients there was one stage surgery and in 19 multistage (two stages 12, three stages 6, four stages 1). Mean lengthening achieved was 5.2 cm (2.5 to 12). Complete axial correction was observed in all cases, but in 10 cases recurrence of the deformity was observed during growth. As a complication, knee flexion limitation needing quadriceps plasty was observed in 4 cases and fracture of the regenerate in 2 cases (treated with external fixation). As an obstacle premature regenerate consolidation (treated with osteoclasia) was noted in 6 cases, knee ROM limitation needing secondary stabilization in 2 cases.

Conclusion: External fixation in postseptic bone deformity treatment allows simultaneous axial correction and lengthening with low rate of complications and no risk of recurrence of septic arthritis. In younger patients multistageprocedure isneeded.

#75: The timing of conversion to intramedullary nailing in cases of infection during external fixation

Yuko Irie (Japan),
Tomohiro Yasuda, Kazumasa Watanabe, Mitsutoshi Sagara, Masaya Yamaguchi, Shu Obara

Question : Infectious pseudarthrosis is treated by bone transport once the infection has been alleviated, and treatment is completed with external fixation in place. Although external fixation does not require additional surgery, it has the disadvantage of reducing patient's quality of life (QOL). However, internal fixation is accompanied by the risk of re-infection. In the present study, we treated two patients who developed infection during external fixation, and after treating osteomyelitis; we therefore had no choice but to convert to intramedullary nailing.

Method : Here we examine two cases and their timings of conversion to intramedullary nailing, following concurrent infection. Case 1: A 21-year-old woman incurred an open fracture of the right femur after a fall. The open wound was contaminated with soil; hence, deep infection developed. Following debridement and surgical removal of the infected bone, bone transport was performed using orthofix external fixation; however, the docking site developed a re-infection. Therefore, after waiting for a certain period of time after completing the bone extension and treating the infected region, we converted to intramedullary nailing. Case 2: A 40-year-old man underwent internal fixation at a different hospital for a fracture of the right femur when he was 23 years old. At 40 years of age, the patient underwent leg-lengthening for the shortened femur. Infection developed at the site of pin insertion, and the patient was transferred to our department. Once the infection was alleviated, we corrected an alignment of the femur by osteotomy, and converted to intramedullary nailing.

Results : The waiting periods following external fixation removal were 14 and 22 weeks for Cases 1 and 2, respectively. The waiting periods were determined on the basis of laboratory tests and clinical findings. GK Dendrinos et al. successfully treated 28 patients with infectious pseudoarthrosis using the Ilizarov method with no concurrent infections occurring during the external fixation.

Conclusion : To treat patients with concurrent infection during external fixation, we converted to intramedullary nailing after treating infection with a certain waiting period. We hereby report the timing and incidence of this along with a review of available literature.

#76: Management of tibial osteomyelitis associated with soft tissue loss

Andres Machado (Colombia),
Gustavo Calvache, Byron Miranda, Mauricio Zuluaga, Gabriel Fletscher, Federico Persico

Question: In patients with panosteomyelitis of the tibia associated with soft tissue defect, which surgical techniques are useful to manage both problems

Methods: Multiple surgical techniques had been described to manage bone infections with soft tissue coverage problems. The right choice of technique and timing to perform the procedures improves the outcome on this challenging cases.

Results: We describe a case with staged-combined surgical techniques for the management of bone infection and insufficient bone coverage as well as timing chosen to performed those procedures. First stage: surgical lavages and debridements of the tibia and deep soft tissues, external fixation with ilizarov frame extended to the foot to protect the ankle joint. Also, the Vaccum Assisted Closure (VAC) was used to close the wound. Second Stage: a soleus flap was used to resolve the soft tissue problem with delayed split thickness skin graft 5 days later

Conclusion: The surgical debridement is the main aspect in the treatment of tibial osteomyelitis. Even in critical bone loss and loss of soft tissue coverage, th ere are tools to solve those problems.

#77: Simultaneous Bilateral Femoral and Tibial Lengthening in Patients with Achondroplasia

Lior Shabtai, MD (USA)
, Julio J. Jauregui, Martin G. Gesheff, Shawn C. Standard, John E. Herzenberg

Question : Previous studies reported bilateral extensive (~10 cm) femoral lengthening followed 2 years later by bilateral extensive (~10 cm) tibial lengthening. This can be very stressful on the limb. In an effort to decrease the trauma on soft tissues and joints, we propose bilateral simultaneous moderate (~7 cm) femoral lengthening and moderate (~5 cm) tibial lengthening. A few years after this initial treatment, the same lengthening strategy is repeated. Both extensive and moderate strategies result in the same 20 cm of total lengthening. What is the safety and effectiveness of this moderate lengthening method?

Method : Fifty patients (29 boys, 21 girls) with achondroplasia underwent 65 lengthening procedures. We defined a procedure as simultaneous bilateral femoral and tibial lengthening. Minimum required follow-up after frame removal was 12 months. Amount of lengthening of each bone, range of motion (ROM), and complications were obtained from the medical records.

Results : Mean follow-up after bone healing was 35.6 months (range, 12102 months). Mean age at the first lengthening was 11.8 years (range, 7.129.3 years). Mean duration of treatment with external fixation was 6.7 months (range, 4.410.5 months). Mean tibial lengthening was 52 mm (range, 2579 mm), and mean femoral lengthening was 72 mm (range, 11105 mm). One patient experienced compartment syndrome during the second lengthening and chose not to continue lengthening after the compartment syndrome resolved. Average healing index was 1.4 months/cm for the tibia (range, 0.582.23 months/cm) and 1 month/cm for the femur (range, 0.574.56 months/cm). Sixty of the 78 complications required additional surgical procedures, and all 78 resolved by the end of treatment. Excluding pin-site infections and other obstacles, the complication rate was 0.23 complications/limb segment. Mean hip, knee, and ankle ROM remained the same after treatment. The mechanical axis deviation improved from a mean of 15 mm medial to 8 mm medial. No correlation was found between the complication rate and the amount of lengthening or secondary lengthening procedures.

Conclusion : Bilateral simultaneous moderate femoral (~7 cm) and tibial (~5 cm) lengthening in patients with achondroplasia is an effective procedure. ROM recovers after treatment. We observed a lower complication rate than what has been reported in the literature for limb lengthening in patients with achondroplasia.

#78: Infection during motorized internal lengthening

Connor J. Gre
en (USA), Shawn C. Standard, Janet D. Conway, John E. Herzenberg

Question: What are the risk factors for infection during limb lengthening using a motorized internal nail?

Methods: This was a retrospective review of a defined cohort. We identified all patients who had undergone limb lengthening using a motorized internal nail at our institution. We then defined a list of known risk factors for surgical infection and carried out a chart review to identify these risk factors in our cohort. These risk factors included age, BMI, smoking, diabetes mellitus, vascular disease, cancer, prior irradiation, endocrinopathy, neuromuscular disease, previous trauma to lengthened limb, immunosuppressive disease, intravenous drug abuse, steroid use at time of surgery, prior external fixation in that bone, prior external fixation in a different bone, previous infection in the lengthened bone, surgical duration, blood loss, perioperative blood transfusion and antibiotic type and dose at induction at induction.

Results: A total of 158 patents were identified. There were 84 males and 74 females. The average age was 20 years. We had a total of 3 deep infections (1. 9%). When the defined list of infection risks were analyzed no factor reached statistical significance as an individual risk factor for infection. This is not surprising given the low rate of infection and the diverse patient cohort. However, when the groups were subdivided into those who had and had not undergone previous external fixation for lengthening in the past all of the infections were in the previous external fixator group. This resulted in an infection rate of 4% in this group. This is a statistically significant difference between the groups in terms of infection rate.

Conclusion: We found 4% in the subgroup with a previous external fixator compared to 0% in those who had no previous external fixator. We suggest that patients with a history of external fixation be counseled in relation to the increased infection risk. For high risk patients we suggest pre-operative STIR MRI may be helpful. If edema is identified in previous pin sites a staged procedure could be considered. The first procedure would be to debridement of the previous pin sites and insertion of an antibiotic eluting intramedullary device to sterilize any latent infection. At a second procedure the motorized internal nail is inserted for lengthening.

#79: Treatment of patients with chronic periprosthetic infection of the hip joint using temporarily stabilizing systems

Artem Ermakov (Russia),
Nikolay Klyushin, Yuri Ababkov

Question: Study the effectiveness of differentiated treatment techniques of patients with chronic periprosthetic infection of the hip joint using temporarily stabilizing systems

Methods: There was done analysis of treatment of 155 patients with chronic periprosthetic infection of the hip joint with the use of temporarily stabilizing systems in the form of a spacer and/or Ilizarov fixator

Results: The proposed complex of treatment of patients with chronic periprosthetic infection with the installation of a spacer and/or the Ilizarov fixator allows saving the support ability of the limb for the arresting time of the pyoinflammatory processes, prevents dislocation of the hip, reduces the risk of the disease recurrence, allows to do re-replacement with the restoration of limb function to the fullest extent possible. Provision of the support limb function during treatment of chronic periprosthetic infection contributes to the arrest of the pyoinflammatory process and optimizes the reparative process as evidenced by normalization of clinical, biochemical and immunological parameters by the end of surgical rehabilitation

Conclusion: The use of the proposed technology of treatment of patients with chronic periprosthetic infection of the hip joint allows us to achieve a stable arresting of the pyoinflammatory processes and the subsequent maximum possible anatomical and functional recovery of the affected limb by re-replacement or resection arthroplasty that improve the functional state of the limb by 26%

#80: Osteosynthesis by Ilizarov in patients with chronic osteomyelitis

Artem Ermakov (Russia),
Nikolay Klyushin, Yuri Ababkov, Sergey Burnashov, Alexey Mikhailov

Question: Study the effectiveness of the developed technology of regenerative treatment of patients with chronic osteomyelitis by transosseous osteosynthesis according to Ilizarov in a specialized Center of purulent osteology

Methods: There was done analysis of treatment of more than 9 000 of patients with chronic osteomyelitis of different localization and various concomitant orthopedic and trauma pathology. At the same time in 3670 patients during rehabilitation treatment in addition to conventional clinical and radiological studies have been examined bactericidal properties of the tissues in the apparatus-limb.

Results: Method of controlled transosseous compression-distraction osteosynthesis provides possibility of successful treatment of patients with chronic osteomyelitis by a comprehensive approach to the relief of persistent purulent-necrotic process in the tissues of the affected segment and complete or partial elimination of concomitant orthopedic and trauma pathology

Conclusion: So, this study allows us to state that treatment of patients with chronic osteomyelitis by Ilizarov techniques can successfully arrest pyoinflammatory process of the restoration of limb function to the fullest extent possible

#81: An unhappy triad in limb reconstruction; management by Ilizarov methods

Barakat El-Alfy (Egypt),
Sallam Fawzy

Question: Bone loss, soft tissue loss and bone infection are considered to be un unhappy triad in the field of limb reconstruction. In presence of this triad the scope of reconstruction becomes very narrow and amputation may be the eventual outcome. During distraction osteogenesis, not only the bone but also the soft tissues are lengthened and this may help in spontaneous closure of the soft tissue defects without the need for major plastic surgery

Methods: 18 cases with bone loss, soft tissue loss and infection were managed by distraction osteogenesis in our institution. Acute shortening of the limb was done in three cases to help in rapid closure of both the bone and soft tissue defects, then re-lengthening was done from a distant corticotomy to restore the limb lengths.

Results: infection was eradicated in all of the cases. All the soft tissue defects healed during the process of bone transport without the need for plastic surgery, except in one case .

Distraction histogenesis is a good method that can treat the three problems of this triad simultaneously.

#82: Incidence of deep infection in grade 3 open fractures treated with a circular frame

Cher Bing Chuo (UK)
, Hemant Sharma, Andrew Kilshaw, Gavin Barlow, Elizabeth Moulder, Joanna Bates

Question: Open fractures of the long bones of the limbs are associated with an increased risk of osteomyelitis and few studies investigate this complication in circular frames. We reviewed the incidence of and contributory factors toward infection-related outcomes in Grade 3 open fractures, managed with a circular frame, at a single level 1 trauma centre.

Methods: We performed a retrospective study of consecutive adult patients presenting with a Grade 3 open fracture, who required a circular frame for definitive skeletal fixation from 2005 to 2014. Patient case notes were reviewed for demographic details and surgical management. Microbiology results and radiological studies were reviewed where complications were identified. Infection-related outcomes were classified as possible and definitive, based on clinical findings and microbiology at a minimum of 12 months follow-up.

Results: 74 patients (with 78 long bone fractures) were identified with an average age of 43 years. Most treated limbs had a tibial fracture (97%). There were 24 Gustillo-Anderson grade 3A, 37 grade 3B, 4 grade 3C and 9 not sub-classified. 33% of patients were debrided on the day of injury. Average time to circular frame stabilization was 14 days. 27 Ilizarov, 44 Taylor spatial and 4 patients had an unspecified type of circular frame stabilization. A variety of plastic surgery reconstruction was used to provide wound coverage: skin grafts, local and free flaps. Circular frames were in place for 265.9 days on average. 13 patients with 15 treated limbs underwent bone grafting. 22 patients (22 limbs) were excluded: 4 lost to follow-up, 2 below knee amputation

Conclusion: Patients managed with circular frames typically have complex fracture configurations less amenable to other methods of definitive fixation. Our patient cohort has a limb salvage rate (97%) and a soft tissue infection rate (possible infection) comparable to other reported series. We report a low rate of osteomyelitis (definitive infection) in consecutive patients managed in our trauma centre.

#83: Treatment of infected femoral segmental defect by distraction osteogenesis with monolateral external fixation

Qin Chenghe (China),
Yu bin, Xulei, Hu yanjun

Question: To discuss the clinical outcomes of bone transport in the treatment of infected femoral segmental defect.

From October 2010 to September 2013, we treated 37 patients with femoral osteomyelitis of Cierny-Mader IV. They were 23 males and 14 females, aged from 19 to 53 years old (averagely, 39.5 years old). Prior to admission to our hospital the patients averagely received 3.3 (1 to 7) operations other than bone transport. In our hospital, they received bone transport by monolateral external fixation to treat femoral segmental defects following debridement and resection of femoral lesions.

Results: The patients were followed for 12 to 26 months (averagely, 17.3 months). Their average long bone defect was 13 (6 to 20) cm, and the fixation index was 48d/cm. Five patients underwent two-step treatment while others one-step. Bone transport led to poor outcomes in three patients which were finally improved by slow intermittent distraction. Superficial pin tract infection was observed in 64% of the cases, which were treated by oral antibiotics. Bacteriologic examination characterized 38% of the infections as staphylococcus aureus (SA). Re-infection occurred in two and was healed by second debridement. Postoperative routine tests demonstrated that erythrocyte sedimentation rate (ESR) recovered after 63 (31 to 104) days, and C reactive protein (CRP) after 17 (10 to 28) days. The knee range of motion was 121.7 (107to 134). The mechanical alignment was normal in all patients. According to Paley criteria, bony union was excellent in the 34 cases and good in 3 cases, and the functional recovery was excellent in 32 cases, good in 4 cases, and poor in 1 case

Conclusion: Bone transport by monolateral external fixation can play an effective role in the treatment of infected long bone defect.

#84: Treatment of calcaneal osteomyelitis by egg-shell-like debridement with carrier of calcium sulfate admixed with antibiotics

Qin Chenghe (China),
Yu bin, Xulei, Hu yanjun

Question: Debridement, a traditional treatment for calcaneal osteomyelitis, is very important because it is a prerequisite for further treatment such as partial and total calcanectomy, flap coverage and amputation. However, because complete eradication of the calcaneal nidus is difficult due to the particular anatomical feature of the calcaneus, calcaneal osteomyelitis may reoccur and develop into a chronic condition which needs more successive operations, leading to elongation of healing and additional financial burden on patients. Therefore, improved debridement is of great significance for calcaneal osteomyelitis.

From October 2011 to April 2015, we treated 23 patients with calcaneal osteomyelitis. They were 18 males and 5 females, aged from 23 to 64 years old (averagely, 47.6 years old). Prior to admission to our hospital the patients received 7.3 (2 to 19) operations on average. They underwent debridement in which the infectious focus and necrotic tissues were thoroughly eliminated until bleeding was visible (paprika sign) in the calcaneus and the calcaneus became an egg-shell-like void. Subsequently the void was filled with vancomycin-impregnated calcium sulfate (Stimulan), a bioabsorbable supporter which was characterized by remarkably sustained release of antibiotics and elevated local antibiotic concentration without any significant adverse effect.

The patients were followed up for 18 to 30 months (averagely, 23 months). Recurrence of infection was found in one patient, which responded to secondary debridement. Bone graft was conducted in another patient. Because of extensive defect at the calcaneus and lateral column, one patient received free fibular transplantation to compensate for the defect and support hind food and lateral column. In three cases, partial calcaneal defect and malformation were corrected by Ilizarov technique. According to the Mayo Hindfoot-Ankle Scoring System, foot functional recovery was excellent in 19 cases, good in 3 cases and poor in 1 case.

Conclusion: As egg-shell-like debridement can thoroughly eradicate the infected cancellous bone of the calcaneus, it may be an effective treatment of calcaneus osteomyelitis.

#85: Cosmetic Orthopaedics- by Ilizarov Technique

Mofakhkhrul Bari (Bangladesh)

How to correct the congenital, acquired and posttraumatic deformities?

Methods: All the deformities can be corrected by Ilizarov technique. Surgery for anthropometric corrections to correct the form of extremities is Cosmetic Orthopaedics. Cosmetic orthopaedics is that branch of medical science that making a person beautiful though changing his limb form, improvement in the appearance of physical feature and defects. Ilizarov is the most natural way of treating all bones and joint problems.

Results: Results are excellent and good.

Conclusion: All the deformities with shortening can be corrected simultaneously by Ilizarov technique.

#86: Ilizarov Technique in Aesthetic Surgery of Legs (Problems, Obstacles And Complications)

Mirzoyan A. E. (Armenia),
Malkhasyan G. A., Vahramyan A. G.

Question: Correction of leg shape by the Ilizarov technique are relatively recent in aesthetic surgery of legs. With more treated patients, the number of complications invariably increases, and this requires some looking into.

Methods: We analyzed success complication ratio of aesthetic surgery of legs using Ilizarov technique with an emphasis on problems, impediments and complication.

Results: Between 2000 and 2014 a total 58 patients (aged 18 to 48) was treated, of which number 17 underwent surgical treatment for correction of "O"-type curve; 5 for correction of "X"- type curve; 14 for mono-local lengthening of both tibias; 8 for bi-local lengthening of both tibias; and 14 for cross-lateral lengthening of both tibias and femurs (up to 16 cm).

Conclusion: In the majority of cases, increasing the height or correcting the shape of legs is justified and helps individuals experiencing significant psychological discomfort. It increases their self-esteem and enhances professional and personal interaction. Minor complications, such as broken wires, light half-pin infection, scars, etc., lend themselves to easy fixes, with no impact on the duration of treatment or final outcome. Moderate complications: delayed bone formation, stiffness of joints, tend to extend treatment time, which is usually frowned upon by patients. Rare complications, such as deformity after frame removal, non-union, patella baja, joint subluxation, require additional surgical intervention and are quite hard on the patient and the doctor as well. In aesthetic surgery of lower limbs the price of complications, however insignificant, is not the same as, for example, the encumbrance of complications in the treatment of orthopedic patients. Apart from planning the purely technical aspects, dealing with aesthetic surgery patients requires a not insignificant personality assessment, in order to foretell and, if possible, prevent surprises during the often lengthy period of treatment.

#87: Assessment for sense of well-being, self-esteem, and satisfaction for patients undergoing cosmetic stature lengthening

Dong Hoon Lee (Korea),
Keun Jung Ryu, Jin Ho Hwang, Hyun Woo Kim, Hoon Park

Question : Distraction osteogenesis can be used not only for the patients with dwarfism or deformities arising from congenital anomalies or trauma, but for the individuals with psychological disturbances related to a dis-satisfied short stature. Recently, cosmetic stature lengthening is receiving attention, but still under controversy from an ethical standpoint. Although, cosmetic stature lengthening is thought that it is for the individuals with body dysmorphic disorder, which involves a belief that one's own appearance is unusually defective and is worthy of being hidden or fixed, psychological assessment for them has not been fully documented. We aimed to investigate the effect of stature lengthening on patients (1) sense of well-being, (2) self -esteem and (3) overall satisfaction.

Method : This study is based on prospectively collected data. October 2009to March 2013, we evaluated 104 patients who underwent stature lengthening who met the pre-specified inclusion criteria. All patients underwent bilateral lower limb lengthening at femur (10 patients with ISKD) or tibia (4 patients with ISKD, 63 patients with LATN, and 27 patients with LON). The preoperative height and the final length gain were 163.57.2 cm and 6.32.4 cm respectively. The mean age at the time of surgery was 22.54.4 years. Patient assessment included (1) sense of well-being, (2) self-esteem, and (3) overall satisfaction after the index surgery. Evaluation for patients sense of well-being was via the index of well-being score, which consisted of eight items (interesting, pleasant, worthy, friendly, full of energy, hopeful, fruitful, and optimal) with each answered on a seven point scale (1-7 points), therefore total 8 points (best) to 56 points (worst). Evaluation for patients self-esteem was via the Rosenberg self-esteem scale, which consisted of tem items (satisfied, do good, have a number of good qualities, do things well, have proud of myself, feel useful, feel worthy, have respect for myself, feel successful, take positive attitude toward myself), with each answered on a four point scale (0-3 points), therefore total 0 points (best) to 30 points (worst). Evaluation for patients overall satisfaction was via five patient-reported questionnaire which consisted of the (a) degree of satisfaction on the surgery, (b) willingness to undergo the surgery if goes back to the preoperative state, (c) willingness to recommend the surgery to their family members or close friends), (d) what is best for the surgery, and (e) what stresses you the most after the surgery. Evaluation for sense of well-being and self-esteem was performed preoperatively and 3 months, 6 months, 1 year, 2 years, postoperatively. Evaluation for overall satisfaction was performed at 2 years postoperatively.

Results : The index of well-being score was 28.98.1 points preoperatively, 29.310.5 points at 3 months, 24.97.9 points at 6 months, 23.89.0 points at 1 year, and 25.09.1 points at 2 years postoperatively. Significant difference was found at 6 months and thereafter postoperatively when compared to preoperative state. Rosenberg self-esteem scale was 21.25.2 points preoperatively, 18.95.3 points at 3 months, 18.25.1 points at 6 months, 18.55.7 points at 1 year, and 19.24.5 points at 2 years postoperatively. Significant difference was found at 3 months and thereafter postoperatively when compared to preoperative state. For overall satisfaction, response for the degree of satisfaction on the surgery was very satisfied 68.1%, satisfied 31.9%, do not know 0%, dissatisfied 0%, and very dissatisfied 0%. Response to the willingness to undergo the surgery if goes back to the preoperative state was absolutely yes 38.7%, probably yes 47.9%, do not know 8.4%, probably no 1. 7%, and absolutely no 3.4%. Response to the willingness to recommend the surgery to their family members or close friends was absolutely yes 12.9%, probably yes 37.1%, do not know 37.9%, probably no 10.3%, and absolutely no 1.7%. Response to what is best for the surgery was increased self-confidence 56.6%, increased self-esteem 25.7%, increased human relationship 7.1%, increased sexual appeal 5.3%, and increased cheerful disposition 5.3%. Response to what stresses you the most after the surgery was decreased function 48.7%, operation scar 44.2%, still dissatisfied short stature 7.1%, decreased self-confidence 0%, and decreased human relationship 0%.

Conclusion : Patients undergoing stature lengthening showed improved sense of well-being and self-esteem. All patients (100%) were satisfied with the stature lengthening and 86.6% of the patients responded to undergo the same surgery if going back to the preoperative state. Overall, patients were satisfied with increased self-confidence and self-esteem after stature lengthening, but about half of them (48.7%) were dissatisfied with decreased function more or less.

#88: Cosmetic lengthening: Less is more

Miliind M Chaudhary (India)

How much lengthening is safe for Cosmetic and Aesthetic indications?

Methods: We looked at axial deviation, healing index, and amount of length gained when performing lengthening for cosmetic purposes. We had 33 patients, 3 women and 30 men of an average age of 27.9 years. 20 patients had lengthening using an Ilizarov or TSF external fixator. 13 had lengthening with the LON method. We operated upon 64 Tibiae and 3 femora and had overall 73 regenerate lengthening.

Results: Length gain ranged from 1.5 cm to 8 cm. ( mean 5.5 cm) Mean length achieved was 15.8% ( 95%CI : 13.6--16.7) 4% to 25.7% SD 4.56%. The LON group (13 pts) had a mean gain of 6.3 cm whereas the ilizarov group had a mean gain of 5 cm. Percentage gain was 17.3 in LON group and 13.9 in the Ilizarov group. ( Mann Whitney test 2 tailed P value = 0.0139)

A 27 year old developed pulmonary embolism on the 20 th day post surgery done using Ilizarov exfix. He was resuscitated but we decided to stop at 15 mm length. There were 2 deep intramedullary infections in patients who had lengthening with the LON method. Both had achieved full length. The nail was removed; reming, debridement and an Antibiotic coated nail were inserted. The Ilizarov external fixation device was retained till maturation was complete. The infection was completely cured. One of them was smoking all the time during treatment and the other had had excessive reaming. One patient developed a cyst formation in the regenerate area after achieving 4 cm. He needed iliac crest bone grafting and reduction of length gain to 2 cm only. He healed uneventfully. Axial deviation more than 15 degrees has not occurred in any patient. 3 patients developed valgus deviation between 8 to 12 degrees in one of the legs, one of them had Ilizarov lengthening and two had LON method. Premature consolidation occurred in 6 cases, needing a re-corticotomy .

Conclusion: Modest length gains (avge 5.5 cm) are possible without significant complications in carefully selected patients. Approx 15% lengthening is possible without significant complications LON method can yield a little more length. This however, has a higher rate of complications including deep infection.

#89: Severe femur-tibia fusion in 150 degrees of flexion corrected with circular external fixator

, Hilario (Brazil), Clinco Junior, Osvaldo Dias, Alexandre Rial, Silva, Fabio de Assuno, Linhares, Glauber Kazuo, Bastos, Thiago Amorim

Question: A Femoral tibial fusioned at 150 degrees of flexion can be corrected by gradual distraction with external fixator?

Methods: The authors present a patient 26 years old with severe knee flexion deformity since she was 3 years old. The patients related that she had a fracture around the knee in the childhood and was treated by cast. The cast was removed before the fracture healing and a gradative deformity was increasing. The patient had a femur and tibia fusioned in 150 degrees and the correction was a real challenge. It was performed a knee level osteotomy and gradual correction with an Ilizarov external fixator.

Results: The full extension and limb lengthening was obtained. There was no knee motion but the patient was able to walk without using any clutches.

Conclusion: The circular external fixator was very usefull to correct the severe deformity and perform the limb lenghtening

#90: Use of Computer-assisted Ortho-SUV Frame in Treatment of Knee Joint Contractures.

Elena A. Shchepkina (Russia)
, Konstantin L. Korchagin, Dmitry G. Nakonechny, Leonid N. Solomin

Question : To analyze the results of knee joint stiffness elimination by Ortho-SUV Frame (O-SUV), used in addition to mobilizing procedures.

Method : O-SUV was used in the treatment of contractures of the knee in 21 patients for 24 joints. In 9 patients (10 joints) were eliminated extension contractures: in 1 case (2 joints) - A consequence of heterotopic ossification, in 8 cases - As a complication in the treatment of fractures of the femur. After arthrolysis, tenolysis and myolysis the joint was fixed by O-SUV in flexion 40 60 for 3-10 days. Thereafter, 2-4 cycles of flexion-extension with the rate of 5-10 in a day were performed. Features of O-SUV and its software allowed providing physiologic motion of the knee (flexion + sliding + rotation), which cannot be achieved while using the hinge joints. After removing of the frame we continued physical therapy, physiotherapy, massage, mechanotherapy. Of the 12 patients (14 joints) with a flexion contracture in one case, the cause was an absence of immobilization after amputation at the level of the lower leg, in one - the absence of immobilization in mechanical-thermal injury, in other patients contractures had neurogenic etiology (spastic paresis after spinal and brain injuries, myelodysplasia). The operation began with release of the peroneal nerve, flexor tendons elongation at the knee and capsulotomy. After that, we assembled O-SUV. The joint is fixed in position of maximum possible extension (40-60) for 5-10 days, followed by a gradual extension in frame. After fixation period of 4-6 weeks, patients underwent rehabilitation treatment using a night splint for 2-3 months.

Results : In elimination of extension contractures the period of working out the movements in frame was 31.56 16.38 days. In 3 patients achieved range of motion 40-60, in other cases 80-90. Loss of achieved correction in 8-12 months was observed in 2 patients (the result is rated as unsatisfactory); in other patients the range of motion remained the same or increased in the range of 20. In patients with flexion contractures extension period in frame was 38.36 13.79 days, the period of external fixation after extension was 53.14 25.79 days. Complications occurred in 2 patients in the group of flexion contractures pin-hole fracture of the femur that required reassembling of the frame and longer fixation period after the extension of the knee joint to achieve the fracture union, but it did not affect the result of treatment. In 2 patients, violated the recommended mode of immobilization, marked loss of extension in the range of 20, in two cases, while maintaining full extension, range of motions did not exceed 20, in other cases.

Conclusion : Application of O-SUV, working on the basis of passive computer navigation allows dosed elimination of the contracture using a physiological path of motion in the knee joint.

#91: Rationale of Lower limb complex muscle flap stabilization with circular fixation

Edgardo Rodriguez-Collazo (USA),
Steve Frania

Question: How lower limb vascular soft tissue reconstructions could be optimize in the compromise patients?

Methods: Circular fixation provides an ideal way to stabilize complex muscle flaps by preventing motion across the surgical area. Motion could interfere with the vascular viability of the muscle flap.

Results: N-15 patients undergone complex flap reconstruction utilizing peroneus brevis and soleus muscle flaps for soft tissue defects tibia, foot or both simultaneously. Improved and faster healing was observed with minimal complications.

Conclusion: Circular fixation provides an ideal method of stabilization compare to other devices such a monolateral fixators. Utilizing cast immobilization prevents the application of negative wound pressure devices that are very commonly use in ortho-plastic procedures.

#92: Large Joint Mobilisation with a Hexapod External Fixator System

Klaus Seide (Germany)
, Matthias Muench, Ulf-Joachim Gerlach

Question : The hexapod kinematics in an external fixator offers the possibility to realise planned complex 3-dimensional movements. Can it be used for the mobilisation of joints, especially the knee joint with shifting rotational axes?

Method : 3 elbow joints and 4 knee joints were treated with a hexapod kinematics mounted on in Ilizarov ring fixator construction. Causes were posttraumatic, postinfectious or congenital. The hexapod consists of 6 length controllable elements between two rings, the necessary adjustments of each are calculated by a software, realising the ring movements with respect to any position of the rotating axis in space by the software input parameters. There are two options to input a joint movement. One is to measure the correction angle and a position of the axis on radiographs, typically applied for the elbow joint. The other is to input the correction angle on the one hand and a translational movement of a point on one joint surface to move this point opposite to a point on the other joint surface in the corrected situation on the other hand. The latter is especially useful for the knee joint, considering its shifting-rotational mechanics. At the beginning of the treatment, before the axial correction started, a moderate distraction was performed with the system to lower the pressure in the joint.

Results : Maximal joint contractions of 70 have been successively mobilized. In one elbow joint a joint could be newly formed, a missing olecranon was substituted by a cancellous bone graft and the fixator movement performed repeatedly over the full range every day. A loadable joint resulted.

Conclusion : The hexapod kinematics is a valuable option for joint reconstructions in difficult cases.

#93: Severe Fixed Flexion Deformities of the knee jointscorrected by Ilizarov External Fixator

Harshad M. Shah (India)
, Ashok Kumar; Sandeep Reddy; Naresh Shetty

Question : Can moderate to complete (Total) fixed flexion deformities of the knee joints be corrected by Ilizarov External Fixator without serious neuro-vascular complications?

Method : Severe fixed flexion deformities are difficult to correct by conventional methods; also are associated with neuro-vascular complications can be corrected by Ilizarov methods without neuro-vascular complications.

Results : Correction of the severe fixed flexion deformities of the knee joints was possible with Ilizarov external fixator. These could be achieved without any neuro-vascular complications. The other complications of a pin tract infections, few fractures of the femur, tibia, recurrence of deformity, knee joint stiffness of less than the terminal arc of motion expected have all been seen in a few of the patients and successfully treated. But for achieving the correction of these severe deformities, these complications have been minimal.

Conclusion : Ilizarov external fixator can be used for gradual arthrodiastasis and gradual correction of the flexion deformity. This may be combined with soft tissue surgeries. No disastrous neuro-vascular complications were seen. In most of the patients, deformity correction was performed by percuataneous wiring and bloodless surgeries. Some were associated with soft tissue surgeries. Gradual differential distraction helps us to correct severe fixed flexion deformities of the knee joints with minimum complications. Spastic cases should be avoided and this method is contra-indicated in these.

#94: Difficult Multiple Contractures of Both Lower Limbs Treated by Ilizarov External Fixation - A Rare Case Report

Harshad M. Shah (India)
, Ashok Kumar P., Sandeep Reddy, Naresh Shetty

Question : How best to treat an adult bedridden patient who had a hip (fused in 90 degree), both knees (more than 90 degree) and an ankle of moderate to severe contractures due to a fall from height? Having been unconscious for 8 months, operated several times for head injury and multiple fractures, he had recovered from his head injury. He had developed a fused right hip, severe bilateral knee contractures, equinus of right ankle with bed sores on both trochanters, knees, ankles. Which contracture/deformity was to be treated first?

Method : The hip could not be tackled first due to bilateral severe fixed flexion deformities of his knees would not have allowed for the same. Hence his knees were treated first with the right lower limb tied vertically onto a Balkon Frame on top of the bed. This staged treatment of all his problems, particularly of both knee joints' severe contractures with Ilizarov external fixators followed by surgical treatment for his hip and ankle problems solved all his problems to a large extent to make him stand on his both lower limbs.

Results : His both knee contractures were corrected simultaneously by bilateral Ilizarov External fixation. Excision of his right hip was done to release hi fixed flexion deformity of the hip. This helped us to make him stand on his own feet after a period of 5 years after his initial injury. Thus he has 1. After 8 months of coma: Recovered from head injury with multiple surgeries 2. Recovered from bedridden for 5 years from untreatable contractures of both lower limbs to standing up with support of callipers.

Conclusion : Even in such severe contractures with multiple problems from head to toe, one should not lose hope. Recovering from 8 months of coma, he who had developed multiple contractures and bedsores recovered with Ilizarov method of treatment to stand up. Truly, Ilizarov External Fixation has changed this tall man's life from a miserable bedridden patient to stand on his own and become mobile.

#95: Hip and knee deformities correction with Mini external fixation.

Ghassan Salameh (Germany),
Michael Schmidt

Question : Correction of hip and knee deformities like old hip dislocations, subluxations, dysplasia or even paralytic malformations, pelvic obliquity and Trendelenburg gait, also knee deformities with a classic methods which have either long incisions or big uncomfortable external fixators, more complications difficult to achieve right angles of correction hip and knee misalignment, which need a special correlation measures of alignment between hip and knee and using qualified small comfortable external method for correction is better to use.

: A small external arc system modified for correction, using just one arc system for correction of either hip or knee deformities and two isolated arcs for combined deformity, this is modified hinges of Salamehfix four, which allows stable fixation because off pin insertion is in deferent angles and levels. Treated cases are neglected hip dislocations, subluxations, dysplasia, post traumatic and post paralytic hip or knee mal alignment, cases of osteoarthritis. Main procedure done is pelvic support osteotomy according to Ilizarov principal, same principal was used in treatment hip post paralytic problems, in order to replace some of muscle power insufficiency with bone support, this will decrees Trendelenburg gait and limping and at the same time we can restore limb length inequality and align the extremity in functional position .

: From 2002 to 2014, 192 cases where treated with various hip, knee or combined deformities. And the functional results were 96 cases excellent, 67 good, 27 fair and 2 bad, pelvis obliquity and static scoliosis completely corrected in most cases and with improvement also of hyperlordoses, Trendelenburg gait was also improved in most cases, complications; are mostly superficial pin infection which treated locally 3 cases breakage of screws 2 cases deep infection required pin removal and replacement, tolerance to the system was high.

: Correction of hip and knee deformities is not easy to treat and it needs a special strategy and the used method is differs from others by simplicity, small size in correlation to its functional hinges and stability of fixation, gives good results and correction of even sever deformity is possible.

#96: Use of adult mesenchymal stem cells in arthrodesis and bone transport with external fixation

James C Wang (USA)

Can adult mesencyhmal stem cells have a positive affect on fusions and callus distraction.

Methods: By using it in fusions and callus distraction with external fixation.

Results: 20% faster fusion rates and 24% faster regenerate formation.

Conclusion: That adult mesenchymal stem cells should be used in orthopaedic surgery.

#97: Can BMP2 combined with the superhip procedure lead to ossification of the unossified femoral neck and lower recurrence of coxa vara in severe congenital femoral deficiency

David A. Packer (USA)

Can BMP2 combined with the SUPERhip procedure lead to ossification of the unossified femoral neck and lower recurrence of coxa vara in severe congenital femoral deficiency.

Methods: Compared to SH procedures performed using non-fixed angle implants without BMP2, to those treated with fixed-angle devices and BMP2. A. Rate of persistent delayed ossification of the femoral neck B. Rate of AVN C. Rates of recurrent deformity.

Results: Compared to SH procedures performed using non-fixed angle implants without BMP2, the incidence of recurrent coxa vara for type 1b2 hips decreased from 36.8% (25/68) to 10.5% (4/38) [p = 0.003] in those treated with fixed-angle devices and BMP2. Similarly, the rate of persistent delayed ossification of the femoral neck improved from 28/68 (41.2%) to 5/38 (13.2%) [p = 0.004] in this same group. The incidence of femoral neck persistent delayed ossification in type 1b2 hips undergoing revision SH surgery after being treated initially with a fixed-angle implant but no BMP2 dropped from 8/16 (50%) to 1/11 (9.1%) [p = 0.042] by the addition of BMP2. There were two cases of AVN in the type 1b2 group, one treated with and one treated without BMP2.

Conclusion: As compared to the high rates of recurrent deformity and persistant delayed ossification (non-union) with the SH procedure using non fixed angle devices and no BMP, the use of a fixed-angle implant with the off-label use of BMP2 leads to the most predictable anatomic correction of the severe deformities of severe CFD with the lowest rates of failure. Advancing from to the use of fixed-angle implants in neck group hips, alone, significantly decreased the rate of varus recurrence among primary SH procedures. However, it was not until BMP2 was added to the un-ossified portion of the femoral neck that there was a statistically significant decrease in the rate of femoral neck delayed ossification (non-union) for both primary and revision surgeries. The findings of this study support the off-label use of BMP2 as a strategy to induce femoral neck union and thereby fewer complications in patients undergoing SH procedures.

#98: Preoperative Planning and Intraoperative Technique for Accurate Realignment of the Midfoot Osteotomy

Bradley M. Lamm (USA),
Matthew J. Hentges , Martin G. Gesheff

Question: The goals of a midfoot osteotomy (MFO) are to restore normal angular relationships between the midfoot/forefoot segments and the hindfoot, as well as to establish a painless, plantigrade foot. Accurate realignment in all planes, including translation and rotation, is critical to obtaining a plantigrade foot. To date, no study has described preoperative planning or an intraoperative method to define the amount of wedge resection required for MFO. What are the short-term radiographic results of using our preoperative planning and intraoperative method to define the wedge resection required when performing acute realignment of MFO?

Methods: Medical records of patients with osseous midfoot deformities who underwent realignment MFO between 2004 and 2014 were retrospectively reviewed. Patients were excluded if they underwent correction with percutaneous Gigli saw midfoot osteotomy, underwent treatment with external fixation, or had incomplete radiographic records. To perform realignment MFO, transverse plane wires were inserted under fluoroscopic guidance at the apex of the deformity [Figures 13]. To ensure the appropriate amount of bone wedge resection, the proximal wire was placed perpendicular to the hindfoot and the distal wire was placed perpendicular to the forefoot. Alignment was verified in the sagittal plane prior to wedge resection. After bone resection, the forefoot segment was translated in a medial/lateral and/or superior/inferior direction. If indicated, internal fixation was applied and adjunct soft tissue and osseous procedures were performed. Pre - And postoperative angles were measured on the weightbearing anteroposterior and lateral view radiographs of the foot.

Results: Eighteen patients (10 women, 8 men, 18 feet) underwent realignment MFO. Mean age at the time of surgery was 53 years (range, 21-76 years). Mean follow-up was 25 months (range, 4-120 months). Causes of deformity were Charcot neuroarthropathy (11 feet), pes cavus (3feet), pes planus (2 feet), recurrent clubfoot (1 foot), and posttraumatic deformity (1 foot). Mean AP talo-first metatarsal angle was 20 degrees preoperatively and decreased to 10 degrees postoperatively (p = 0.02). The mean mechanical axis deviation preoperatively was 7 mm and decreased to 2 mm postoperatively (p = 0.02). No significant differences were found in the remaining radiographic measurements. Nine complications were encountered and none negatively impacted the final result: 6 superficial infections successfully treated with wound care and oral antibiotics, 1 delayed union healed with immobilization and use of a non-invasive bone stimulator, 1 nonunion (stable at final follow-up), an! d 1 hardware removal due to symptomatic screw fixation.

Conclusion: The goal for realignment is to re-establish normal angular relationships between the hindfoot and forefoot [Figure 1]. Our technique for performing MFO allows for accurate realignment while potentially minimizing the amount of required bone resection [Figures 23]. To our knowledge, this is the first in-depth description of a preoperative planning method, an intraoperative technique, and realignment outcomes related to MFO. It is our belief that proper ground reactive forces will be restored after proper realignment of the midfoot in all planes, including translation. Our short-term results show that this realignment technique accurately corrects all planes of deformity.

#99: Normal Foot and Ankle Radiographic Angles, Measures, and Reference Points

Bradley M. Lamm (USA),
Paul A. Stasko , Anil Bhave , Martin G. Gesheff

Question: Limb deformity principles provide accurate references for producing predictable results and originate from a standard set of radiographic angles and reference points. Deformities are evaluated in an objective manner with static radiographic measures. Normal foot and ankle radiographic angles have been defined for specific criterion; however, no study to date has defined normal angles for the foot and ankle. How can the average normal foot and ankle angles and reference points be quantified systematically in multiple radiographic planes to provide standard angles and nomenclature for pre-operative planning and post-operative evaluation?

Methods: Thirty-two multiplanar radiographic angles and reference points were measured using radiographs obtained from 24 subjects. Anteroposterior view radiographs were taken in standard fashion with the patient weightbearing on the foot with the tibia in neutral position over the talus and the x-ray beam 15 degrees to the dorsal aspect of the foot. Lateral view radiographs consisted of standard weightbearing radiographs with the tibia neutral over the talus and the x-ray beam lateral to the foot and parallel to the weightbearing surface. Axial Saltzman weightbearing radiographs were obtained with the foot and heel flat on the weightbearing surface in rectus position, with x-ray beam 20 degrees from the weightbearing surface and posterior to the foot. Standard deviations and mean angles were calculated for 13 lateral, 5 axial, and 17 anteroposterior view angles. All angles were independently measured two times by two authors and statistical tests for reliability were conducted.

Results: Radiographic images were taken for each patients foot. These images were then measured and analyzed to obtain normal radiographic values [Table 1] for lateral [Figure 1 and 2], axial [Figure 3 and 4], and anteroposterior views [Figure 5 and 9].

Conclusion: Although there are studies in the literature that determine average radiographic angles for a given population and even specific radiographic angles used to determine underlying pathology, no research exists that comprehensively presents a known lower extremity nomenclature, the average radiographic angles, and measurements for the foot and ankle. The radiographic angles and measurements presented in this article demonstrate a comprehensive and useful set of standard angles, measures, and reference points that can be utilized in clinical and perioperative evaluation of the foot and ankle.

#100: Analysis of tibial osteotomy for condition of the foot and ankle

Douglas Beaman, (Oregon, USA),
Paul Fortin, Todd Irwin, Erin Baker, Jordan Etscheidt, Kevin Baker

Question: Tibial osteotomy is a powerful method to treat a number foot and ankle disorders, thereby providing deformity correction and an alternative to amputation. Three institutions collaborated to identify 54 patients who underwent tibial osteotomy procedures for various foot and ankle conditions. Cases were evaluated through a retrospective radiographic and medical record analysis to assess patient complications and radiographic outcomes of tibial osteotomy procedures treated by both spatial frame (gradual correction) and ORIF (acute correction). Your Answer: Using available records, we performed chart review and radiographic measurements (distal tibial articular angle, tibial alignment, tibial length, and hindfoot alignment) to define the demographics, complications, and radiographic-based outcomes of each group.

Methods & Results: Fifty-four cases including tibial osteotomies to treat various foot and ankle conditions were retrospectively assessed. In the spatial frame cohort (n = 36), 20 males and 16 females were treated, with an average age at first surgery of 48 years (range, 10-71), average BMI of 27 (range, 16-45) and average follow-up (after first surgery) of 30 months (range, 2-73). The average time in frame was 217 days (range, 91-737). In the ORIF cohort (n = 18), six males and 12 females, with an average age at first surgery of 50 (range, 19-60) and average BMI of 30 (range, 24-47) were treated, with an average follow-up of 16 months (range, 4-47). The average time in cast was 40 days (range, 0-71). In this study population, the most common foot and ankle conditions treated by osteotomy included fracture malunion, fracture nonunion, tendon contracture, and cavovarus deformity. Preoperative and postoperative (latest follow-up available) radiographs were measured. The average pre and postoperative tibial alignment in the anteroposterior (AP) plane for the spatial frame cohort was 96 and 89 degrees, respectively, pre and postoperatively. Pre and postoperative tibial length was 37.6 and 39.1 cm, respectively. For the ORIF cohort, the average pre and postoperative tibial alignment in the AP plane was 90 and 88 degrees, respectively. Tibial length, measured pre and postoperatively, was 36.8 and 38.0 cm, respectively. For each study cohort, average distal tibial articular angles were measured in the coronal and sagittal planes on preoperative and postoperative. When comparing pre and postoperative radiographs, in the spatial frame cohort, the DTAA changed 1 degree in the coronal plane and -4 degrees in the sagittal plane, while in the ORIF group, the DTAA changed -2 degrees in the coronal plane and 0 degrees in the sagittal plane. Pin tract infections, fixation failure and fracture healing were the primary complications evaluated. Eleven pin tract infections (31%), three fixation failures (8%) and two tibial malunions (10%) occurred in the spatial frame cohort. No infections, fixation failures or tibial non/malunions occurred in the open/internal fixation group; however, two patients required implant removal (11%).

Conclusion: Radiographs and medical records of 54 tibial osteotomy cases were identified and analyzed through a three-institution collaboration, in order to determine radiographic-based outcomes and complications. Proper deformity analysis and preoperative planning, assessment of clinical variables such as soft tissue conditions as well as familiarity with a variety of surgical techniques are necessary to treat these complex conditions. Additionally, patient education and compliance are factors in achieving favorable outcomes. Work is ongoing to further analyze radiographic data by osteotomy type and location.

#101: Simultaneous distal tibial distraction osteogenesis & lower extremity reconstruction: A retrospective review

Todd M. Chappell (USA),
Casey C. Ebert , Byron L. Hutchinson , Kevin M. McCann

Question: Lower extremity deformity due to trauma and/or unsuccessful rearfoot and ankle reconstruction results in life-altering effects, especially when it leads to significant functional and anatomical changes that increase patient morbidity. When faced with unfavorable sequelae and residual deformity, subsequent corrective attempts are a challenge for the reconstructive surgeon. Often large bone voids or limb length discrepancy (LLD) add an additional level of complexity. Our retrospective review aims to address whether reconstructive rear foot/ankle surgery with concurrent lengthening through a distal tibial corticotomy using circular external fixation offers a successful treatment option for patients with LLD as a component of their overall deformity?

Methods: A review of patient records was undertaken for patients who underwent lower extremity reconstruction from July 2009 to September 2014. Our study included patients that underwent rearfoot/ankle reconstructive surgery and simultaneous distal tibial lengthening to address their deformities. Demographic data including comorbidities, concurrent procedures, distraction rates, minor and major complications, union rates, and clinical and radiographic analyses were performed after a mean duration of follow-up of 15.3 months.

Results: Nine patients underwent surgical reconstruction of rearfoot/ankle deformity with simultaneous distal tibial distraction osteogenesis. The mean patient age was 51 years with a mean of 27 years from initial injury to presentation in our clinic. There were six males and three female patients with a mean BMI of 28.25. Two patients presented with a history of smoking. The mean latency period was 9.33 days with a mean duration of external fixation of 179.11 70.88 (range, 116 to 347 days). The mean distraction length was 1.78 0.66 (range, 0.9 to 2.5 cm) resulting in a final LLD for all patients of & #8804; 1.5 cm. Five minor complications (treated conservatively) and two major complications (treated surgically) occurred. Both major complications included incomplete regenerate formation with both patients going on to require bone grafting and internal hardware fixation, both of which achieved solid union.

Conclusion: Lower extremity deformity correction utilizing the technique of simultaneous lengthening through a distal tibial corticotomy was shown to be successful utilizing circular external fixation. This technique yielded a clinically satisfactory result in patients with substantial preoperative deformity inclusive of activity limiting arthrosis, pain, and loss of function. We, therefore, conclude that the ability to address long-standing or surgically induced LLD at the site of reconstruction is a successful treatment option for lower extremity deformity correction.

#102: Analysis of serial radiographs of the foot to determine normative Values for the growth of the first metatarsal to guide hemiepiphyseodesis for Immature hallux valgus

Janelle D. Greene (USA),
Allen D. Nicholson, James O. Sanders, Daniel R. Cooperman, Raymond W. Liu

Question: Hallux valgus deformity in the immature patient can be difficult to manage, as osteotomy can result in recurrence with additional growth. Lateral hemiepiphyseodesis of the first metatarsal offers a promising alternative, by permitting gradual correction of the intermetatarsal angle with growth. An important limitation of this approach is the lack of normative tables of first metatarsal growth to guide timing of intervention.

Methods: First-metatarsal lengths were measured from AP foot radiographs of children with an average of 9 serial radiographs from the historic Bolton Brush collection. For females, 95 patients totaling 894 x-rays were used ranging from 6 months to 18 years of age. For males, 120 patients totaling 1,003 x-rays were measured ranging from 8 months to 19.5 years of age. All patients with image series including a closed proximal metatarsal physis were sorted into the older group, with multipliers generated by setting last image to a multiplier of 1. Patients with serial imaging not inclusive of a closed physis were classified as the younger group, with multipliers based off of the multiplier at age 7 from the older group. First metatarsal multiplier values were then compared to published multiplier values for the overall foot.

Results: For both females and males, the multipliers followed a logarithmic curve versus age, with R-squared values of 0.923 and 0.892, respectively. Comparison of the first metatarsal multiplier values with previously studied multiplier values of the entire foot found small average differences of 0.039 in females and 0.098 in males, with R-squared values of 0.982 and 0.974 (see Table for male multiplier values).

Conclusion: The pattern of growth of the first metatarsal follows a logarithmic regression curve. These normative tables allow for clinical prediction of first metatarsal remaining growth based on age and gender, and in turn guide timing of hemiepiphysiodesis for the surgical correction of hallux valgus deformity.

#103: Radiological study of the relationship between fibula and talus of ankle osteoarthritis with the use of upright ankle lateral X-ray

Shota Harada (Japan),
Motoyuki Takaki , Narutaka Katoh, Nobuyuki Takenaka, Tsukasa Teramoto, Takashi Matsushita

: Upright frontal X-ray is standard diagnostic technique of ankle arthritis for stage classification generally. We have performed distal tibial oblique osteotomy (DTOO) for ankle arthritis and posttraumatic ankle arthritis, and experienced several patterns of arthritis. Then we have felt limitations in assessment of ankle arthritis only by upright frontal X-ray. In comparison at lateral X-ray, same classification has variation, for example anterior or posterior subluxation of talus and anterior or posterior displacement of fibula. But there is no standard procedure, which assesses in a quantitative way. The purpose of this study is to research the relationships between fibula and talus with the use of upright ankle lateral X-ray.

Method : We examined total thirty-three ankle arthritis (twenty nine feet of female and four feet of male) treated at our institution. An average age was 53`81 years old. At the view of upright ankle lateral X-ray, we located some points (anterior border of tibial plafond: A, posterior border: B, intersection point of talocrural middle point and segment AB: C, intersection point of fibular axis and segment AB: D). We defined AC/AB = anterior talus migration rate (ATMR) and AD/AB = anterior fibular migration rate (AFMR), and investigated relationships between ATMR and AFMR.

Results : The mean ATMR was 47.1%(range 26.7% to 75.7%) and AFMR was 60.4%(range 35.3% to 86.7%), and they had negatively-correlated.

Conclusion : Anteroposterior position of fibula or talus has possibilities on clinical condition of ankle arthritis. We have need to consider this when we performed DTOO for ankle arthritis.

#105: Two distraction arthroplasty methods in treatment of mid-term ankle arthritis a comparative study

- mou Zhao (China), Xiao-jun Liang, Yi Li

Question: Distraction arthroplasty have shown efficacy in the treatment of ankle arthritis. However, to distraction with fixation or motion is still unclear. The objective of current retrospective comparative study is to evaluate the functional outcomes of motion versus fixed distraction in treatment of the mid-term arthritis of ankle joint.

Methods: From June 2009 to December 2013, a total of 36 patients with mid-term osteoarthritis (Takakura stage II and III) were treated with joint debridement and distraction arthroplasty with two methods. There were 11 males and 25 females with a mean age of 54.7 years (range 43 to 69 years) included. In the Ilizarov group, 15 cases were included, the patients were operated with minimal open debridement and drilling and fixed with a circumferential external fixator, and distraction was carried out over a distance of 5 mm (0.5 mm twice daily for 5 days), starting the day after application of the apparatus. Full weight bearing with ankle joint motion was allowed 2 weeks post-operation, and the fixator removed 3 months later. In the fixed group, 21 cases were included and the operation post-operation case were same to Ilizarov group except the distraction was finished during operation and fixed with a combined type of fixator could not motion of the ankle joint. The AOFAS and VAS scores were used for functional outcomes evaluation.

Results: Thirty-two cases were followed with a mean time of 37.6 months. Two cases in fixed group were fused 21 and 43 months post-operation. Mean AOFAS score in other 30 cases was 73.116.9 points, significant improved in compare with pre-operative mean (56.212.6, P0.01). Also the VAS scares significant improved post-operatively (2.72.1 vs. 5.63.2P0.01). The AOFAS scores reached no significant difference at the last follow-up time (71.817.5 vs. 74.516.2P = 0.66); As well as the VAS scores (P = 0.53).

Conclusion: Distraction arthroplasty could delay the progress of osteoarthritis, and improve the functional outcomes of those patients. And motion distraction showed an early beneficial effect on outcome, however similar with fixed distraction at a longer follow-up time.

#106: Talus dislocation or subluxation in the correction of equinus deformity using Ilizarov technology.

Jian cheng Zang (China),
Sihe Qin, Shaofeng Jiao, Qi Pan, Zhenjun Wang

Question: To observe the occurrence of talus dislocation or subluxation in the correction of equinus deformity using Ilizarov technology, and summarize the methods of prevention and treatment.

Methods: October 2011-April 2012, 38 patients of clubfoot deformity had been treated by the Ilizarov technology . There were 25 males and 13 females, with an average age of 34.5 years, including 5 cases of simple clubfoot, talipes 25 cases of equinovarus deformity, 3 cases mergered valgus deformity and 5 cases combined with cavus deformity. Some surgeries had been carried out in the same period, which included percutaneous cutting off the Plantar fascia 37 cases, percutaneous lengthening Achilles tendon 38 cases, the first metatarsal basal osteotomy 4 cases and so on. They were accomplished by the same medical group with the standarded percedure. It took 5-7 days to begin to adjust the Ilizarov external fixator after operation, the first step was the correction of adduction and varus or valgus deformity, the next high cavus deformity and equinus deformity. It was routine to take ankle& foot X-ray in order to have a good knowledge of the progress of correct! ion, after 1 week, 2 weeks, 4 weeks ,8 weeks or to take at any time if necessary.

Results: AII the cases were followed up, and the duration ranged from 6 to12 months. 5 cases suffered from talus anterior dislocation or subluxation, accounting for 13.2% in all, and 20% of the talipes equinovarus patients. The treatment steps of 1 case in 5 were as follows: release the fixed rod of talus, reset tibia-talus joint manipulatively, and then reset the hinge center of external fixator. Tibia-talus joint traction resetted gradually with the dislocation-reduction device after reset the hinge center of external fixator in other 4 cases. At the latest follow-up, all patients have been corrected completely. According to the score of International Club Foot Study Group (ICFSG), 10 cases got an excellent result, 23good, 4 fair and 1 poor, no obvious complications.

Conclusion: Penetrating a 2.0 mm Kirschner in the hinge holes of ankle joint only can reduce the occurrence of talus anterior dislocation or subluxation to a certain extent. The concept of Instantaneous Rotation Center of ankle joint should be emphasized in the correction of equinus deformity. The frame hinge center should match with the center of tibia-talar joint. The Dislocation-Reduction Device should play a key role in the reduction of talus anterior dislocation or subluxation.

#107: Ilizarov method combined limited surgery for defective foot & ankle deformity on the verge of amputation

Jiancheng Zang (China),
Sihe Qin, Shaofeng Jiao, Zhenjun Wang, Qi Pan

Question: To explore the choice of indication for defective foot and ankle on the verge of amputation when dealing with the limited orthopaedic surgery combined Ilizarov method.

Methods: 35 patients with severe ankle deformity in our study, multiple hospital suggested amputation and installed the prosthesis , including 24 males and 11 females with an age 9 to 52 years old. Among 19 cases due to trauma, 16 cases were sequelae of spine bifida. All of the patients exist serious rigid ankle deformity and with a different degree of poor circulation in preoperative. 17 cases with disturbance of sensation, 13 cases combined skin ulcers that all the year round can't heal. Following the principle of Ilizarov method, the standard of external fixator technique and postoperative management procedures, We first implemented limited soft tissue release and osteotomy surgery, and install the Ilizarov external fixation subsequently, slowly adjustment geometry of fixation after operation, and achieve to the goal of treatment finally. At the last, external fixator change to orthoses for regular walking exercise to promote bone mineralization.

Results: All the patients meet the requirements of the deformity correction and functional reconstruction in the preoperative setting. There are not any infections and other serious complications. Limb function obtained satisfactory recovery.

Conclusion: Ilizarov method combined limited surgery can effectively repair the foot & ankle deformity on the verge of amputation.

#108: Ankle fixation using a circular external fixator

Tomohiro Yasuda (Japan),
Shu Obara, Yuko Irie

Question: Was a circular external fixator for ankle fixation useful for cases accompanied by infection Ankle fixation is generally used to treat ankle osteoarthritis. However, it is difficult to use ankle fixation to treat osteomyelitis and septic arthritis. When infection is also present, internal fixation cannot be used. Here, we report on good outcomes that were achieved by performing ankle fixation after reducing the infection using a circular external fixator.

Methods: Subjects were patients who underwent ankle fixation using a circular external fixator at our hospital between 2000 and 2015 (men: three, women: three, mean age at the time of surgery: 46.0 years, mean observation period: 40.6 months). Surgery involved invasive curettage of the lesion and bone resection. Fixation was performed with a circular external fixator filled with cement beads containing antibiotics as necessary. photographs1,2). After the infection subsided, the ankle was fixated and pressure was applied with the ring. After synostosis, the ring type external fixator was removed. Five patients received bone grafts during joint fixation and one patient did not. Causative diseases were talus dislocation accompanying osteomyelitis after fracture dislocation of the ankle (four patients), osteomyelitis after plafond fracture (one patient), and talar osteomyelitis after diabetic gangrene (one patient). The causative agent was detected in five patients. Parameters investigated were external fixation duration, bone healing rate, bone healing duration, preoperative activities of daily living (ADL), and postoperative complications.

Results: Mean external fixation time was 151 days and the bone healing rate was 100% (all six patients). No patients experienced infection recurrence. Mean bone healing duration was 105.2 days. Bone healing duration and external fixator duration tended to be prolonged. Complications comprised pin insertion site infection in two patients, foot contracture in two patients, and wire cut out in one patient. Four patients underwent complete talar extraction and tibiocalcaneal arthrodesis. (photographs3,4) Two patients underwent tibiotalar arthrodesis. Infection receded in all patients and bone healing was achieved.

Conclusion: After talus dislocation, blood flow is obstructed and the body is susceptible to infection. Therefore, extracting the talus and fixating the joint is effective for reducing the infection and was used in four of six patients. When infection is present, internal fixation cannot be used and a circular external fixator is useful. We found that ankle fixation with a circular external fixator was useful for cases accompanied by infection.

#109: Free vascularized fibula transfer for the treatment of bone defects in children

Lee Phillips (USA),
Chris Stutz, Scott Oishi, Mikhail Samchukov, Alex Cherkashin, John Birch

Question: Reconstruction of bone defects with free vascularized fibula transfer has been described as a treatment option following resection of tumors, post-traumatic or post-infectious bone loss, pseudoarthrosis, and avascular necrosis. Successful reconstruction with a free vascularized fibula transfer allows for a lasting reconstruction that maintains its ability for linear growth and hypertrophy. However, complications are common including prolonged immobilization, non-union, fracture, and donor site morbidity/deformity. The aim of this study was to review our experience with free vascularized fibula transfer in pediatric patients.

Method: We retrospectively reviewed the charts and radiographs of 11 patients with a mean age of 8.8 years and mean follow-up of 45.8 months. Patient factors including age and diagnosis as well as surgical parameters including method of fixation, defect size, and harvest technique were determined. The time of immobilization, time to union, hypertrophy of the graft, donor and graft site complications, and subsequent surgeries were recorded.

Results: 11 patients underwent free vascularized fibula transfer at our institution between 1999 and 2014. The diagnoses were as follows: chronic osteomyelitis (3), neurofibromatosis pseudoarthrosis (3), gunshot wounds (2), fibrous dysplasia (1), and femoral neck fracture (1 nonunion, 1 AVN). Segments involved were the forearm (6), humerus (2), proximal femur (2), and midshaft femur (1). Four patients had plate and screw fixation and 7 had external fixation or hybrid fixation. Average fibula graft length was 8.5 cm and 3/11 had periosteum preserved at the donor site. Mean healing time was 7 months and those treated with external fixation had their frames removed at a mean of 2.6 months. Hypertrophy of the fibula was observed in all but 1 case. There were 6 complications in 5 patients requiring subsequent surgery at the graft site. Ankle valgus was noted at the donor site in 1 patient requiring surgery.

Conclusion: Free vascularized fibula transfer is a versatile tool for the treatment of bone defects in children. Special consideration should be given in each case to the method of fixation and prevention of deformity at the ankle. Our case series highlights the potential benefits of the use of external fixation and preservation of donor site periosteum to limit complications.

#110: Hybrid Fixation in Management of Complex Fractures Using Ilizarov External Fixator and Rush Medullary Pins

Yehia Rady (Egypt)
, Mohamed Y. Rady

Question : Various problems are usually associated with the management of complex fractures. Deployment of Ilizarov external fixator is considered the most reliable procedure in treatment of these cases. However, the difficulty in controlling comminuted shattered long bone segment, moving a bone segment for a long distance in fracture with segmental bone loss, reducing and maintain neglected displaced and unstable fractures, and in providing rigid stable frame in severely porotic and infected bone still in need for augmentation.

Method : The use of Ilizarov external fixator and Rush intramedullary pins, hybrid fixation, probably represents a solution for this challenge. The objective of this work is to evaluate the reliability of this new hybrid fixation as a treatment of complex fractures. The material included 38 cases. Twenty cases suffered comminuted shattered and long bone segment, four cases suffered segmental bone loss, ten cases suffered neglected displaced and unstable fractures, and four cases suffered severely osteoporotic and infected bone. In all cases, fractures were fixed by using malleable Rush intramedullary pins and an Ilizarov frame under the control of the image intensifier.

Results : The results obtained were satisfactory in all cases. The shortest time for union was 12 weeks and the longest was 28 weeks with an average of 18.3 weeks. Bone marrow injection was needed in 8 cases to enhance fracture healing. Migration of the pin outside the bone occurred in one case. Penetration of the pin through the skin occurred in one case during segment transferee that needed rotation to redirect the pin distal end.

Conclusion : The use of Rush intramedullary pins preserves bone alignment in comminuted segmental fractures. Not only it acts as a good guide on which the bone segment can be transported for a long distance, but it reduces also the number of rings needed for stable fixation.

#111: Results of Combined Use of External Fixation and Blocking Intramedullary Osteosynthesis in Long-Bone Lengthening and Bone Transport

Elena A. Shchepkina (Russia)
, Leonid N Solomin, Ivan V. Lebedkov, Fanil K. Sabirov

Question : To compare the results of Lengthening Over the Nail (LON) and Bone Transport Over the Nail (BTON) with the same by Ilizarov.

Method : LON was used in 24 patients at 26 segments (femur 17, lower leg- 9). The average lengthening was 4.89 + 1.8 cm. The rate of lengthening was 0.25 × 4 times/day, the rate was increased up to 2 mm/day in cases of mismatching of the x-ray data with the rates of distraction. After lengthening we locked the intramedullary nail (IN) according to the static scheme and removed the frame. To determine the terms to full weight-bearing we used the three-cortices rule, no dynamization of the IN was performed. In patients treated by Ilizarov (25 patients) the average lengthening was 3.8 + 1.7 cm. BTON was used in 9 patients (defects of bones forming the knee joint 4 cases, defect of femur of tibia - 5). The average length of bone transport was 11.72 + 9.8 cm. While docking site procedure we fixed the adapted bone fragments by plate and removed the frame. For comparison we analyzed the results of bone transport by Ilizarov in 15 patients: 6 with the defects of bones forming the knee joint, 8 with defects of femur and tibia. The average length of bone transport in this group was 10.0 + 4.37 cm. At femur in LON and BTON extra-cortical clamp devices were used (www. ortho-suv. org).

Results : The time in frame (TF) while LON was 73.5 36.7 days and was higher then the time of lengthening (49.22 19.7 дней), in lengthening by Ilizarov TF was 201.474.4. External Fixation Index (EFI) in LON was 15.91 6.44 days/cm (in lengthening by Ilizarov 68.23 3.4 day/cm). In LON the total number of complications we found in 5 cases 19,2% (in lengthening by Ilizarov 11 (44,0%). From them: pin-tract infection 1 (3.8%) (in lengthening by Ilizarov 2 (8%)); breakage of transosseous elements 0(in lengthening by Ilizarov- 2 (8%)); breakage while insertion of transosseous elements 1 (3.8%) (in lengthening by Ilizarov- 0); secondary deformity or breakage of regenerate 0 (in lengthening by Ilizarov- 2 (8%)); preliminary fusion at osteotomy site- 1 (3.8%) (in lengthening by Ilizarov- 2 (8%)); deep infection or recurrence of chronic osteomyelitis 1 (3.8%) (in lengthening by Ilizarov- 1 (4%)); knee joint contracture 1 (3.8%) (in lengthening by Ilizarov 2 (8%)). On the x-ray and CT scans in LON-group was found intensive periosteal component in the regenerate site, the rates of the forming of cortical layer didn't vary significantly. In BTON TF was 145.6 + 54.5 days, EFI 20.0 15.4 days/cm (in bone transport by Ilizarov - 653,13 220,87 days and 71,28 25,69 days/cm, correspondingly). In 2 cases while BTON tears of the distraction cables were observed. No other complications were observed.

Conclusion : Combined use of External Fixation and BIOS in lengthening and bone transport of long-bones of lower extremities allows to decrease the period of fixation in frame by 3-5 times, to improve the quality of life and decrease the number of such complications as pin-tract infection, breakage of transosseous elements, to rule out breakage of regenerate and its secondary deformities. Use of extracortical Clamp devices allowed to avoid collision between transosseous elements and IN and to use the IN of optimal sizes.

#112: Bone transport with the fully implantable FITBONE System

Rainer Baumgart (Germany)

Bone defects may result primary from bone loss after severe trauma or secondary after resection of necrotic bone, frequently under septic conditions. Other reasons for huge defects are resections of benign or malignant bone tumor. If the defects are located in the midshaft area, bone transport with a fully implantable system may be an alternative for biological reconstruction. Which results can be achieved?

Methods: The FITBONE system coming out in multiple versions is able not only to perform lengthening but also to bridge defects by bone transport. The system can stabilize the bone segments and is equipped with a motor drive and a gear which is able to perform bone transport without any external fixation. Energy is transmitted by high frequency signals from an external power unit to a reception antenna placed in the subcutaneous tissue and connected to the motor drive component by a highly flexible cable. The system is fully implantable without any material connection to the outside, thus the skin is kept completely intact during lengthening. After osteotomy, controlled distraction at a rate of about 1 mm/day applied by electromagnetic impulses, 90 seconds each, can stimulate bone formation of high biological and mechanical quality within the distraction gap.

Results: In our Center 43 bone transports at the femur were performed with a custom made FITBONE SAA-system. The mean age was 32 years; the mean defect size was 74 mm. 31 defects result from accidents or war injuries. 12 defects result after resection of benign or malignant bone tumors in the midshaft. The transport was finished without complication in all cases. In 2 cases with earlier osteomyelitis, both after gunshot injuries, the infection rose up again and the nail was exchanged to a solid nail during consolidation. In 3 cases additional bone grafting was necessary.

Conclusion: The custom made Slide Active Actuator (SAA) variant of the FITBONE system with a diameter of 12 or 13 mm provides the key advantage of a modular design and creates the possibility to fix even extremely short bone-segments

#113: Simultaneous Ankle Fusion with Limb Lengthening using a Retrograde Lengthening Nail

Davida Packer (USA),
Dror Paley, Craig Robbins

Question: Whether ankle fusion and limb length equalization can be achieved together by retrograde intramedullary lengthening with a fully implantable lengthening device?

Methods: We retrospectively reviewed 5 patients with previously failed ankle fusions or osteotomies around the ankle. All patients had preoperative LLD. The ankle was fused from medial or lateral approaches using retrograde lengthening nail and cannulated screws. Lengthening was carried out by a more proximal osteotomy site. Clinical, subjective, objective, and radiographic analyses were performed after an average follow-up of 83.4 months.

Results: The preoperative LLD range was 2.6 to 4.0 cms. All patients complained of pain preoperatively and of significant limp. Ankle fusion was achieved in all 4 cases. The amount of lengthening performed was 1.6 to 3.0 cm (mean 2.4). The final LLD range was 0.9 to 1.1. The foot was plantigrade (90 degrees with no varus or valgus) in all cases. The foot rotation ranged from 5-15 degrees external relative to the knee in all cases. At final followup no patient had pain and all claimed to be walking much better than before surgery. Patients were walking with minimal to no limp after surgery based on the surgeons observation. One patient had a superficial skin infection after surgery. There were no other complications in this series. Two patients have already had their lengthening nail removed according to the manufacturers recommendations.

Conclusion: Early preliminary results show that retrograde lengthening nail is a safe and effective technique for equalizing leg length discrepancy simultaneous with ankle fusion. Previously only external fixation could achieve limb lengthening and ankle fusion at the same time. Although this is a small preliminary series the results of treatment are very promising with fusion and limb length equalization achieved in all 4 cases. Meticulous surgical technique to ensure optimal foot alignment after fusion is critical to the success of this treatment.

#114: Management of both tibial bone and nerve defects by distraction histogenesis with monolateral external fixation

Qin Chenghe (China),
Yu bin, Xulei, Hu yanjun

Question: The purpose of this presentation was to introduce a novel management of both tibial bone and nerve defects by distraction with monolateral external fixation.

Methods: We present a 29-year-old man who suffered a severe open comminuted fracture at We present a 48-year-old male patient with open fracture of the left distal tibia (Gustile IIIB), injury to the left posterior tibial artery and related veins, and a 6 cm tibial nerve defect after a traffic accident. The patient received debridement and temporal fixation immediately after he was admitted to our hospital. Five days later he underwent advanced debridement during which the tibial defect was measured to be 8 cm and the infected talus was removed. The proximal stump of tibial nerve was marked and embedded into the tibial stump (through a bony hole). Subsequently osteotomy of the proximal tibia and bone transport were conducted. Two months later, the docking site of the tibia with the calcaneus was freshened, the previously defective tibial nerve was distracted to be docked, and the both stumps of the tibial nerve were anastomosed.

Results: Bone transport continued until the plantar sensation was gradually recovered in the next year. The defects of tibial bone and nerve were thus restored.

Conclusion: Management of both tibia and tibia nerve defect by distraction histogenesis is effective and reliable

#115: Treatment options for non-unions with segmental bone defects: meta-analysis

Janet D. Conway, (USA),
Muayad Kadhim, Martin G. Gesheff

Question: What is the effectiveness (i. e., bone union and function) of different treatment modalities for nonunion with segmental bone defect (SBD)?

Methods: PubMed was utilized to identify all publications on SBD treatment published between January 1975 and December 2014. The eligibility criteria were non-experimental retrospective design studies that had radiographic and functional outcome data, a minimum sample size of 10 patients, and included patients with SBD caused by fracture non-union regardless of infection. Studies of SBD caused by acute fracture or tumor resection were excluded. Eligible studies were stratified by type of treatment and anatomic location.

Results: A total of 2,334 abstracts were reviewed to identify 189 studies of SBD yielding 24 publications that met the inclusion criteria. The sample size was 504 patients (395 males, 109 females). The lesions were located in the tibia (334), femur (96), radius (16), ulna (19), and humerus (39). Overall mean length of bone defect was 6.8 cm (range, 2.9-10.7 cm). Overall mean follow-up was 54 months (range, 19.3-116.0 months). Surgical treatment included bone transport utilizing various fixation methods and vascularized fibular autografts. The summary or pool estimate of success of bone union ranged from 71.5% to 99.8%, and function ranged from 57.6% to 99.8%. In the tibia, we observed the highest pool estimate of success for bone union and function (99.8% for both) with bone transport using external fixation over intramedullary nail. In the femur, monolateral external fixation had the highest pool estimate of success for bone union and function (99.7% and 94.7%, respectively).

Conclusion: Treatment of SBD can be challenging. This meta-analysis shows that bone union was achieved by different procedures with variable bone union and functional outcomes. Although these results are promising, the interpretation of this meta-analysis should be taken with caution as high variability exists between studies.

#116: Bone transport through an induced membrane in the management of tibial bone defects resulting from chronic osteomyelitis

Nando Ferreira (South Africa)
, Leonard Charles Marais

Question: Is bone transport an effective method for the reconstruction of bone defects after chronic osteomyelitis management.

Methods: We performed a retrospective review of ten patients who were treated by bone transport after chronic osteomyelitis treatment. All patients were treated according to a standardized treatment protocol and we review the anatomic nature of the disease, the physiological status of the host, as well as the outcome of treatment in terms of remission of infection, time to union and the complications that occurred.

Results: Nine patients, with a mean bone defect of 7 cm (range 5-8 cm) were included in the study. At a mean follow-up of 28 months (range 18-45 months) eradication of osteomyelitis was achieved in all patients without the need for reoperation for infection. The mean total external fixation time was 77 weeks (range 52-104 weeks), which equated to a mean external fixation index of 81 days/cm (range 45-107). Failure of the skeletal reconstruction occurred in one patient, who was not prepared to complete the reconstructive process and requested amputation.

Conclusion: The temporary insertion of antibiotic-impregnated PMMA appears to be a useful dead space management technique in the treatment of post-infective tibial bone defects. Although the technique does not appear to offer an advantage in terms of the external fixation index, it may serve as a useful adjunct in dead space management and achieving resolution of infection.

#117: Treatment of the segmental bone defects of the tibia with the Ilizarov method

Sergio Iriarte, (Bolivia)

: Is the Iizarov's method a valuable resource in the treatment of the segmental bone defects of the tibia?

Methods : Analyzing the treatment and results of 64 patients with bone loss defects of different length, different chronic forms of bone infection and other causes, from April 1993 to April 2014

Results : Healing of infection in 64 patients, 100% of effectiveness of the method; bone consolidation in 63 (98.43%), correction of the bone defect in 64 patients (100%). Angular deviations and restoration of function of the limbs were also corrected in a large percentage of patients.

Conclusion : The Ilizarovs method is a valuable resource of our orthopedic therapeutic arsenal in the treatment of the segmental bone defects, as consequence of the own traumatism or the failure of previous treatments.

#118: Limb salvage in large segmental bone defects (greater 3 inches)

Gerald E. Wozasek (Austria),
Julia Koettsdorfe

Question: The reconstruction of large segmental bone defects exceeding 8 cm remains a major therapeutic challenge. Strategies to avoid amputation and thereby provide satisfactory functional outcomes have not been sufficiently evaluated. Therefore, the present study reviews the clinical and functional outcomes after limb salvage.

Methods: From 1994 to 2011, a consecutive series of 12 patients with lower-limb segmental bone loss exceeding 8 cm were reviewed. Eight patients had suffered from a third-degree open fracture, whereas fourpatients had undergone bone resection after osteomyelitis. All patients underwent initial skeletal fixation with a simple, external frame. In six patients, the bone healed with no further stabilization after osteodistraction, while internal fixation by intramedullary nailing or plating was necessary in six patients.

Results: In reference to the clinical outcome, ten patients returned to their pre-injury activity level despite sustaining a total of 25 complications. Overall, patients with external fixator alone were at higher risk of sequelae (P = 0.014). In comparing the two groups, axis deviation at the lengthening site occurred in three patients without additional internal fixation; the only refracture occurred in this group. Generally, the size of the bone defect after debridement averaged 12.5 cm (range 826 cm). The mean distraction period until frame removal was 11 months (range 3.216.2 months). The EFI averaged 33.4 days/cm, whereas no significant differences in EFI were found between the groups.

Conclusion: We observed a reduced incidence of axial deviation and refracture in patients with large segmental bone defects who underwent an additional internal stabilization after fixation with an external frame. The two-stage technique caused no increase in infectious complications and might therefore be a preferable approach for successful limb salvage in patients suffering from large segmental bone defects exceeding 8 cm with insufficient bone formation during external fixation.

#119: AO-principles based classification of long bone defects

Leonid Solom
in (Russia), Theodor Slongo

Question: To develop a classification of long bone defects, allowing considering the severity of the bone lesion and serves as a basis for treatment and for evaluation of the results.

Method: The principles of Muller-AO of long-bone fractures classification were used to develop long-bone defect classification: from simple to complex, with an alphanumeric designation of a particular type of pathology.

Results: The defects of each bone segment are divided into four types and with further subdivision into three groups and their subgroups generating a hierarchical organization in triads (not shown here due to technical reasons).

Conclusion: The proposed classification allows identifying priority treatment methods. For example, different kinds of free bone grafting, dependent on degree of pathology. Free and vascularized grafting. A variety of Ilizarov techniques. Arthroplasty and prosthetics. Undoubtedly, the development of methods bone defect treatment will require improving classification that has been happening with the Muller-AO fractures classification.

#120: Management of bone defect in tibial metaphyses by bone transportation with ring-bar hybrid external fixators

Xing Teng (China),
Lei Huang, Shengsong Yang

Question : Functional reconstruction for the tibial metaphyseal bone defect is challenging. It is difficult to securely stabilize the pari-articular small bone segment, especially for those with severe disuse osteoporosis. The poor soft tissue coverage will put higher risk on use of implant. The other late post-traumatic complications, such as mal-alignment, adjacent joint contracture, arthritis and osteomyelitis will make the management tougher. Bone transportation with traditional Ilizarov ring external fixators is a well recognized technique for such problem. However, its bulky volume and the amount of pin tracts make many patients extremely uncomfortable and even unendurable. An frame with smaller dimension, less transosseous implants and reliable stability will make patients more accessible for the bone transportation intervention.

Methods : Ring-bar hybrid external fixator is an unilateral fixator with one pin-clamp mounted in peri-articualr segment replaced by wire-ring system. Wire-ring system used in peri-articular fragment is able to provide secure fixation to smaller fragment and mechanically superior to half-pin fixation in trabecular and especially osteopenic bone. The bone transportation will be performed in the linear unilateral part of the hybrid fixator, which is less bulky with less soft tissue penetration. What's more, the remaining peri-articular wire-ring structure will make the other procedures, such as arthrodiastasis and gradual correction for concomitant pes eqinus possible with additional attachments mounted in feet

Results : We managed 9 male patients with tibial metaphyseal bone defect from December of 2009 to Feburary of 2013 , of which four were suffered in proximal and five in distal, five were infectious and four were non-infected. The average length of tibial shortening was 13 mm (from 2 mm longer to 30 mm shorter) before index operation. The mean length of bone defect was 8.3 cm (4 ~ 13 cm). The non-infected patients were debrided in non-union site and fixed with ring-bar hybrid external fixators, followed by immediate osteotomy or delayed osteotomy after one month or two in the other metaphyseal region. For the patients with infectious nonunion debridement and fixation were used after the defect was filled with antibiotics impregnated bone cement or artificial bone. The osteotomy was performed secondarily. The fixator didn't remove until consolidation was noticed in both distracted area and docking site and the patients were able to ambulate without aids. All of the nine patients achieved bony healing in distracted area and docking site, 8 of which experienced autogenous bone grafting after docking. The average distraction length was 8.9 cm (5 ~ 13 cm). The leg length discrepancy was 4 mm shortening on average (1-14 cm) except one with shortening and equinus deformity who refused to correct. The average external fixator index (EFI) was 1.8 month/cm (1.2 ~ 2.6). The average length of following-up is 22.4 months (16 ~ 35 months) post-operatively and 4.4 months (3 ~ 9 months) after fixator removal. No infection was noticed to relapse. All the range of motion was 24° planti-flexion (15°~30°) and 4° dorsi-flexion (0-10°) in ankle joints and 108°of flexion( 80°-140°) and full extension in knee except one with pre-existing 20°equinus deformity, who denied the correction. The bony results were 7 excellent and 2 good, and the functional results were 4 excellent and 5 good according to Paley's criteria. Complications comprised of 8 problems, 4 obstacles and one sequelae. The total complication was 1.4 per patient.

It is an effective way to cure tibial metaphyseal bone defect by bone transportation technique with application of ring-bar hybrid external fixators, preserving adjacent joint functions as much as possible. The small peri-articular segments are able to be stabilized securely enough by such fixators. The easily wearing and convenient pin tract care make patients more accessible to such surgical intervention. It is prudent to stimulate union at docking site by gradual compression. Autograft is strongly recommended to the docking site.

#121: Is there a difference between the utilization of a ANKL non-locked two-hole plate in growth modulation: a Sawbones© study

Sheikh Taha,
Taha Abdel Majid


#122: Acute knee-joint subchondral bone bruises: manifestation of MRI and histopathology in rabbit models manufactured by different impact force

in Ch en (China), Jinsong Hong, Xiaohua Pan, Gang Li, Yuxin Sun

Question: Knee-joint subchondral bone bruises are focal abnormalities in subchondral bone marrow due to trabecular microfracture as a result of different force and clinical data's indicated that subchondral bone bruises will seriously affect the daily life, even result in early degeneration if not timely intervened. In this study, the manifestation of MRI and histopathology of subchondral bone bruises created by different impact force are to observe.

Methods: Total 30 18-months female New Zealand rabbits were divided into 3 groups (High Moderate and Low energy group) by randomly and the medial tibia platform of rabbits of each group were struck by a 0.5kg-weight hanging-Hammer (diameter: 2 cm) vertically fell down from different heights( 0.6m0.5m and 0.4m) through a transparent hollow pipe with scale. Then all animals were detected by MRI to get SNR (Signal to Noise Ratio) later at time point of 4 hours7 th day and 21th day. Beside, knees of 3 rabbits in each group were dissected when being sacrificed after MRI scanning in each time and specimens of knee-joint were scanned by Micro CT to analyze bone morphology parameters of subchondral bone bruises. Finally, the histological changes of the subchondral bone of tibial plateau were observed through microscope.

Results: The manifestation of T2WI and fat suppressed sequence T2WI of animal models after 4 hours appeared as areas of high signal intensity and the SNR of each sequence in 3 groups were statistically significant (p0.05) by the completely random design analysis of variance. Besides, the SNR of High Moderate and Low energy group were gradually decrease (p0.05) in further analysis. After 1 and 3 week the representation of T2WI and fat suppressed sequence T2WI also represented as areas of high signal intensity, but it was weaken after 3 week and the SNR of each sequence in 3 groups were statistically significant (p0.05). Furthermore, the consequences of Micro CT showed that after 4 hours, the differences of Tb. Sp in each group were statistically significant (p0.05); After 1 week and 3 weeks , Tb. N and Tb. Sp in High and Moderate energy group had no statistical difference (p0.05), but compared with low energy group the differences were statistically significant (p0.05). In the end, hemorrhages and edemas were prominent in histological examination of the subchondral bone areas of bone bruises and 1 trabecula bone micfracture was observed in High energy group. Nevertheless, after 3 weeks, hemorrhages and edemas still existed in the subchondral bone areas of bone bruises.

Conclusion: Animal models of knee-joint bone bruises can be manufactured by free vertically fall facility; The expressions of T2WI and fat suppressed sequence T2WI of each animal model are areas of high signal intensity, different levels of bone bruises of subchondral bone caused by different impact forces and the SNR gradually decrease over time; Upon histological examination, hemorrhages and edemas are prominent at the subchondral bone areas of bone bruises, and trabecula bone micfracture can exist part of animal model

#123: Single stage surgery for osseointegrated implants for lower limb amputees a case series

Munjed Al Muderis (Australia),
Aditya Khemka, Sarah J Lord, Belinda Bosley

Question: The Osseointegrated Prosthetic Limb (OPL) was introduced in 2011 to address major requirements of normal gait that are not met by socket prostheses. Our hypothesis is that OPL will result in superior function of daily activities, without compromising patients' safety. Previously this surgery was done as a two-stage procedure.

Methods: A. To describe the single - surgical procedure for OPL; and B. To present data on clinical and functional outcomes, andadverse events at the one year.

We retrospectively reviewed the first 18 single-stage procedures performed between 2013 and 2014 in a single centre, Sydney, Australia by a single surgeon. Patient inclusion criteria were strict and included: a formal interview with the multidisciplinary team (surgeon, radiologist, anaesthetist, pain physician, psychiatrist, physiotherapist, rehabilitation physician, and prosthetics). Baseline patient characteristics were collected. Outcome assessment was conducted at each follow-up visit (3, 6 months and yearly) and included health-related quality-of-life questionnaires (SF-36 and Q-TFA), Mobility Predictor (K Levels AMPRO), functional testing (6MWT and TUG) and energy expenditure evaluation. Change in pre versus post-operative function was assessed using paired t-tests.

Results: The total number of patients was 16 with 18 implantations (9 Trans femoral, 9 Trans tibial). 2 patients were bilateral amputees. K scores, Time Up and Go and 6 MWT tests showed a statistically significant improvement (p = 0.0006, and P = 0.0149, respectively). HRQOL improved for all patients. Average energy expenditure increased by 4 fold at final follow up. Infections occurred in 5 patients (4 grades 1A, 1 grade 1C) including only low grade superficial infections.

Conclusion: This study demonstrates the feasibility of performing OPL as a single stage procedure for above knee as well as below knee amputees. The results are encouraging, indicating improvement in patient functionality and quality of life, with a low rate of complications

#124: Safety of osseointegrated implants for trans femoral amputees

Munjed Al Muderis (Australia),
Aditya Khemka, Sarah J Lord, Belinda Bosley

Question: Although osseointegration has been shown to increase walking ability andprosthesis-related quality of life, uncertainty about the risk of infectiouscomplications has prevented introduction to a larger scale.

Methods: The purpose of this study is: A. To describe a comprehensive classification for infection thatincludes clinical, radiological signs and treatment criteria. B. To present preliminary data on the safety of press-fit type of osseointegrated implants including rates of infection, reactions at the skin implant interface, breakage of fixation parts, periprosthetic fractures, and refashioning outcomes. C. To investigate the association between patient characteristics and risk of infection.

After IRB approval, the university hospital in Australia conducted a prospective cohort study to analyze all consecutive subjects with trans-femoral amputation (2 bilateral) who underwent implantation of osseointegrated femoral prosthesis (ILP Ortho Dynamics GmbH Lubeck Germany). Infectious complications were prospectively registered and classified. Potential risk factors for complications were determined including gender, age, duration after amputation, cause of amputation, co morbidity including BMI, smoking behavior and length of stoma.

Results: Infectious complications occurred in; n = 20 of 44 patients: 15 grade 1A, 1 grade 1C, 3 grade 2C and 1 Grade 4. Risk factors that might have contributed to these complications included smoking, and female gender.

Conclusion: Post-operative infections following osseointegrated leg-prosthesis implants are not uncommon. The majority of these infections (80%) are superficial and can be managed with intensive local irrigation and antibiotics. In this series of 44 patients

#125: Osseointegrated implants connected to a hip replacement for amputees: A proof-of-concept study

Munjed Al Muderis (Australia),
Aditya Khemka, Sarah J Lord, Belinda Bosley

Question: Over the last two decades, osseointegrated implants have been used as an alternative for prosthetic attachment for above knee amputees, particularly for individuals suffering from socket interface related complications. Amputees with a very short femoral residuum

Methods: A. To describe the surgical procedure combining total hip replacement (THR) with Osseo integrated implants for the first time; and B. To present preliminary data on potential risks and benefits with assessment of clinical and functional outcomes.

We retrospectively reviewed the first three cases of trans-femoral amputations presenting with extremely short femoral residuum that underwent the procedure between 2013-2014. We used an osseointegrated implant connected to the stem of a THR prosthesis enabling the femoral residuum and the hip joint to act as weight sharing structures by transferring the load directly to the pelvis. We performed a tri-polar THR connected to a custom made TCBAP at the first stage followed by creating a skin implant interface at a second stage. Patients were assessed clinically and functionally including validated measures of health-related quality of life, amputee mobility predictor tool, ambulation tests and actual activity level. Progress was monitored for 12-30 months.

Results: Patients were aged 36-62 years, including 1 male and 2 females. No major complications were observed. All subjects showed improved functional outcomes as early as their 6 months follow up related to their health related quality of life questionnaires (QTFA- Quality of life questionnaire for transfemoral amputees and SF36 Short Form 36) and functional mobility tests including 6 MWT- 6 minute walk test and TUG-timed up and go. All cases were wheelchair bound pre-operatively (K0 AMPRO) and improved to walking with one stick (K3 AMPRO) at 12 months follow up.

Conclusion: This proof-of-concept study describes the first 3 cases performed using a novel technique to connect a THR to an osseointegrated implants. The preliminary outcomes indicated that this procedure is potentially a safe and feasible procedure to manage despite the theoretical increase in risk of ascending infection through the skin-implant interface to the external environment. We suggest larger comparative series to further assess safety and effectiveness.

#126: Expression of calcitonin receptor in subchondral bone of osteoarthritis

Zhibin Chen (China),
Jinsong Hong, Xiaohua Pan, Gang Li, Yuxin Sun

Question: In clinical observation, when 20 case female patients terminal stage of knee osteoarthritis (OA) combined with Osteoporosis were prescribed for 3 months with calcitonin (Salmon Calcitonin Nasal Spray 12.5ug/d), their symptoms were remarkably released compared with the non-intervention patients as long as the manifection of bruises signals of subchondral bone by magnetic resonance imaging (MRI). To observe the Calcitonin Receptor (CTR) expression of subchondral bone of terminal knee OA in order to further explain the clinical phenomenon.

Methods: 20 specimens of subchondral bone tissue in patients collecting from terminal knee OA after joint replacement were collected and the staining by SP method of immunohistochemistry was used to detect Calcitonin Receptor (CTR) expression of subchondral bone.

Results: Calcitonin Receptor in bruises-site of subchondral bone was positive, the positive rate of 35%; Calcitonin Receptor in normal zone of subchondral bone captured by MRI was also positive, but the positive rate of 78%. And The expression of Calcitonin Receptor between bruises-site of subchondral bone and normal zone of subchondral bone captured by MRI was statistically different (p0.05).

Conclusion: The data indicate a potential association between Calcitonin Receptor and subchondral bone of osteoarthritis.

#127: Effects of hyperbaric oxygen therapy on regenerated bone formation in post traumatic deformities results at 5 years follow-up

Roberto Bevoni (Italy),
Giorgio Montanari, Giuseppe Mignani, Mauro Girolami

Question: Is the Hyperbaric oxygen therapy (HBOT) able to accelerate the bone formation in distraction osteogenesis?

Methods: From May 2009 to May 2014 we treated with distraction osteotomies 40 patients (25 males, 15 females), mean age 34 years (18-57), affected by malunion of the lower limb. 20 patients (Group A) were treated with surgery and HBOT, 20 patients (Group B) only surgically. Each patient was evaluated clinically and radiographically preoperatively and every 30 days until healing has occurred.

Results: Clinically, all patients but one obtained a solid bone ingrowth at the osteotomy site. According to the ASAMI score system in Group A we had excellent results in 65% of cases, good in 30%, and poor in 5%; in Group B results were excellent in 50% of cases, good in 40%, and poor in 10%. There were no major complications. Group A achieved complete healing, with removal of the apparatus, in an average time of 132 days from the end of distraction, while Group B in 178 days. The average of the initial limb shortening was 3.8 cm in Group A (2.2 8.3) and 3.9 cm in Group B (1.8 7.7). Average distraction time was 41 days in Group A and 65 days in Group B. Average distraction rate was higher (0.23 mm/day) in the Group A.

Conclusion : In conclusion HBOT shortened the bone ingrowth time, with the achievement of a better quality of regenerated bone if compared with the control Group, at the same time. It is possible to apply this therapy in all the patients, excepted in selected cases, without any complication. The limits of this therapy are the costs for the therapy

#128: Can calcitonin lessen knee-joint subchondral bone bruises of eldly rabbit model?

Zhibin Chen (China),
Jinsong Hong, Xiaohua Pan, Gang Li, Yuxin Sun

Question: In our mid-term clinical observation, when twenty case female patients terminal stage of knee osteoarthritis (OA) combinded with Osteoporosis were prescribed for 3 months with calcitonin (Salmon Calcitonin Nasal Spray 12.5ug/d), their symtoms were remarkably released compared with the non-intervention patients as long as the manifection of bruises signals of subchondral bone by magnetic resonance imaging (MRI) Furthermore the specimens of subchondral bone tissue of these patients were collected and immunohistochemical analysised , th e result revealed the quantity of Calcitonin Receptor (CTR) in the bruises-site of subchondral bone distinctly diminished compare with that of normal zone of subchondral bone captured by MRI . Besides, the same results were also found in animal experiment. Thus on the basis of the hypothesis developed which the repaired insufficient of bruise in subchondral bone of the elder may be associated with the reduce of specific CTR, and Calcitonin could alleviate this kind of lessen.

Methods: 20 18-months female New Zealand rabbits were divided into 2 groups randomly (experimental group and control group), and the medial tibia platform of rabbits of each group were struck by a 0.5kg-weight hanging-Hammer (diameter: 2 cm) vertically fell down from 0.6m heights through a transparent hollow pipe with scale. All animals were scaned by MRI to obtain SNR (Signal to Noise Ratio) later at time point of 4 hours7 th day and 21th day calcitonin were injected in experimental group intramuscularly once per day at 5U/kg and control animals. were injected the same volume of normal saline Finally, the animals were all sacrificed at 3 weeks post-MRI scanning, and specimens of knee-joint were scanned by Micro CT to analyze bone morphology parameters of subchondral bone bruises.

Results: The expression of T2WI and Fat suppressed sequence T2WI of animal models 4-hour later appeared the extent of high signal intensity and the SNR of each sequence in 2 groups were no statistically significant (p0.05). 1-week and 3-week later the manifestation of original site areas also represented as of high signal intensity T2WI and T2WI, but it was weaken after 3 week and the SNR of each sequence in 2 groups were statistically dropped (p0.05). Besides, the further repeated measurement data analysis of variance result showed that time effect and interaction between time and intervention effect were statistically significant (p0.05);SNR in 3 weeks with time linearly reduced (p0.05), the SNR of each group were gradually dropped (p0.05). The result of Micro CT revealed that the differences of BV/TV, Tb. N, Tb. N and Tb. Sp in each group were statistically different (p0.05).

Conclusion: In conclusion, calcitonin can alleviate subchondral bone bruise of the elder New Zealand rabbit, maybe targeting the Calcitonin Receptor (CTR) of subchondral bone to , and may be a potential option to remedy the knee-joint subchondral bone bruises.

#129: The effect of platelet rich plasma on bone healing during distraction osteogenesis. An experimental study

Barakat El-Alfy (Egypt),
Ayman Ali

Question: what is the effects of platelet-rich plasma (PRP) on bone healing during distraction osteogenesis.

Materials and methods: Tibias of 36 New Zealand white rabbits were distracted at a rate of 0.25 mm/8 h for 20 days with a circular external fixator. The animals were randomly divided into a control group that did not receive PRP therapy and an experimental group, with PRP injection into the distracted area. Radiographic examinations were performed at the 10 th , 20 th , 30 th , 40 th and 50 th days after end of distraction. By the 50 th day after distraction, all animals were sacrificed. After that, each group was subdivided into two subgroups: one for pathological study and another one for mechanical study.

Results: The experimental group demonstrated higher radiologic scores at the 40 th and 50 th days. Histopathologic examination revealed a statistically significant higher score in the experimental group.

Conclusion: The results of this study show that PRP enhances new bone formation during distraction osteogenesis and shorten its consolidation phase.

#130: How distraction arthroplasty works: Chondrogenesis of cartilage progenitor cells under the stimulation of intermittent hydrostatic pressure

Jianchao Gui (China),
Yang Li, Yiqiu Jiang, Xiaofei Yang

Question : The purpose of this study was to explore the effects of intermittent hydrostatic pressure IHP on chondrogenic differentiation of cartilage progenitor cells cultivated in alginate beads.

Method : Cartilage progenitor cells (CPCs) isolated from the knee joint cartilage of rabbits was the major object of this experiment. Meanwhile, the infrapatellar fat pad derived stem cells (FPSCs) and the cartilage cells (CCs) were selected as the control groups. The 3 rd passage cells, embedded into alginate beads, were treated with the mechanical stimulation [intermittent hydrostatic pressure (IHP) of 5Mpa and 0.5Hz with the duration of 4h/day for 7, 14 and 28 days]. The cells migration and proliferation capacity were separately contrasted by the scratch assay and MTT assay. At the same time; Safranin O staining and immunohistochemistry analysis were performed to check the effects of IHP on the synthesis of ECM. RT-PCR was simultaneously performed to analyze the expression of the relative genes.

Results : The scratch assay and MTT assay revealed that IHP could promote the three kinds of cells migration and proliferation in different levels. Along with the time advancement, the cartilage matrix component ( GAGs and Collagen) and chondrocyte-related genes expression in IHP-groups were significantly higher than the control groups. Among the three cells, CPCs owned the overwhelming superiority under the stimulation of intermittent hydrostatic pressure as well as CCs showed the worst reaction.

Conclusion : Cartilage progenitor cells CPCs owned more stronger chondrogenic differentiation capacity than many other cells under the stimulation of intermittent hydrostatic pressure. This well source cells combined with the mechanical stimulation could help develop the cartilage tissue engineering and cartilage repair.

#131: Analysis of effect of p38 MAPK on osteogenic differentiation

Haidong Liang (China),
Zhengnan Zhao, Xianglong Yang

Question: P38 MAPK signal pathway has been found to be a potent stimulator of osteogenic differentiation and has potential application in preventing bone loss. However, the signaling pathway underlying its anti osteoporosis effect remains unclear. Rat were underwent either bilateral laparotomy or bilateral ovariectomy and treated with Anisomycin (the activator of P38), and effects were examined on the expression of signal messengers (p-p38 MAPK, OPG, RANKL and p38 MAPK) and the levels of osteogenic markers (serum E2, BGP, ALP, FSH and LH). It was found that Anisomycin significantly increased E2 level, BMD, and decreased BGP, ALP, FSH and LH levels. The addition of Anisomycin increased the p38 MAPK, OPG expression significantly, but had no significant effect on p38 MAPK expression. These results suggest that the osteogenic effect of Anisomycin involves the p38 MAPK signal pathway. All developing or even the developed countries face an increase in number of elderly people and, consequently, a growing prevalence of chronic age-related conditions. As a result, osteoporosis has become a major public health concern. Estrogen deficiency causes increased activation frequency for bone remodeling (Eriksen, 1986). The chief consequences are an increase in osteoclasts and resorption lacunae. There is also evidence that the reduced levels of estrogen decrease bone formation, albeit to a lesser extent than the increase in bone resorption (Lerner, 2006). Hormonal and pharmacologic interventions are often associated with adverse side effects and target the skeleton as a whole, as opposed to specifically targeting skeletal sites at increased risk for failure. Mechanical strain interventions, however, are noninvasive and have demonstrated promising results. In vivo studies have shown low-magnitude, high-frequency vibrations to be anabolic in both human (Rubin et al., 2006) and animal models (Rubin et al., 2001). In addition, whole bone accelerations have been shown to be anabolic to bone (Garman et al., 2007a, b). A contributing mechanism, by which low-magnitude mechanical stimulations act, could involve bone fluid flow. Previous studies have shown that in the absence of mechanical strain, intramedullary bone fluid flow can drive bone remodeling (Qin et al., 2003, 1998). MAPKs are evolutionarily conserved serineCthreonine kinases that participate in cell differentiation, growth and survival (Ding et al., 2001). They include ERK, stress activated protein kinases (or c-Jun-N-terminal kinases) (SAPK or JNK) and p38 MAPK. Signal transduction involves sequential phosphorylation of a tripartite kinase module, culminating in an activated MAPK. Activated MAPK might stay in the cytoplasm to phosphorylate structural proteins or translocate to the nucleus, where it could activate transcription factors involved in DNA synthesis and cell division (Choudhury et al., 2006). There is evidence that MAPKs are implicated in RANKL and OPG regulation (Tsubaki et al., 2012; Takami et al., 2005). This study aims to elucidate the involvement of p38 MAPK signalling pathways in the regulation of RANKL and OPG expression in OVX rats bone.

Method: Animals Female Sprague Dawley rats (n = 36), 3 months old, 240C280 g were used for the present study. To get adjusted to our animals quarters they were maintained under room temperature of 23C25 C, relative humidity 55%, and 12 h light/dark cycle for 3 weeks. During the experimental period, all the rats were pair-fed and allowed free access to distilled water and fed with standard rat chow. The acclimatized rats underwent either bilateral laparotomy (Sham, n = 12) or bilateral OVX (OVX, n = 24). Four weeks after recovering from surgery, the OVX rats were randomly divided into two groups: OVX with vehicle (OVX, n = 12) and OVX with Anisomycin (OVX + Anisomycin, n = 12); The experimental group received Anisomycin by an intraperitoneal injection at a dose of 15 mg/kg of body weight daily, and the control group received only the vehicle for 3 days. The body weight of the animals was recorded weekly during the experimental period. After laparotomy using anesthetized with diethyl ether, blood sample was collected via abdominal aorta puncture, serum was then prepared by centrifugation of the collected blood (2000 rpm for 20 min). Serum samples were then stored at 80 C for biochemical determinations. Femurs were dissected and filled in physiological saline and stored at20 C for measurement of bone mineral density (BMD) by Dual-energy X-ray absorptiometry (DXA). All studies were conducted according to the principles and procedures contained in the most recent publication of the NIH Guide for the Care and Use of Laboratory Animals National Research Council. Biochemical analysis: Serum samples were also subjected for the measurement of Ca and P by commercial assay kits (Nanjing Jiancheng Bioengineering Institute, Nanjing, China) for the in vitro determination. The levels of serum estradiol (E2), BGP, FSH, LH and ALP were also determined with a sandwich enzyme-linked immunosorbent assay (ELISA) assay kit (R& D Systems Inc., USA). ELISA assays were performed for serum E2 according to manufacturer instruction. Western blot assay: Protein was extracted from rats bone. The protein concentration was measured using Bio Rad protein assay kit. Equal amount of protein samples were separated on SDSC polyacrylamide gel electrophoresis (PAGE) and then electro-transferred to a polyvinylidene difluoride membrane (PVDF, Pall, USA). The membranes were blocked and incubated with appropriate primary antibodies including rabbit anti rat P38, phosphorlyted-P38 (p-P38) (CST, USA, dilution, 1:1000), and mouse anti rat actin primary antibody (Sigma, USA, dilution, 1:5000). Finally, the membranes were visualized with horseradish peroxidase (HRP) conjugated goat anti-rabbit, and rabbit anti-mouse (Beyotime, China) using the ECL plus reagents (Amersham Pharmacia Biotech, USA) by an UVItec ALLIANCE 4.7 gel imaging system. RNA preparation and mRNA quantification Total RNA was extracted from the rat bone using peqGOLD TriFast; according to the manufacturers instructions (PEQLAB Biotechnologie GmbH, Erlangen, Germany). RNAs from the same treatment group were pooled and DNA contamination was eliminated by subsequent enzymatic digestion (RQ1 DNase, Promega, Karlsruhe, Germany). Success of the DNA elimination was checked by PCR. Quantitative real-time PCR was applied for mRNA amplification with SybrGreen I (SigmaCAldrich, Chemie GmbH, Steinheim, Germany) as detection dye using the iCycler; Real-Time PCR Detection System (Bio-Rad Laboratories GmbH, Mnchen, Germany). Expression of all genes was normalized to the housekeeping gene cytochrome c-oxidase subunit I (1A). The primers used for the quantitative PCR are shown in Table 1. The CT method was used for the evaluation of the relative gene expression levels (Pfaffl, 2001). Statistical analyses were performed using Minitab 14 (Minitab, Inc., State College, PA, USA). The data were presented as mean standard deviation. One-way analysis of variance was used to compare the data among the groups and P.

Results: To investigate the effect of Anisomycin on bone quality, femurs were assessed for BMD, serum Ca and P determination. As expected, OVX significantly decreased BMD and increased serum Ca and P levels in OVX group compared to sham group. Anisomycin administration significantly increased BMD and reduced serum Ca and P levels in OVX + Anisomycin group compared to OVX group [Table 1]. In the present study, E2 level was significantly lower in OVX group than one in sham group. Anisomycin administration significantly increased serum E2 level in OVX + Anisomycin group compared to OVX group [Table 2]. Serum BGP, ALP, FSH and LH levels were statistically higher in OVX group than those in sham group. Treatment of Anisomycin significantly reversed the OVX-induced increased levels of serum BGP, ALP, FSH and LH levels to normal in OVX + Anisomycin group [Table 2]. The level of femur p-p38 MAPK protein was significantly decreased in OVX rats as compared with sham controls.

Conclusion: We demonstrated that Anisomycin increased expression of femur p-p38 MAPK at the mRNA and protein level in OVX rats. Then, increase of p-p38 MAPK expression increased the ratio of OPG to RANKL both in OVX rats. Moreover, activation of p-p38 MAPK in OVX rats femur effectively reverse abnormal levels of some bone metabolism related biochemical indexs. Our present study provides the first line of evidence p-p38 MAPK expression in OVX rats femur plays a pivotal role in OVX-induced osteoporosis via the regulation of bone metabolism related gene expression.

#132: FGFR3 Acts as a Switch Between Intramembranous and Endochondral Ossification: Implications for Enhancement of Distraction Osteogenesis

Simon P Kelley
(Canada), Chunying Yu, Heather Whetston, Benjamin Alman

Question: Fibroblast growth factor receptor 3 (fgfr3) mutations cause skeletal dysplasias with disparate phenotypes. Gain-of-function mutations such as in achondroplasia are characterized by disproportionate short stature, whereas loss-of-function mutations such as CATSHL syndrome are characterized by tall stature and scoliosis. Fgfr3 is known to be a negative regulator of chondrocyte proliferation affecting long bone growth by modulating endochondral ossification. However, individuals with achondroplasia show enhanced bone regeneration during distraction osteogenesis (intramembranous ossification) for limb lengthening. We hypothesize that fgfr3 affects mesenchymal proliferation and osteoblast differentiation, which act in concert with its known effects on chondrocyte function, a manifestation of which is the abnormal healing of bone fractures.

Methods: To investigate the role of fgfr3 in fracture healing we used an established murine semi-stabilized tibia fracture model in genetically modified fgfr3 knockout mice and their wild type controls. Fractures were harvested and analyzed at critical time points (PFD3, 7, 14 and 21) using histomorphometry, micro-CT and gene expression analysis (qPCR) to assess fracture callus structure and composition. The proliferative ability of bone marrow MSCs (BM-MSCs) from fgfr3+/ - And WT mice was studied using an in-vitro colony forming unit-fibroblast (CFU-F) assay, BrdU assay, limiting dilution and qPCR. The ability of BM-MSCs to differentiate to osteoblasts and chondrocytes in-vitro was examined using colony forming unit-osteoblast (CFU-O) and colony forming unit-chondrocyte (CFU-C) assays respectively, and were analyzed using staining techniques and qPCR.

Results: We show that fgfr3 modulates the size and structure of healing fracture callus with the fgfr3 mutant calli showing peak callus size earlier than their WT controls (D7), yet showing reduced callus size at the later time points (D14, D21) suggesting an acceleration of fracture repair. Despite the overall rapidity of healing, the structural integrity of the healed mutant fractures was diminished. In controlled in-vitro assays fgfr3 was shown to regulate the number, and proliferative ability of osteochondral progenitors and also has disparate effects on osteogenic and chondrogenic differentiation of murine bone marrow MSCs, whereby under-expression of fgfr3 decreases osteogenic differentiation but increases chondrogenic differentiation. These findings were recapitulated in our in-vivo model of fracture healing in fgfr3+/- knockout mice; peripheral subperiosteal bone formation from the intramembranous pathway was diminished whilst central bone formation from the endochondral pathway was accelerated. Thus we showed that fgfr3 affects fracture healing by acting as a switch between the two major regenerative systems of bone formation.

Conclusion: Our results demonstrate that fgfr3 is critical in coordinating the regeneration and repair of skeletal tissues by modulating multiple different cell types of the mesenchymal lineage. Modulation of fgfr3 signaling may offer the ability to enhance the proliferation and differentiation of skeletal progenitor cells for limb reconstruction therapy specifically to direct progenitor cells towards the intramembranous bone regenerative pathways, which has enormous appeal for enhancing the process of distraction osteogenesis.

#133: Results of limb lengthening in patients with systemic diseases of skeleton

Anna Aranovich (Russia),
Oleg Klimov, Konstantin Diachkov, Dmitry Popkov, Alexander Shchukin

Question: Our aim is to study results and time of regenerate formation when lengthening upper and lower limbs with simultaneous deformity correction in patients with systemic diseases of skeleton.

Methods: Russian Ilizarov Center has experience of treatment of over 800 patients with systemic diseases of skeleton: achondroplasia and hypochondroplasia, metaphyseal dysplasia, Turner syndrome. The diseases are characterized by short stature of the patient, deformities of segments, disproportion of body and limbs. Techniques of mono - And bilocal lengthening of femurs, tibias and humerus were used. Lengthening of segments was done consecutive (at the age of 6-8 both tibias), cross (femur and tibia from the age of 9-10 years).

Results: Lengthening of lower limbs in stages was performed by 28-30 cm; upper limbs by 9-11 cm. 3 stages of treatment allowed us to get more significant results both anatomically and aesthetically; make body proportions close to normal. The method of bilocal distraction osteosynthesis is efficient for limb lengthening in patients with systemic diseases of skeleton. It allows for 1.5-2 times increase of the speed of lengthening compared to the monolocal method and decrease of the period ofbone regenerate mineralization. Complications were classified according to the time of manifestation. The most frequent complications occurred at the most critical for final result distraction period (74%). The frequent complications during treatment included pin track infection (12.6%), neuropathy (8.6%). At long-term follow-up bone structure was normal, medullary canal was completely restored. 98% of cases were evaluated as good and excellent at long-term follow-up. All patients were pleased with treatment results; they noted improvement of function and life quality.

Conclusion: Limb lengthening in patients with systemic diseases of skeleton can be done by the method of Ilizarov transosseous osteosynthesis. Regenerate maturation time allows us to achieve limb lengthening up to 38-40 cm.

#134: Femur lengthening in children with achondroplasia

Veklich Vitaliy (Ukraine),
Veklich Viktoria

Question: We aim to answer the following questions: 1) Does life improve for children after limb lengthening?2) Can we fully eliminate the disproportion of limbs to the torso?3) What complications can occur during leg lengthening in children?

Methods & Results: We have operated on 134 achondroplasia patients with shortening of both thighs ages 3 to 16 (95% were aged 3-4). The thighs were lengthened by 8-11 cm using external fixators. We have found that in ages 3-4 lengthening of both thighs by 9-10 cm fully eliminates the disproportion of the thighs and torso and extends the thigh to normal size. During lengthening, the device is attached to the distal parts of the bone, causing fixation of the knee joint. One of the complications is contracture of the knee joint during the period of lengthening and treatment. After the device is removed, children require rehabilitation to restore functioning of the knee. Our main goal is to improve a child's physical and psychological well-being, so that they dont feel different from other children.

Conclusion: Use External Fixators on children with achondroplasia can extend legs by 9-10 cm. After removal of External Fixators the child fully recovers and has healthy bone structure.

#135: Hemiepiphysiodesis in Skeletal Dysplasia - With and Without Concurrent Limb Lengthening

Hae-Ryong Song (Korea),
Kwang-Won Park, Tae-Jin Lee

Question: Growth modulation in skeletal dysplasia is unpredictable due to an abnormal growth potential around the physes. When this is compounded by a lengthening procedure on the limb segment before hemiepiphysiodesis, physes is further affected and results could be difficult to predict. The aim of this study was to analyze the effectiveness of growth modulation in skeletal dysplasia and the results of hemiepiphysiodesis with and without lengthening in the patients with skeletal dysplasia.

Methods: We retrospectively analyzed 43 limb segments in 18 patients with skeletal dysplasia operated by hemiepiphysiodesis for angular deformity correction around the knee. 9 patients underwent lengthening before hemiepiphysiodesis. The results were grouped as effective and poor depending on the rate of correction. Rate of correction before and after lengthening was compared using difference of means in a general linear model with compound symmetry covariance structure.

Results: Hemiepiphysiodesis was effective in 39.5% and poor in 60.5%. Rate of correction was less than 0.5degree/month in 26 out of 43 limb segments. 32.5% either did not show improvement or worsened. Rate of correction after lengthening was higher in femur and lower in tibia compared to without lengthening.

Conclusion: Hemiepiphysiodesis in skeletal dysplasia should be used with caution due to a slow rate of correction and high failure rate. Femur lengthening improves the rate of correction hence epiphysiodesis could be considered even at a later age after lengthening. Tibial lengthening decreases the rate of correction hence an osteotomy might be considered after lengthening.

#136: Deformity correction in Pseudoachondroplasia and Multiple Epiphyseal Dysplasia Ishani Shah (India), Kwang won Park, Han-Ju Kim, Suh-Woo Chay, Somshekhar Dayal, Hae-Ryong Song

: Pseudoachondroplasia and Multiple epiphyseal dysplasia (MED) have a different disease course, however some forms of MED are allelic to Pseudoachondroplasia due to the same COMP gene mutation. Many genetic studies have been done on these two disease entities till date, but there is no study on the natural course of deformity, its management, complications of surgery and residual malalignment or recurrence.

Method : Patients with Pseudoachondroplasia and MED often require multiple surgeries which should be done at an earlier age. Even after early surgery there is progression of deformity and recurrences with increasing age. It is difficult to achieve anatomical axis in these patients due to severe deformities and ligament laxity.

Results : 17 segmental deformities were operated in the MED group. Mean age of surgery was 11.3 (6.7-19) years. Mean angular correction was 16 (7-43) degrees and segmental lengthening of 4 (1.8-5.8) cm was done for severe deformity correction. MAD improved by 27.7 mm. Anatomical correction was achieved in 58% (10/17), there was a residual deformity in 41% (7/17) and recurrence in 23.5% (4/17). Mean number of surgeries per patient was 1.2. Mean age at surgery in the Pseudoachondroplasia group was 15.2 (3.2-44) years. Mean angular correction was 17.4 (1-70) degrees and segmental lengthening for severe deformity correction was 4.8 (3-8) cm. MAD improved by 25 mm. Anatomical correction was achieved in 37.2% (16/43) and there was a residual deformity in 44.2% (19/43). Hemiepiphysiodesis failed in 5 segments. Mean number of surgeries per patient was 1.6. Out of 20 patients, 9 patients had minor complications and 4 had major complications. Clinical results were good in 7 patients, fair in 9 patients, poor in 4 patients.

Conclusion : Patients with Pseudoachondroplasia and MED often require multiple surgeries which should be done at an earlier age. Even after early surgery there is progression of deformity and recurrences with increasing age. It is difficult to achieve anatomical axis in these patients due to severe deformities and ligament laxity.

#137: Correction of Fasciogenitopopliteal syndrome by Ilizarov external fixator

Mofakhkhrul Bari (Bangladesh)

Popliteal pterygium syndrome is rare congenital anomaly characterized by a web like skin formation in the Popliteal area leading to fixed flexion contracture with an incidence of less than 1 in 300000. Most of the literature is on its clinical description rather than on its treatment. After Trelat's initial description in 1869, Gorlin was the first to introduce the term Popliteal Pterygium Syndrome (PPS) in 1968. It has been associated with other congenital anomalies and is further known as "faciogenitopopliteal syndrome". This may be due to Dermatogenic, Desmogenic, Myogenic, Osteogenic, Neurogenic, Primary treatment goals are improvement in functional extension, hygiene independence and cosmesis. Reported treatment options are anterior femoral stapling, supracondylar extension osteotomy, feumoral shortening and Ilizarov external fixator.

Methods: We report 8 cases with severe webbing causing FFD of both knee joints (ages ranged from 3-14 years). One 14 years old boy presented to us with severe right sided webbing causing FFD of knee with 8 cm shortening ( 3 cm femur, 5 cm tibia fibula), his daily activities were limited a movement was only by crawling or jumping. He used to walk upright. We corrected his deformity using gradual soft tissue distraction with Ilizarov fixator for 120 days. After correction of the deformity, we lengthened his tibia fibula; immediately after removal of Ilizarov fixator he was in plaster for four weeks.

Conclusion: Correcting Popliteal pterygium syndrome with Ilizarov method is a good choice in managing this difficult problem.


I = You must have intelligent

L = You can lengthen limb whatever you like

I = You can control infection

Z = You can correct Zigzag (deformity)

A = You will get angiogenesis with adaptation

R = This technique is of course reliable with a lot of

O = Opportunities, having

V = Versatile effect.

#138: Limb Lengthening in Achondroplasia before primary school - A natural growing approach

Robert Roedl (Germany)
, Frank Schiedel, Melanie Horter, Georg Gosheger, Henning Tretow, Bjoern Vogt

Question : Achondroplastic patients need huge lengthening more than 20 cm to achieve significant change of their body proportions. These procedures are demanding and compromises normal life. We want to minimize those effects by gaining 18 cm lengthening before primary school. Our hypothesis was that lengthening procedures should follow natural growing. The younger the patient the better is bone healing. Soft tissues are waiting for growth. Compromises of mobility and bad nights are better to compensate at nursery age.

Method : In 2006 we started with a concept of bilateral lengthening of the femur for 6 cm at the age of 2.5, tibia for 6 cm at the age of 4 and tibia again for 6 cm at the age of 5.5 years. Humeri are lengthened for 10 cm during primary school and a final femur lengthening is planned at the age of 14 with bilateral lengthening nails.

Results: Up to now we lengthened with this concept 266 segments in 50 patients (96 femora, 134 tibiae, and 36 humeri). All femurs underwent prophylactic elastic stable intramedullar nailing and all tibiae were treated with long leg cast after frame removal. 35 of 266 had complications: 1 infection of an intramedullary rod, migration of 4 intramedullary rods, 11 fractures of the regenerate (2 of them caused by stress shielding in patients below 3 years of age), 1 weak regenerate which needed bone grafting, 10 transient radial nerve palsy, 6 transient peroneal nerve palsy, 2 transient ankle valgus caused by insufficient fixing of the fibula. No patient spent more than 6 month in frame for 1 bilateral lengthening procedure.

Conclusion : Starting lengthening at nursery age is possible with acceptable complication rates. Time in frame is well defined; no patient was treated longer than 6 month. We found additionally that at age below 3 years problems arise with bone size and stress shielding.

#139: Intraoperative neurological monitoring of patients with skeletal dysplasias

Marina Makarov (USA),
John Birch, Mikhail Samchukov, Steven Sparagana, Elizabeth Van Allen

Question: External fixation procedures of patients with skeletal dysplasia bear a high risk of neurological complications with reported incidence of 35-48%. We reviewed the incidence of intraoperative monitoring (IOM) abnormalities using somatosensory evoked potentials (SSEPs) and clinical evaluation for postoperative neuropathy in our series of patients.

Methods: Fifty-four pediatric patients with various skeletal dysplasias underwent external fixation application with or without acute deformity correction on 94 segments of both upper and (primarily) lower extremities. Fifteen patients underwent bilateral external procedures. IOM involved stimulation of peripheral nerves distal to frame application site, with recording proximally to the frame, as well as over lumbar and cervical regions of the spinal cord. After establishing a baseline prior to surgery, SSEPs were recoded continuously throughout the surgery. Amplitude reduction 50% and/or latency prolongation 10% relative to baseline were considered significant and indicative of potential nerve injury.

Results: The overall incidence of peripheral nerve compromise in our series of patients was 15% (8 of 54). Five neuropathies (9%) were related to surgery and three (6%) occurred during treatment in the postoperative period. All five surgery-related neuropathies were accompanied by significant SSEP abnormalities during IOM. Due to our inexperience with interpretation of these changes, no corrective manipulations were attempted in two earlier cases and both patients developed permanent peroneal neuropathy postoperatively. In the subsequent three cases, timely corrective manipulations with wire/half pin removal and reversal of nerve tension during acute deformity correction resulted in good restoration of SSEPs and milder postoperative neuropathy which fully resolved within 1-6 months. Patients with achondroplasia had the highest incidence of neurologic complications (four of 12 patients, 33%), involving the peroneal nerve exclusively.

Conclusion: Reduced rate of peripheral nerve compromise in our series of patients with skeletal dysplasia was credited to the use of intraoperative SSEP monitoring of peripheral nerve function. Patients with achondroplasia are most at risk for neurologic complications. However, our modifications in the technique permitted sufficient time for detection of SSEP abnormalities, timely corrective manipulations, and good cooperation between surgical and IOM teams that considerably reduced the rate and severity of postoperative neuropathies.

#140: Lower limb alignment in limb lengthening for achondroplasia

Yuki Harada (Japan),
Kenichi Fukiage Tohru Futami

Question : Limb lengthening for achondroplasia is an established treatment method to improve the short stature and the lower limb alignment. Good functional results have been reported, although there are few reports about the lower limb alignment in skeletally mature patients after the limb lengthening. The purpose of this study is to report the lower limb alignment at skeletal maturity after the limb lengthening and to evaluate the associated factors with the lower limb alignment at skeletal maturity.

Method : From 1994 to 2008, 25 patients (male: 16, female: 9) were included in this study with whole standing radiograph at their skeletal maturity. The mean age at the initial lengthening was 10 years 6 months (Range 6 years 6 months to 17 years 9 months) years. All patients underwent bilateral tibial lengthening, and 17 patients, bilateral femoral lengthening. The mechanical axis deviation (MAD) was evaluated on the standing radiograph using absolute %MAD, and the standing radiograph was taken before the lengthening, after the external fixator removal, and at the skeletal maturity. As the candidates of the associated factors with the lower limb alignment at the skeletal maturity, MAD before the lengthening, and after the external fixator removal, post-operative fracture and LDFA were assessed. The lower limb alignment at the skeletal maturity with 50%MAD or less was categorized as e good f, and that with more than 50%MAD, as e poor f.

Results : Between the e good group and the poor group, there were significant differences in %MAD before the lengthening and that at the skeletal maturity (p0.05), LDFA at skeletal maturityi0.05j, and occurrence of post operative fracture (p0.05). The %MAD at the skeletal maturity correlated with that after the external fixator removal (AUC : 0.806).

Conclusion : To achieve the e good group alignment at skeletal maturity, the %MAD after the external fixator should be 50% or less because it has correlation with the alignment at skeletal maturity. The incidence of the femoral fracture after external fixator leads to the poor alignment, then it should be avoided and the fracture needs the accurate anatomical reduction.

#141: Perioperative management in limb lengthening of patients with achondroplasia

Connor J. Green (USA),
Julio J. Jauregui, John E. Herzenberg, C. Standard

Question: Limb lengthening and deformity correction for patients with achondroplasia can significantly improve function and quality of life. Simultaneous bilateral lengthening of femora and tibia (four-segment lengthening) is an accepted practice to reduce treatment time. The perioperative management of this patient group is ill defined. Current management is based on anecdotal evidence and case reports. We observed a case of postoperative lower limb paralysis and carried out an audit of our perioperative care. What are the risk factors for limb paralysis in patients with achondroplasia and what management protocol is appropriate to minimize the risk?

Methods: Consecutive patients with achondroplasia who underwent four-segment lengthening from February 2002 to August 2014 were identified. Medical records were reviewed. The main variables were previous spinal surgery, surgery duration, anesthesia type, positioning, and blood loss.

Results: Fifty-three patients (68 four-segment lengthening procedures) were included. We identified one spinal cord injury in a patient who had sagittal plane spinal deformity correction prior to lengthening. The patient received an epidural during surgery for four-segment limb lengthening. The patient was an outlier for blood loss but not surgical time. No other variables examined reached statistical significance.

Conclusion: No evidence-based perioperative protocol exists for patients with achondroplasia. No single factor was identified as a cause for the spinal cord injury. We suggest it is a cumulative effect from positioning, surgical time, blood loss, sagittal plane spinal deformity, and use of an epidural. As the relative risk of each variable cannot be quantified, we have adjusted our protocol (including discontinuing epidural use) in an effort to reduce the risk from all these factors. As we are now transitioning from external to internal limb lengthening devices, which involve increased surgical time and blood loss, these risk factors have become critical for future perioperative care.

#142: Results of using super hip technique for treatment of severe hip deformity in fibrous dysplasia

Mohamed Elkhosousy, (Egypt),
Amr Azzam

Question: Patients with severe forms of fibrous dysplasia have severe degrees of coxa vara with abductor muscle insufficiency , greater trochanter impingement over the pelvis and positive Trendelenburg sign. This result in limited hip abduction and difficult walking, and may result in stress fracture of the femoral neck because of the severe coxa vara as seen in two cases of our series. the question was how to correct all these deformities with one stage procedure to obtain the desired results.

Methods: Using a super hip osteotomy combined with iliac crest transfer of the abductor muscles and fixation with pediatric dynamic hip screw, the deformity can be corrected and the abductor muscle working length could be restored.

Results: The results were excellent. The normal neck shaft angle was restored from 70 degree to the 125 degrees with improved Trendelenburg sign. Active range of abduction was improved from 10 degree before surgery to 40 degree postoperative. Good healing was obtained for stress fracture of the femoral neck after correction of the neck shaft angle.

Conclusion: Super hip technique is an effective procedure for treatment of severe coxa vara deformity complicated with stress femoral neck fracture in severe forms of fibrous dysplasia.

#143: Analysis of achondroplasic bone lengthening during the last 20 years in our center

David Cancer Castillo (Spain),
Sergi Oliv Vias , Anna Isart Torruella , Ignacio Ginebreda Mart

Question: An analysis of bone lengthening of upper and lower extremities using the ICATME technique conducted in 102 patients with genetic achondroplasia operated in our center over the last 20 years.

Methods: 102 patients, 51 men and 51 women with genetic diagnosis of achondroplasia or hipoacondroplasia operated for the past 20 years in our center: segmental tibia lengthening, femurs and/or humerus between 11 and 18 years. Initial length and final length of each segment have been measured. Elongated centimeters, time of elongation, post-operative complications and need second surgery.

Results: The average initial length of each segment is: right tibia 18.23.4 cm, left tibia18.23.2 cm, right femur 24.43.3 cm, left femur 24.33.4, right humerus 16.42.2 and left humerus 16.42.3. The average elongation of each segment is: 144 cm in tibias, 13'2 cm in femur and 9 cm in humerus. The average elongation time was: 278 days in tibias, 345 days in femurs and 227 days in humerus. The average age for start elongation was 12.12.5 in tibias 14.82.7 in femurs and 162.7 in humerus. There was a 40.2% complication in right tibia, 34.3% in left tibia, 11.8% in right femur, 13.7% in left femur, 2.9% in right humerus and 3.9% in left humerus. There were no statistically significant differences in terms of gender or age of surgery and the appearance of complications, elongated centimeters and lengthening time required, except in the case of the humerus where we found that if the age of elongation is elderly, we need less time of elongation.

Conclusion: Elongation segmental limbs in patients achondroplasic allow an increase of almost 30 cm tall. It is a safe technique with a considerable rate of complications, mostly minor, but it causes a considerable improvement in quality of life such as psychological functional in these patients.

#144: Intertrochanteric Varus/Valgus Osteotomies Do Not Create Femoral Torsion

Harold J. P. van Bosse (USA),
Elsio R. Negron Rubio, Roger E. Saldana

Question: Varus or valgus osteotomies of the proximal femur are performed frequently to decrease or increase the neck-shaft angle, for a variety of conditions. The literature is conflicted as to whether such an angulating osteotomy itself can alter the femoral torsion. Our purpose was to investigate whether torsion is introduced when performing a straightforward proximal femoral valgus or varus osteotomy, using a bone model where all parameters could be carefully controlled.

Methods: A uniplanar external fixator was applied to a femoral bone model in the plane of the femoral neck, spanning the intertrochanteric region. An intertrochanteric osteotomy was performed, so that the neck shaft angle (NSA) could be positioned strictly into varus and valgus, without altering positioning in any other plane. The femur was mounted on a platform that allowed for rotation through the shaft of the femur, to create torsion. The NSA was varied from 90 to 150, at different torsion settings between -15 to 90, for a total of 30 position combinations. At each position, photographs were taken in the coronal and transverse planes, as well as parallel to the femoral neck to measure the inclination angle. The photographs where randomly ordered and measured twice each by 3 investigators.

Results: The measured version equaled the fixed version at a NSA of 120 (0.2 +/- 5.8), then varied by 0.047 per degree change in NSA, from a mean of -1.4 +/- 4.6 at NSA of 90 to 1.4 +/- 9.3 at NSA of 150. Measured versions varied from the fixed version by a mean of -0.386 +/- 9.4 at -15 version, to 1.8 +/- 6.0 at 90 version (overall P = 0.149). The inclination angle and the NSA were by definition the same at a NSA of 90; the measured inclination angle differed from the calculated inclination angle at each position by less than 1 on average (r = 0.967, P = 0.0001). The intra observer ICC for all angles was 0.97, whereas the inter observer ICC varied between 0.93 and 0.97.

Conclusion: A valgus or varus osteotomy of the proximal femur to alter the neck-shaft angle does not introduce changes in femoral version. The error in measurement of NSA and version increases at the extremes of both the NSA and version, but by less than 10, with 95% confidence. When performing an intertrochanteric osteotomy, the surgeon can be confident that femoral version will not be inadvertently altered by merely changing the neck-shaft angle.

#145: Reorientational Proximal Femoral Osteotomies forArthrogryposis Hip Contractures

Harold J. P. van Bosse (USA),
Roger E. Saldana

Question: Severe hip contractures are the single most crucial deformity that makes walking impossible for children with arthrogryposis multiplex congenita . These contractures occur in 50-85% of patients and are usually multi planar (flexion/abduction/external rotational). We developed a reorientational osteotomy at the intertrochanteric level, aligning the femoral shaft with the body axis, leaving the hip joint itself in its natural position. We sought to answer if the reorientational osteotomy could correct specific hip contractures, how it affected the total arc of motion along the various motion axes, and whether it allowed children to maximize their ambulatory potential.

Methods: Since 2008, 50 consecutive arthrogryposis patients had undergone reorientational osteotomies with a minimum of 2 years' followup, for a total of 94 hips (44 bilateral) for this retrospective study. Age at surgery ranged from 14 months to 12 years (average 45 months). An intertrochanteric wedge osteotomy was performed, the proximal cut in the transverse plane with the hip in its natural position, the distal cut perpendicular to the femoral shaft. The two osteotomy surfaces were married together with a cannulated hip blade plate, aligning the lower limb appropriately with the body axis. Hip motions were recorded pre operatively, at hardware removal, and at latest followup, as was ambulatory ability.

Results: Sixty-five hips had flexion contractures greater than 20 preoperatively (average 52), which improved an average 37; 65 hips had less than 15 adduction (average -19), improved an average 42; 76 hips had less than 30 internal rotation (average -15) which improved an average 34, all P values.

Conclusion: Children with arthrogryposis often have the potential for ambulation, if their limbs can be positioned to maximize their abilities. Hip contractures are the main lower limb deformity that prevents efficient ambulation. The reorientational osteotomy described allows the lower limb to be positioned appropriately for ambulation, altering the range of motion, but in most axes not changing the TAM. Most of the walker dependent children had less than 3 years followup, we expect many of them to become independent over time as well.

#146: Trochanteric entry for femoral lengthening nails in children: Is it safe?

Ahmed I. Hammouda (Egypt),
Julio J. Jauregui, Martin G. Gesheff, Shawn C. Standard, John E. Herzenberg

Question : Antegrade intramedullary (IM) nailing for femoral fractures in skeletally immature patients can damage the capital femoral epiphysis blood supply, leading to avascular necrosis (AVN) of the femoral head. Reported AVN rates are 2% for piriformis entry and 1.4% for trochanteric entry. None of the previous reports describe IM lengthening nails for limb lengthening procedures. We have used self-lengthening telescopic nails with a proximal Herzog bend and standard trochanteric entry for femoral lengthening in children. Can trochanteric entry IM lengthening nails be used safely in the femur without causing AVN or proximal femoral deformity in skeletally immature patients?

Method : Medical records were retrospectively reviewed to identify skeletally immature patients who underwent insertion of an IM lengthening nail through the greater trochanter. Inclusion criteria were IM nail insertion occurred between January 2004 and January 2014, at least 1 year of follow-up after insertion, and age younger than 18 years.

Results : Thirty-one femora were lengthened in 28 patients (17 males and 11 females). The etiology was congenital femoral deficiency (10), achondroplasia (6), post-traumatic causes (5), hemihypertrophy (3), Ollier disease (2), and miscellaneous (5). An attending surgeon was present for all procedures. Mean age at time of surgery was 12.7 years (range, 7-17.3 years). Mean follow-up after insertion was 3.3 years (range, 1-9 years). Average lengthening amount was 5.4 cm (range, 3-6.7 cm). Nails had diameters of 10.7 mm (24 nails) and 12.5 mm (7 nails). First generation IM lengthening nails were used in 18 femora and second generation in 13 femora. Ten limb segments (7 first generation nails; 3 second generation nails) had 13 complications. None of the patients developed AVN or proximal femoral deformity.

Conclusion : IM lengthening nails inserted through the greater trochanter may be utilized in skeletally immature patients without increased risk of AVN of the femoral head or proximal femoral deformity. Larger trials would be helpful to confirm our hypothesis. We recommend careful surgical technique with liberal use of fluoroscopy to avoid trauma to the femoral head blood supply.

#147: Hip deformity in post meningococcal septicemia sequelae.

Laura Deriu (UK),
Stephen N Giles, Sanjeev S Madan, James A Fernandes

Question: Which is the long-term effect of meningococcal septic arthritis of the hip on the proximal femoral epiphysis? Can a common deformity pattern be identified?

Methods: The record of all the patients admitted at our institution from 1991 to 2011 with a primary diagnosis of meningococcal septicemia who eventually required orthopaedic management for musculoskeletal problems were retrospectively reviewed. Inclusion criterion in the present study was the involvement of the hip joint. Medical records were specifically reviewed to determine age at the onset of the sepsis, age at surgery, and number of surgical procedures on the hip. Radiographs were reviewed and the following variables were measured: epiphyseal height quotient, epiphyseal index of Eyre-Brook, epiphyseal quotient of Sjovall or the femoral head index after epiphyseal closure as described by Tonnis, the joint surface index and the joint surface quotient of Meyer. Each radiograph was assessed for the presence and type of growth arrest at the proximal femoral epiphysis (Chois classification) and the type of deformity. Computed tomography scans, when available, were also reviewed to analyze the 3D characteristics of the deformity of the proximal femoral epiphysis. Statistical analysis was performed using statistical software SPSS v. 19 (SPSS, Chicago, Illinois). Comparison for each time interval was performed with the Student's t-test for all the continuous variables.

Results: Nine patients for a total of thirteen hips were included in the study. Mean follow-up was 5.3 years (4-9 years). The mean age at the onset of sepsis and at the first surgery was 1.2 years (4 months-4 years). The mean number of surgical procedures, excluding the hip washout was 4 (1-18). Comparison for each time interval showed a significant difference for the epiphyseal height quotient, the epiphyseal index of Eyre-Brook, the epiphyseal quotient of Sjovall and the femoral head index after epiphyseal closure. The joint surface index and the joint surface quotient of Meyer did not show any significant difference at different time interval. Growth arrest of the proximal femoral physis was observed in all the patients at follow-up. A progressive deformity was observed in the proximal femoral epiphysis at a mean follow up of 5.4 years from the initial event. Such deformity was associated to a type II growth arrest of the proximal femoral physis in all cases. Computed tomography scans analyzed confirmed the observations made on the radiographs.

Conclusion: The long-term effect of meningococcemia on the proximal femoral epiphysis is a severe progressive deformity associated with a type II growth arrest of the proximal femoral physis. All the patients who had an involvement of the hip joint developed such a deformity at a mean follow-up of 5.4 years from the onset of sepsis.

#149: Results of single-event multilevel orthopaedic surgery in patients with cerebral palsy

Dmitry Pokov (Russia),
Sergey Leonchuk

Question: The single-event multilevel orthopaedic surgery is the modern approach in the operative treatment of children with cerebral palsy.

Method: We studied results of the single-event multilevel surgery in 108 patients with CP in 18 to 24 months follow up. The average age is 11,31,7 years. Detailed physical examination, functional assessment, imaging, Edinburgh visual gait score and Gillette Functional Assessment Questionnaire were used in this study.

Results: In our series during 141 surgeries we performed 647 procedures. The patients had an average of 4.59 procedures per surgery. The observational gait analysis showed an improvement of stance and swing gait phases parameters in ambulatory children. According to Gillette Functional Assessment Questionnaire we noted an increase of functional level in 50 patients, it didnt changed in 32 patients.

Conclusion: The single-event multilevel surgery for children with cerebral palsy is defined as two or more soft-tissue or bony surgical procedures at two or more anatomical levels during one operative procedure or two operations because of the large volume of surgery with a short break, requiring only one hospital admission and one rehabilitation period. This approach requires the adapted methods of surgical intervention, appropriate methods of anesthesia and pain control in the postoperative period to the early start of rehabilitation. Compliance with the above principles allowed to achieve the necessary correction of orthopedic complications in all cases.

#150: The use of Ilizarov Technique to Correct Arthrogryposis Deformities-15 years follow up

, Hilario (Brazil), Dias, Alexandre Rial, Cavalcanti, Raul Mnch Silva, Fabio de Assuno, Linhares, Glauber Kazuo, Bastos, Thiago Amorin

Question: Is the Circular External Fixator Device effective to correct severe deformities in arthrogryposis?

Methods: Between January 2001 and January 2015 thirty nine patients with 57 knees and 68 feet deformities caused by arthrogryposis multiplex congenital were treated by Ilizarov technique. The patients ages ranged from 6 to 35 years with a mean age of 10,7 years. Twenty seven patients were male and twelve female. The knee flexion deformities ranged from 50 to 130 degrees (mean of 71 degrees) and 26 patients had bilateral club feet associated. Four patients had only unilateral knee deformity, nine patients had only bilateral feet deformity, two patients had unilateral foot deformity and one patient had unilateral knee deformity. The mean treatment time was eight months (range 5-11 months). All the patients were treated without any soft tissue release. The knee flexion deformities were corrected only by arthrodiastasis. Six weeks after the correction of the deformities the Ilizarov External Fixator was removed and a cast was carried out in order to keep the obtained correction. After a week the cast was replaced by a brace and the patient starts rehabilitation.

Results: The deformity was correct in 31 patients and recurrence was observed in 8 patients that didnt used the brace all the time. The absence of severe complications and the correction achieved emphasizing the important contribution of Ilizarov fixation to correct severe deformities caused by arthrogryposis multiplex congenital.

Conclusion: The Ilizarov External fixator is effective to correct the deformities without complications

#151: The use of Ilizarov Fixator device to correct severe deformities in Myelomeningocele

Boatto, Hilario (Brazil),
Clinco Junior, Osvaldo, Engelen, Carlos Luiz, Utsunomiya, Marcelo Fumio, Kiyohara, Robinson Toshimitsu, Dias, Alexandre Rial

Question: Is the Ilizarov external fixator efficient to correct severe deformities in myelomeningocele?

Methods: Between January 2001 and December 2014 fifteen patients with feet and knee deformities caused by myelomenincocele were treated by Ilizarov technique. The patient's ages ranged from 8 to 17 years with a mean age of 12 years. Eight patients were male and seven female. The typical deformity was equinus cavus- varus, adduction of the feets. Six patients had deformity at the right foot and four patients had deformity at the left foot. Four patients had bilateral feet deformity and one patient had deformities at the knees and feet bilateral. The mean treatment time was 6 months (range 5-9 months). All the patients were treated without any soft tissue release. The deformities were corrected only by arthrodiastasis. Six weeks after the correction of the deformities the Ilizarov External Fixator was removed and a cast was carried out in order to keep the obtained correction. After a week the cast was replaced by a brace and the patient starts rehabilitation.

Results: The deformities were well correct and recurrence was observed in 4 patients that did not used the brace all the time

Conclusion: The absence of severe complications and the correction achieved emphasizing the important contribution of Ilizarov fixation to correct severe deformities caused by myelomeningocelis.

#152: Combined external fixation and flexible intramedullary nailing in management of comminuted long bones fractures in children?

Ayman M Ali (Egypt),
Barakat El-Alfy, SallamI Fawzy

Question: Could combined fixation improve the results in comminuted long bone fractures in children?

Methods: 27 children with comminuted diaphyseal fractures of the tibia and femur were treated in our institution by combined external fixator and elastic stable intramedullary nailing. There were 19 fractures of the femur and nine fractures of the tibia. The ages ranged from seven to fifteen years with an average of 9 years. All cases were operated within first 7 days of injury. The nails were used to keep the alignment and the external fixators were used to restore the length and control the rotation. The fixators were removed early in the course of treatment once the callus that prevent rotation and collapse becomes evident on X-ray.

Results: The mean duration of the external fixation was 2.9±0.3 months for fractures of the tibia whereas it was 1.9 ±0.6 months for fractures of the femur. The average time for tibia fracture union was 2.38 ±0.7 months for fractures of the tibia whereas it was 1.7 ±0.8 months for fractures of the femur. Misalignment in varus less than 5 ° was noted in one patient. There were five cases (18.5%) with pin tract infection. According to ASAMI evaluation system; Bone results were excellent in 23 cases (85.2%) and good in three cases (11.1%) and poor in one case (3.7%). Functional results were excellent in twenty-two (81.5%) cases, good in four (14.8%) cases and poor in one case (3.7%).

Conclusion: Combined external fixators and elastic stable intramedullary nails seem to improve both clinical and radiological outcome in comminuted long bone fractures in children.

#155: Management of Upper Femoral Traumatic Slipping and Femoral Neck Fractures in Children by Intra-osseous Wiring

Yehia Rady (Egypt)

: Traumatic separation, fracture separation of the upper femoral epiphysis, and femoral neck fractures always require internal fixation to control the proximal fracture fragment floating in the intra-articular haematoma. To achieve stable fixation, screws must reach the subchondral bone in the epiphysis destructing the epiphyseal plate and enhancing early epiphyseal fusion. This will result in small head, short neck, and early degenerative changes.

Method : Since February 2007 till March 2014, five cases with Salter-Harris types II and III traumatic fracture separation and three cases with transcervical femoral neck fracture. All of the cases were male with an age range of 5.25 to 9.16 years and 6.72 years on average. Three cases had the injury at the right side, and the other 5 were injured at the left one. All patients were operated in the first week after the injury under endotracheal general anesthesia, on fracture table, and with image intensifier control. After achieving closed reduction, the fracture fragments were fixed with three 1.8 mm Kirschner wires. The wires were fixed to an arch; and this arch is attached to the femoral shaft by two Schanz pins. Patients were allowed to ambulate non-weight bearing with crutches for three weeks. Weight bearing was allowed starting from the fourth week. Frames were removed in all cases after six weeks. The shortest follow-up was 13 months and the longest follow up was 98 months, with an average of 49.4 months.

Results : Results obtained were satisfactory in all cases. Radiographic union was achieved in six weeks. All patients achieved normal range of hip movements within three months with no limp and no pain. Assessment after along term follow-up showed neither changes in the head and neck configurations nor mal-rotation or orientation.

Conclusion : Using of Kirschner wires to fix the upper femoral epiphysis is effective to achieve union. Also, it is a safe procedure, as it has no harm to the epiphyses or the epiphyseal plates.

#156: Are Patient Demographics Different for Early - And Late-onset Blount Disease? Results Based on Meta-analysis.

Steven Rivero (USA)
, Caixia Zhao, Sanjeev Sabharwal

Question : Two clinically distinct forms of Blount disease have been identified: Early - And Late-onset, based on whether the deformity was noticed before or after the age of 4 years. Both mechanical and genetic components have been implicated in the pathogenesis of this developmental disorder. While some clinical features are common to both forms, there are also key differences. The purpose of our study was to perform a pooled analysis to detect any differences in laterality, race and gender between the two presentations.

Method : Using PRISMA guidelines we searched five online databases for articles published between 1965 and September 2014 involving patients with Blount disease. Inclusion criteria were articles, which specified the child's age at disease onset, provided the above noted patient demographics, and the available data could be analyzed to perform comparison between the two forms of Blount disease.

Results : Based on 24 articles that met our inclusion criteria, we identified significant differences between the two presentations for all three demographic variables. Patients with Early-onset Blount were more likely to have bilateral lower extremity involvement (OR 4.30, 95% CI 2.27 to 8.17)

Conclusion : Our results confirm that differences based on laterality, race and gender exist between the two presentations of Blount disease. These findings support the hypothesis that the two forms may manifest themselves through related but distinct mechanisms. Future studies investigating these differences are needed to provide further insight into the etiology and could potentially affect the treatment and prognosis of children with Blount disease.

#157: Judet's Quadricepsplasty for Knee Contracture

Mofakhkhrul Bari (Bangladesh)

Question: Is Judet's Quadricepsplasty applicable for correction of the knee extension contracture?

Methods: Yes, it is corrected by Judet's Quadricepsplasty

Results: Results are uniformly unique.

Conclusion: By doing 5 steps surgery we can correct up to 90 degree or more flexion of knee extension contracture. It is a useful procedure to increase the range of motion of rigid knees.

#158: Is there a place in the routine practice for Ilizarovexternal fixation in diaphysealtibial fractures? A randomized, prospectivestudy of 58 consecutive patients

Telmo Ramos
, Bengt I. Eriksson, JnKarlsson, Lars Nistor

Question: The aim of this study was to compare the Ilizarovcircular fixator (IL) and locked intramedullary nailing (IM).

Methods: Patients with isolated tibia shaft fractures wererandomly allocated to either the IL (n = 31) or IM (n = 27) method. Conventionalradiographs, postoperative pain assessment, self-appraisal scores and complications were evaluated. At the clinical one year follow-up thepatients were also evaluated by an independent observer.

Results: The minority of patients had open fractures, twoand nine patients in the IM and IL groups respectively. Eight patients inthe IM group and four in the IL group sustained major complications (p = 0.107). In the IM group, two patients developed compartment syndrome, one deep infection, one hardware failure, one delayed union, onepseudarthrosis and two had a malunion. In the IL group, two patients developed pseudarthrosis and two had a malunion. Superficial pin-siteinfections were observed in 16 patients in the IL group. The fractures hadhealed radiographically at 12 weeks in both groups. At the one-year follow-up, there were differences in Pain (VAS) and Satisfaction (VAS) scores in favor of IL treatment (VAS, P = 0.03 and P = 0.02 respectively). Therewere no differences between the groups with regard to range of motion (ROM) in the knee and ankle joints. The registration of local tenderness and painrevealed that there were 19 patients with anterior k!nee pain in the IM group and one in the IL group at the one-year follow-up,

Conclusion: The IL is a safe and reliable alternative to IM for the treatment of tibialdiaphyseal fractures, with a low complication rate and good clinical outcome. Both treatments were well tolerated, but at the one-year follow-up the patients in the IM group had more pain and were less satisfied. Finally, there was a high frequency of anterior knee pain in the IM group. To summarize, we believe that the classical IL should be employed more in the daily practice of fracture care.

#159: Risk Factors for amputation in combat-related tibia injuries

Matthew G. Hanley (USA),
Peter Formby, Daniel Kang, Richard Purcell, Benjamin Potter, Wade Gordon

Question : What are the risk factors for amputation in fractures of the tibia resulting from recent conflicts in Afghanistan and Iraq.

Method : Retrospective review at a Level II Military Trauma Center identified 176 patients with 195 tibial fractures. Data was collected using the hospitals electronic inpatient and outpatient records and by reviewing pre - And postoperative radiographs. The resulting database, OCTIS (Outcomes following Combat Tibia Injury Study), consisted of 65 variables. We compared failed limb salvage at any time point to the 65 variables. Statistical analysis was completed using Chi square analysis and Fishers exact test for categorical variables and Mann-Whitney U test for nonparametric continuous variables. The significance was set at a P value of 0.05. Multivariate analysis using a binary logistic regression was performed to further elucidate independent variables from the significant variables in the univariate analysis. These are presented as odds ratios with 95% confidence intervals.

Results : There was an amputation rate of 19.4% in this cohort. Age, gender, military service, tobacco use, mechanism of injury, days spent in the intensive care unit, days to fasciotomy closure, total transfusions, use of negative pressure wound dressing, positive admission or downrange wound culture, nerve injury, infection within 6 weeks, positive deep vein thrombosis or pulmonary embolism, and heterotopic ossification were not associated with failed limb salvage on univariate analysis. Factors associated with failed limb salvage on univariate analysis included the type of definitive fixation utilized in the treatment of tibia fractures (p = 0.009), time to definitive fixation.

Conclusion : To our knowledge, this is the largest and most comprehensive series in the war trauma literature to describe risk factors for amputation in the combat related tibia injury. Vascular injury and soft tissue infection or osteomyelitis was identified as independent risk factors for amputation with an association for infection after 6 weeks. Further studies are required to identify a scoring system that effectively utilizes these risk factors and serves to guide future treatment recommendations regarding limb salvage versus amputation.

#160: Non vascularized double-barrel fibular graft for thereconstruction of metaphyseal supracondylar fracture of the femur

Tamer Abdel Mawla Abdel Gawad (Egypt),
Nabil Ahmed Elmoghazi

Question: Does the Non vascularized Double-barrel fibular graft restore metaphyseal bone defect in distal fracture of the femur in the presence of stable mechanical environment?

Method: From January 2011 to December 2014, 13 cases of supracondylar fracture of the femur with metaphyseal bone defect were performed in our institution, eight case were male. Five were female, with average age 45 years (range 19-73 years), lateral condylar blade plate was used in ten cases (AO type 33A, 33C2). and circular external fixator in 3 cases with intra-articular comminution (AO type 33C ). There were 2 cases of open grade 3c, according to the Gustilo and Anderson classification system and was managed initial by spanning fixator and vascular repair. later approach of the distal femur was used to expose the fracture site, ipsilalateral nonvascularized fibular harvest according to length of the defect, the fibla was cut in two halves. The fibula was put centrally in canal and medial l to restore deficient medial cortex, augmentation with cancellous bone graft (autologus in 8 and allograft 5 cases) and application of fixation device (plade plate or circular frame).

Results: The overall functional outcome was assessed using the criteria of Neer et al. This is based on 6 variables which describe the subjective, functional, and anatomical condition of the patient. The mean follow-up period was 32 months (range, 1550 months). Radiographic union was achieved by a mean of 6 months (range, 511 months). A 90 degree knee flexion was achieved in 9 cases at final follow up. Quadricepsplasty was done in one case to improve knee range of movement in internal fixator cases which has fixed with tibiofemoral external fixator for three months before referral to us, the range of motion has been increased to 95 degrees. The functional outcome was satisfactory (score 73-89) in 12 cases while the outcome was unsatisfactory (score 60) in 1 case who had Grade IIIB fractures

Conclusion: Surgical reconstruction with Non vascularized Double-barrel fibular graft, fixed with either blade plate or Ilizarov ring fixation is a suitable option for treatment of distal femoral fractures with metaphyseal defect where union had been achieved with satisfactory functional outcome.

#161: Open reduction and internal fixation with liss plate compared with circular fixator application for complex distal femural fractures (ao/ota type 33.c3)

Andrea Elli (Italy),
Francesco Sala, Paolo Capitani, Danilo Buniato, Dario Capitani

Question: Standard open reduction and internal fixation (ORIF) technique with Less Invasive Stabilization System (LISS) have been successful in restoring normal anatomy and osseous alignment for distal femoral fractures (AO/OTA Type 33). However, treatment of distal femoral fractures with severe comminution of the articular surface and metaphyseal area (AO/OTA Type 33. C3) represents a real challenge for the Orthopaedic surgeon. Surgical morbidity and soft tissues injuries, associated with high-energy trauma, have been reported frequently. For this reason, several authors have proposed minimally invasive methods of fracture reduction followed by circular external fixation as an alternative approach. To our knowledge, there has been no direct comparison of the two operative techniques.

Methods: From January 2002 to August 2013 we have operated 49 complex distal femoral fractures (AO/OTA Type 33. C3) in 45 patients with an average age of 44.7 yo ( range, 21 to 90 yo). In thirty-eight cases the fractures were caused by high-energy trauma, with a mean ISS score of 24. Pediatric fractures and patients with metabolic bone diseases were excluded from the study. Twenty-eight fractures were treated with an ORIF approach using the Less Invasive Stabilization System -Distal Femur, whereas seventeen fractures were treated with limited open internal fixation of the condylar joint surface and circular external fixation of the metaphysis and shaft for axial alignment. All the fractures treated with circular external fixation were open with III A-C grade according to Gustilo and Anderson system, and in five cases there was meta-diaphyseal bone loss. The patients were followed for a mean period of 29.4 months postoperatively, obtaining a history, radiographs and recording of complications and reoperation rates. Completion of the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Short Form-36 (SF-36) General Health Survey were obtained at a mean distance of 6 years after the injury for the two groups. Statistical analysis was performed using the Student t-test with significance set at a P value.

Results: There were no significant differences between the groups in terms of demographic variables and mechanism of injury. However, patients in the circular fixator group had higher ISS score than those in open reduction and internal fixation group (26.8 and 21.1, respectively; P = 0.033), and spent more time in hospital, even if non significantly different (45 days and 38 days; P = 0,062). There was no difference in terms of union and non-union rate between the groups (p = 0.326). Complication rates were not significantly higher in patients who underwent circular external fixation (p = 0.051) but the number of unplanned repeat surgical interventions, and their severity, was greater in this group compared with the LISS group.

Conclusion: Both techniques provide a satisfactory quality of fracture reduction. C3 fractures treated with open reduction and internal fixation with LISS plate have a lower incidence of complications and reoperation rates. Circular external fixation retards joint motion by binding of the soft tissues with fixation wires and pins and by bridging knee joint temporarily. For these reasons, external fixation technique is recommended only for salvage of severly comminuted and open fractures of the distal femur with extensive soft tissues injury and bone loss. Regardless of treatment method, patients with this injury have similar clinical outcomes at six years of follow up.

#162: Focal dome osteotomy with distraction osteogenesis for correction of post-traumatic tibial malunion: A case report

Casey C Ebert (USA),
Kenneth W Hegewald, Byron L Hutchinson

Question: The purpose of the presented case report is to detail the correction of a post-traumatic distal tibial malunion with acute angular correction by focal dome osteotomy followed by distraction osteogenesis at the osteotomy site. This report questions whether the versatility of the focal dome osteotomy can be expanded to include limb length correction at the level of the osteotomy and whether this technique offers a viable treatment option in diaphyseal tibial malalignment with limb length discrepancy.

Methods: Lower extremity deformity correction was performed in a 49-year-old male with multiplanar post-traumatic tibial malunion of the distal one-third of the tibia. Radiographs illustrated 16 valgus malalignment, 30 recurvatum deformity, and resultant 3 centimeter limb length discrepancy. Treatment included acute angular correction utilizing a focal dome osteotomy and external ring fixation with gradual osseous lengthening at the focal dome osteotomy site.

Results: Postoperative radiographs revealed improved alignment of the tibial anatomic axis and stable bone formation and fusion at the focal dome osteotomy site. Clinically at 13 months the patient showed decreased disability with unassisted gait and maintained alignment and improved limb length. The patient experienced continued dysfunction secondary to his underlying neuropathic pain and anxiety of limb use, however, displays improved mechanics, alignment, and function of his lower extremity. Conclusion: The authors recommend consideration of the focal dome osteotomy in lower extremity deformity correction, particularly in situations where sclerotic bone or previously violated soft tissues could be avoided. Avoidance of these areas, and the use of the focal dome osteotomy to maximize bony contact and minimize formation of secondary deformities, offer more optimized conditions for fusion, regenerate formation, and soft tissue healing. In addition, if limb lengthening is required the distal tibial focal dome osteotomy site may be considered for distraction osteogenesis using the Ilizarov method.

#163: Limb Salvage Surgery After Persistently Infected Total Knee Arthroplasties: Clinical and Functional Outcomes of Knee Arthrodesis with Mono Planar External Fixator

Halil Ibrahim Balci (Turkey)

The purpose of this study was to investigate the success of fusion with mono planar fixators, eradication rates of infection, and to evaluate the satisfaction of patients who underwent knee arthrodesis as a last resort, salvage procedure, for infected total knee arthroplasty.

Methods: It is a retrospective review of infected knee arthroplasties that we could not treated with conventional methods and that we applied knee arthrodesis to prevent amputation using mono-planar external fixators from 1999 through 2012 .

Results: The mean age of 17 patients were 67 ± 16.6 years. The mean duration of fusion was 6.8 ± 2.2 months. Compared with the healthy controls, the SF-36 scores were significantly lower in patients with knee arthrodesis (p < 0.05).

Conclusion Use of monoplanar fixators for arthrodesis in infected TKA with or without soft tissue defect can achieve high fusion rates with the control of infection. If fusion can be achieved, patients have acceptable pain relief and functionality.

#164: Botulinum Toxin A Does Not Decrease Thigh Pain or Improve Range of Motion During the Distraction Osteogenesis of Femur - A Randomized Trial

Keun Jung Ryu (Korea),
Dong Hoon Lee, Jin Ho Hwang, Hyun Woo Kim

Question: During femoral lengthening, distraction-induced muscle pain, contracture of the hip and knee joints are bothersome problems, which requires taking excessive pain killers, strenuous physiotherapy, or sometimes surgical interventions. We aimed to investigate the effect of botulinum toxin A in decreasing thigh pain or improving ROM of the hip and knee joints during femoral lengthening.

Methods: This study is a randomized controlled trial. From January 2011 to December 2014, we evaluated 44 patients (88 segments) undergoing bilateral femoral lengthening who met pre-specified inclusion criteria. The mean age was 26.5 years (range, 18-36 years). All patients underwent bilateral femoral lengthening with intramedullary lengthening devices (ISKD and PRECICE). Patients with implant-related obstacles or implant-related complications were excluded. Botulinum toxin A (BtX-A, 200IU, mixed with 20mL normal saline) was injected at seven spots on anterior thigh and this was made for only one leg at each patient. Selection of the leg receiving BtX-A was randomized intra-operatively by computer-based random number generation. Same amount of sterile normal saline was injected into the other leg as a control. Clinical evaluation included thigh pain VAS, ROM of the hip and knee joints, and maximal thigh circumference. Serial side-to-side differences with 2-4 weeks time interval were analyzed between the two legs within each patient with minimum follow-up of 12 months. Distraction rate, percentage lengthened, and healing index showed no significant differences between the two groups (BtX-A group vs Placebo group).

Results: There were no differences in thigh pain VAS and ROM of the hip and knee joints throughout follow-up between the two groups (BtX-A group vs Placebo group). Maximal thigh circumference showed no differences at each time point postoperatively.

Conclusion: Local application of BtX-A (200IU) at anterior thigh muscles in adult has no effect on decreasing thigh pain or improving ROM of the hip and knee joints during distraction osteogenesis of femur. However, different dosages with multiple or multi-level injections of the toxin and trial for different age group are still required.

#165: Results of acute shortening and re-lengthening methods tibia osteomyelitis with bone loss: five years follow up

Cengiz Sen (Turkey),
Halil Ibrahim Balci, Goksel Dikmen, Mehmet Kocaoglu, Levent Eralp, Mehmet Çakmak

Question: Efficiency and complication rates of the acute shortening and re-lengthening technique for the reconstruction of bone defects, limb length discrepancy and deformities that occur as a result of the radical debridement of tibia osteomyelitis is limited.

Method: In this retrospective clinical study, five-year results of incident series with bone loss caused by the debridement of tibia osteomyelitis are evaluated. 39 patients as having tibia osteomyelitis Cierny Mader type 4 underwent reconstructive surgery with distraction osteogenesis. The mean age was 42.9 years (range, 10-62). The mean loss of bone with preoperative limb length discrepancy was 7.15 cm (range, 3-14). Radical debridement, temporary external fixation and antibiotic-impregnated cement followed by reconstructive surgery with acute shortening and re-lengthening techniques. Docking site grafting was necessary for 18 patients.

Results: The mean follow-up was 74.5 months (range, 61-110). The results were: 33 excellent and 6 good in terms of bone results; and 31 excellent and 8 good in terms of functional results. The bone-healing index (BHI) was 1.31 months/cm (range, 2.3-0.75) and external fixator index (EFI) was 1.35 month/cm. The complication rate per segment was 0.8. We observed no recurrence of bone infection.

Conclusion: The acute shortening method has the ability to treat infection without recurrence but more prone to circulatory problems than conventional techniques; however, its advantages are the shorter fixator time, bone healing index and lower complication rate.

#166: Distraction Osteogenesis: A Comparative Study Between Ilizarov Frame, Lengthening Over Standard Nailing And Over SAFE Nail

Nuno Craveiro-Lopes (Portugal),
Carolina Escalda, Manuel Leao

Question: Commonly we use the technique of lengthening over nail (LON) and lengthening then nailing (LTN) to treat discrepancies and axial deformities of the lower limbs. To overcome infection problems in bone reconstruction procedures we developed a new nail. It is based on a new technology, named DualCore, consisting in a double core of PMMA cement impregnated with antibiotics and a textured metal rod inside it, to get more resistance to fatigue and to release antibiotics trough holes disposed longitudinal on the nail. Those holes are also used to fix intermediary bone fragments with screws. This nail was tested in laboratory showing 220% more resistance than the standard Grosse nail and supporting more than 1.5 million cycles of load, resisting more than 10 months without bone consolidation. By the other side, in vitro tests with 2 gr of Vancomicin showed a antibiotic release 14 folds the MIC during more than a year. The goal of this paper is to compare the results and complication namelly infection rates, of the techniques of Standard Ilizarov lengthening, lengthening over nail (LON) and lengthening then nailing (LTN) utilizing a standard nail (STD) and a special nail with a core of cement releasing antibiotics (SAFE).

Methods: In a first study done between 1993 and 2008, we have compared 25 patients treated with lengthening with a Ilizarov frame (LIF) with 26 patients where a standard nail was used to do a lengthening over nail technique (LON). From 2009 and 2012 we have utilized de SAFE nail in 17 patients to perform lengthening over nail (SAFE-LON) and lengthening then nailing (SAFE-LTN) techniques. Mean age of this group of patients was 52 years old, bone loss was mean 52 mm and the follow up was two years and three months. 7 patients had a pseudarthrosis, 5 a malconsolidation with shortening and or axial deviation and 5 a bone loss after infection of total knee replacements. We used a lengthening over nail in 4 cases, a lengthening and axial correction then nailing in three, acute compression and proximal lengthening then nailing in five patients and knee arthrodesis and femoral or tibial lengthening then nailing in another 5 cases. We have used a Ilizarov frame in all cases.

Results : We found that with LON technique, the external fixation time was 3 times lower and the index 1.5 times lower, promoting the recovery of full range of knee mobility in half the time, comparatively with LIF technique with statistically very significative diferences. By the other side, LON technique showed not to influence the consolidation time and index, the operative time, stay in ward and total costs of treatment. What concerns the influence of the cutting bone technique in regenerate consolidation, comparing Ilizarov corticotomy and the one done with a Gigli saw, we found that there are no statistically significative differences. What seems to influence consolidation time is smoking habits. Time to consolidation was more than the double in smoking patients, with a very significative difference. On the over all, the planed lengthening was achieved in more than 90% of both groups, without statistically significative differences What concerns intercurrences, we found a rate of 30% in the LON group and 24% in the Ilizarov, difference that was not statistically significant. It should be noted that 3 patients got bone infection after LON technique, a rate of 11.5%, which did not undermined the consolidation of the regenerate and healed after nail extraction but required more surgical procedures, more stay in ward time and costs. It was also remarkable that late consolidation and fracture of regenerate appeared only in the Ilizarov technique group, whereas in the LON technique we had 3 cases of premature consolidation of the regenerate. In the SAFE-LON and SAFE-LTN cases, bacteriology was positive in all cases and the most frequent bacteria was the meticilin sensible staphylococcus aureus, present in 47% of the cases. We have used in most of the cases 2 grams of Flucloxacillin and/or 2 grams of Vancomycin. Comparatively with LON technique using a standard nail, the SAFE-LON and SAFE-LTN techniques utilizing the SAFE nail with antibiotics, we found a decrease of the overall intercurrence rate from 30% to 12% and namely, bone infection was cured or didn't appeared after nailing with this new device in all cases.

Conclusion: Lengthening over nail and lengthening then nailing techniques are somehow more demanding, but much more comfortable for the patient, which need to carry the frame for less time, It permits an earlier return to activity, about half the time, it controls better delayed regenerate and its fracture and does not increase complication rate and costs of treatment. What concerns infection when utilizing external fixation combined with nailing, the SAFE nail showed to be a good device to prevent and cure bone infection in high risk patients

#167: LLRS Survey: Decision Making Practice Patterns in External Frame Removal

Christopher Iobst (USA),
Waleed Mohammad

Question: Even for experienced external fixation surgeons, it can be a difficult decision to know when it is safe to remove the external fixator from patients. This study surveyed the LLRS international membership on their practice patterns for external fixator frame removal.

Methods: A survey was emailed to the entire LLRS website membership list. The following 10 questions about their personal practice patterns were sent with each email: 1) What is your personal routine for determining when it is time to remove an external fixator?. 2) Do you routinely dynamize the frame during the course of treatment?. 3) If yes, what do you do to dynamize the frame?. 4) What are your clinical criteria for frame removal (i. e. patient must be walking with full weight bearing, etc.)?. 5) What are your radiographic criteria for frame removal?. 6) Do you perform any special tests to assist in determining the time for frame removal?. 7) Do you protect the limb after frame removal?. 8) If yes, what do you use to protect the limb after frame removal?. 9) When do you release your patient to return to full activities?. 10) Any additional comments on this topic?.

Results: There were 44 responses from surgeons in 10 different countries. Question 1: The top five answers from respondents were: Full weight bearing (52%), three cortices (50%), no pain (39%), after dynamization (27%), and duration of time (27%). Question 2: Yes (44%), Sometimes (23%), No (33%) Question 3: 85% mention dynamization method involving modifying the frame itself, 30% mention dynamization method involving alteration of the fixation points. For rail fixators the most common response was to unlock the clamp from the rail (57%) For Ilizarov fixators, 89% loosen the threaded rods and 11% remove rods For TSF fixators, 63% remove or unlock struts, 25% loosen struts, and 19% covert to threaded rods Question 4: The top answers were: Full weight bearing (83%), no pain (49%), and no change on dynamized frame (29%). Question 5: Three cortices (73%), four cortices (12%), and two cortices (7%) Question 6: Top responses were: No (48%), CT scan (18%), Remove struts (5%), stress test in operating room (10%) Question 7: Yes 55%, Sometimes 33%, No 12% Question 8: Cast 49%, Brace 30%, Decreased weight bearing (30%), Boot (28%) Question 9: Top responses: No specific time mentioned but must demonstrate full weight bearing and range of motion (30%), three months (25%), 1-2 months (20%), 4 cortices (18%), cleared from physical therapy (11%) Question 10: 24% of respondents wanted help with this topic and found this exercise useful.

Conclusion: This study demonstrated that there are a few consistent strategies used by experienced external fixation surgeons when trying to decide when to remove a fixator from a patient. However, this study also discovered there remains vast variation in practice patterns among surgeons world-wide. This indicates that the current information on this topic is unclear and does not provide clear recommendations for surgeons to follow. This study will hopefully stimulate further research into this topic to help make the decision making process easier for surgeons in the future.

#168: Factors Associated with Fracture during Physical Therapy Intervention in Patients Undergoing Limb Lengthening and/or Deformity

Alicia Fernandez-Fernandez (USA),
Carolina Mylett, Kelley Cartwright, Jessica McCarthy

Question : In the process of pediatric limb lengthening and deformity correction, the bone lengthens, or is realigned, at a rate up to 1 mm per day, which is much faster than a bone would physiologically grow. This rapid growth places a challenge on soft tissues including skin, muscle, tendons, fascia, vascular structures, and nerve tissues. Tightness of these structures can lead to joint contracture, joint subluxation, joint dislocation, or nerve damage. Physical therapy (PT) is needed in order to facilitate safe limb lengthening by promoting movement and providing stretch to increase soft tissue length. Without aggressive PT, the process will not be successful. During the deformity correction and/or limb lengthening process, the bone often becomes osteopenic and the soft tissues become rigid. In the process of stretching joints, movement will take the path of least resistance. Unfortunately, in a small percentage of cases, stretches during PT result in fracture. This study seeks to identify factors that are associated with an increased risk of fracture in the post-surgical PT treatment period, in hopes of guiding strategies to decrease future fracture rates during PT in this patient population.

Methods : This was a retrospective chart review study which included medical chart review for patients who underwent PT treatment related to limb lengthening/deformity correction between June 2009 and October 2014. Subjects (n = 36) ranged in age from 3 to 20 years. Out of these, 11 subjects had sustained a fracture during PT. Subjects were excluded if a fracture was identified radiographically, but time of fracture could not be identified as occurring during PT. Two treatment controls were matched to each of the fracture cases as closely as possible based on gender, age, surgical procedure, fixation device, and diagnosis (n = 22). Several variables were included in data collection including anthropometric and demographic characteristics, past medical history, prior level of function, repeat procedure, type of correction, fracture site and date, recent pin or hardware removal, weight-bearing history, characteristics of treating therapist, and patient compliance, among others. Data were analyzed in Stata using a variable-directed approach to establish a relationship between the dependent variable (fracture occurrence) and the predictor variables. Univariate tests were conducted to determine possible associations between fracture occurrence and patient and provider attributes, followed by inclusion of variables in a multivariate logistic regression model. Factors in the multivariate logistic model with p.

Results : On average, fractures occurred 81 days after surgery (range 22-248 days). Variables that were significantly associated with fracture included recent hardware removal within 3 months of fracture (odds ratio = 10.44, P = 0.03), and therapist years of experience with this specific population (odds ratio = 0.48, P = 0.04). There was no significant association with prior level of function, repeat procedure, weight-bearing history, or patient compliance. There was also no association with therapist overall years of experience (non-setting specific). There was insufficient data to make accurate conclusions regarding the influence of distraction rate or range of motion changes.

Conclusion: Patients who are undergoing limb lengthening and/or deformity correction are at increased risk for fracture during the 3-month period following hardware removal. Thus, timeline for hardware removal should be carefully considered, and special caution should be employed during physical therapy intervention to prevent fracture in patients in this group while preserving joint mobility. Additionally, there is a need for optimized training protocols for therapists treating these patients, as there is an association between fracture and therapist experience which is highly specific to experience in this setting. Studies with larger samples may help identify additional factors associated with fracture in this population.

#169: Application of Extracortical Clamp Device in Combined and Consecutive Use of External and Internal Fixation of Femoral Bone

Leonid N. Solomin (Russia),
Fanil K. Sabirov, Elena A. Shchepkina

Question: The use of conventional wires and half-pins in methods of Fixation Assisted Nailing (EFAN), Sequential External Fixation and Nailing (SEFaN), Lengthening Over Nail (LON) and Bone Transport Over Nail (BTON) is quite difficult. The question was to develop original device which will allow fixing of bone fragment containing foreign body (nail; stem of the hip endoprosthesis) to the ring of external fixator without necessity to perforate the cortices and bone cavity and and to evaluate its effectiveness.

Methods: Extracortical Clamp Device (ECD) having the desired properties was developed (www. ortho-suv. org). ECD was applied in treatment of 52 patients: EFAN (20), SeFAN (9), LON (8), BTON (4), periprosthetic fractures (6) and periprosthetic deformities (5). Mean age of patients was 38,0915,32 y. o. (from 13 to 75 y. o.).

Results: In all EFAN cases ECD provided stable fixation of bone fragments at acute one-level (14) and two-level (6) deformity correction. The period of deformity correction when SeFAN varied from 8 till 66 days (20.57.6 days). The period of external fixation was 97108.45 (8-287) days. The distraction period when LON was 40.856.1 (20-65) days; the period of external fixation - 64.445.1 days (14-153) days. The period of bone transport (BTON) was 84 24.9 (21-140) days; external fixation period - 103.7529.2 (26-164) days. In periprosthetic fractures external fixation period varied from 45 till 258 days (mean 166,5106,4 days). The period of gradual periprosthetic deformity correction varied from 24 till 35 days (29.63.4 days). There were complications ECD breakage (1), loss of stability (2), ECD-tract infection (2). All of them did not affect the treatment outcome.

Conclusion: ECD is effective tool for methods of combined and consecutive use of external and internal fixation of femoral bone.


#171: Comparison of hexapod fixator systems

Christopher Iobst (USA),
Mikhail Samchukov, Alex Cherkashin

Question : Multiple hexapod-type external fixators are now available for surgeons to use. The design of these fixators can be divided into two types of systems: 1) struts that utilize ball and socket joints attached to the outer surface of the rings and 2) struts that utilize a cardan type universal joint attached to the undersurface of the ring. This study compares the range of clinical capabilities of each design and identifies any advantages and disadvantages associated with each type.

Method : A hexapod frame consisting of two rings and six struts was constructed using each design type, the cardan type universal joint and the ball and socket joint. The cardan type universal struts were attached to the undersurface of the rings. The ball and socket joint struts were attached to the outside of the rings. The ring sizes were chosen to match in size as closely as possible. The internal diameter of the rings measured 155 mm for the cardan type universal joint and 160 mm in diameter for the ball and socket joint. Three different sets of strut sizes were tested on each ring, small (short), medium, and long. Starting with each strut in the neutral position, the frames were deformed into maximum coronal plane angulation, sagittal plane angulation, coronal plane translation, sagittal plane translation, rotation, and length. For each of these configurations, the software was used to create the maximum amount of each deformity until the limit of each particular strut size was reached. The deformities were pure in each plane without any induced secondary deformity. The frames were then tested on the amount of deformity correction possible before soft tissue impingement inside the rings would occur. A ring block was created using 100 mm diameter rings connected with threaded rods. This ring block was placed inside the 155/160 mm rings with struts to simulate the soft tissue diameter of a patient. The frames were rotated until the struts started to touch the 100 mm ring block indicating soft tissue impingement. This was also tested using 155/160 inner diameter 5/8 rings connected with the opening of the rings rotated 90 degrees externally relative to each other as would be used in a femur or humerus construct (i. e. the proximal ring is open medially and the distal ring is open anteriorly or posteriorly). Using the medium-sized struts set at neutral strut length, a frame was constructed using the cardan universal joints and the ball and socket joints and the 155/160 mm inner diameter rings. The amount of space available for half pin placement between the ring and the strut was evaluated. Using the software, the two different ring/strut designs were compared for the amount of strut changes necessary to achieve full correction of several different types of deformities. For Blount disease, two different deformities were created, one with moderate deformity parameters and one with severe deformity parameters. Each frame was built with a 180 ring proximally and a 155 or 160 mm ring distally. The frames were constructed with the same distance between the rings on the fictional patient. An equinus deformity was also created. The frame construct was similar for each with 155 or 160 mm inner diameter rings placed on the distal tibia and 155 or 160 mm inner diameter foot rings placed on each foot. The distance between the rings was identical in each case.

Results : Simulated soft tissue impingement started when the cardan type universal joints were rotated 39 degrees. Simulated soft tissue impingement started when the ball and socket joints were rotated 52 degrees. The frame construct consisting of two 5/8 rings with the openings rotated 90 degrees relative to one another showed increased soft tissue impingement with the cardan type universal joints compared to the ball and socket joints. There was also increased space for half pin or wire fixation with the ball and socket joints compared to the cardan universal hinge joints. A Blount disease patient with moderate deformity (36 degrees varus, 15 degrees of apex anterior, 20 degrees of internal rotation, and 8 mm of shortening) was entered into the software program for each style of hexapod frame. Each frame construct had the same ring sizes and distance between rings. Both the cardan type universal joints and the ball and socket joints required 3 strut changes to achieve full deformity correction. A Blount disease patient with severe deformity (54 degrees varus, 51 degrees apex anterior, 30 degrees of internal rotation, and 8 mm of shortening) was entered into the software program for each type of hexapod frame. Each frame construct had the same ring sizes and distance between the rings. The cardan type universal joints required six strut changes to achieve full correction. The ball and socket joints required one strut change and two strut adjustments to achieve full correction. For a patient with 45 degrees of equinus deformity, two strut changes are needed for both the cardan type universal joint struts and the ball and socket struts to achieve full correction.

Conclusion : Both the cardan type universal joint and the ball and socket joint hexapod frame designs allow significant multi-planar correction to occur. In the smaller size struts, the cardan type universal joints allow more translation and rotation while the ball and socket joints allow more length. For large rotational corrections and frames built with 90 degrees of offset, the ball and socket joint design may be better at avoiding soft tissue impingement. While systems are comparable with mild to moderate deformity correction, the ball and socket joint design allows more correction with less strut changes for severe deformity types.

#172: Initial experience using the TL-Hex system in pediatric tibial deformity patients

Christopher Iobst (USA)

: New software assisted hexapod external fixators are now available to surgeons. How does the new ball and socket joint hexapod fixator from Orthofix (TL-Hex) perform when correcting multi-planar tibial deformity in children?

Method : A retrospective review of the first ten cases using the Orthofix TL-Hex was performed. Multiple data points were collected including patient age, gender, etiology of deformity, pre - And post-operative radiographic evaluation of mechanical axis deviation and deformity parameters, osteotomy site, frame duration, and complications.

Results : 10 cases in 8 patients (2 bilateral) were reviewed. The average age was 12.5 years. There were 7 males and one female. The underlying etiology was adolescent tibia vara in five cases, infantile tibia vara in three cases and multiple hereditary exostosis in two cases. Seven osteotomies were performed in the proximal tibial metaphysis and one osteotomy was performed in the distal tibial metaphysis. The average angular correction was 14 degrees in the coronal plane and 7 degrees in the sagittal plane. Three patients required simultaneous rotational correction averaging 23 degrees. Two patients required concomitant lengthening of 2.5 cm and 2.0 cm respectively. Two patients had final post-operative under-correction of the posterior proximal tibial angle by two degrees. All other pre-operative deformities were successfully corrected to normal with the TL-Hex. All osteotomy sites and regenerate bone healed primarily without delay or the need for adjunctive treatment. The average frame duration was 126 days. Only one case required a planned strut change to achieve full deformity correction. There were no fractures after fixator removal at an average of 7.6 months follow-up. Three patients had superficial pin track infections requiring oral antibiotics during the course of treatment. One patient's parent did not follow the adjustment prescription and corrected the deformity faster than desired but did not cause any healing complications. One patient had a strut come loose from the ring during the consolidation phase but did not lose any correction.

Conclusion : The Orthofix TL-Hex system is a safe and accurate method for performing multi-planar correction of pediatric tibial deformities. The system was also noted to require a total of only one strut exchange to achieve full correction in this group of ten cases.


#174: New kid on the block - The true look Hex frame: how does it compare to Taylor Spatial Frame? - Direct comparison of results in the treatment of severe open tibial fractures

Konstantinos Doudoulakis (UK),
John Hardman, Satyajit Naique

Question: Taylor Spatial Frame (TSF) is an established hexapod device widely used in the treatment of severe fractures and for deformity correction. The TL-HeX frame is a new generation hexapod device, recently introduced to the European market that claims to offer numerous unqualified advantages for both surgeons and patients. These include an easier surgical technique, friendlier computer software, and a more stable construct . However, clinical studies have yet to prove its efficacy and safety, and to confirm its superiority. In this single surgeon series, we set to make a direct comparison the TSF and TL-HeX frames and examine in detail the clinical and surgical outcomes.

Methods: All patients with open fractures (GA grades 2 to 3C) presenting to our Major Trauma Centre from 2011 onwards and who had received combined orthoplastic treatment with a circular hexapod frame were selected (53 TSF and 15 TL-HeX). Of these, 77 patients completed their treatment at our unit (38 TSF and 15 TL-HeX). Outcomes were compared in these two groups for presence of union, time to union, infection rate, residual deformity, complications and functional outcomes

Results: Patients treated with the TL-Hex frame all exhibited bony union with a mean time to union of 177.5 days (192.6 days for 3B fractures). Of the patients treated with TSF frames, 8 failed to unite, whereas the mean time to bone union for the rest was 243.7 days (245.64 for 3B fractures). Frame complications in the TL Hex group were 5 episodes of strut extrusion in 4 patients. ASAMI bone scores were either excellent (10) or good (5), whereas ASAMI function scores were excellent (8), good (2), fair (2) and poor (2), with one pt lost to follow up. 5 patients developed a superficial infection. TSF complications comprised of one instance of extrusion and two instances of broken wires. ASAMI bone scores were excellent (8), good (16), fair (5), poor (8), while function scores were excellent (16), good (5), fair (1) and poor (13), with two patients being lost to follow up. 18 patients developed a superficial infection whereas 4 developed a deep infection.

Conclusion: Early results show an advantage of using TL-HeX frames for the treatment of severe open tibial fractures. Bony union times are quicker for equivalent fractures, and outcome scores of both bone healing and function are higher. A high incidence of strut extrusion may require further investigation.

#175: Early experience of using a new hexapod circular frame inthe management of severe lower limb trauma

Konstantinos Doudoulakis (UK),
John Hardman, Satyajit Naique

Question: Circular frame Hexapods have been used for treating fractures and deformity for the last 20 years. However the most commonly used hexapod (Taylor Spatial Frame) has some inherent shortcomings in the treatment of fractures. To address these issues and improve patient and surgeon experience as well as clinical results. The TL-HeX hexapod circular frame has been introduced in December 2013. As early users we describe our experience from its use in the management of severe lower limb trauma.

Methods: 26 patients presenting with high energy lower limb trauma and treated in a combined orthoplastic approach using TL-HeX circular hexapods frames were selected. All operations are performed by a single surgeon experienced in using circular frames for the last 15 years. All patients had either closed injuries with Tcherne soft tissue injury above grade 2 (11 patients) or open injuries (GA grade 2 and above, 15 patients) . All patients included had completed treatment and had had frame removal. Of patients with open fractures, 4 had free flaps (2 radial forearm, 1 ALT, 1 LD), 2 had local fasciocutaneous flaps, and 7 had acute shortening of their fractures. All patient had either acute on-table correction or post-op computer guided programs, or both. TL-HeX struts were used in all cases. All patients were allowed to fully weight bear immediately. We evaluated presence of union, time to union, presence of infection, residual deformity, complications and functional outcomes

Results: No patients were lost to follow up. All fractures healed, Average union times were 118.4 days for closed fractures and 177.5 days for open fractures. ASAMI bone scores were either excellent (8) or good (3) in the closed fractures and either excellent (10) or good (5) in the open fractures. ASAMI functional scores in the closed fractures were excellent (7), good (3) and poor (1), whereas in the open group results were excellent (8), good (2), fair (2) and poor (2). There were 6 instances of superficial infection, and one instance of residual values deformity of more than 7 degrees (10 degrees). Complications included 5 instances of strut extrusion in 4 patients.

Conclusion: Despite a moderately high incidence of strut extrusion, bone union is 100% while time to union is low, with few complications, and outcome scores are high. Early experience suggests that this is a safe and effective device to use in the treatment of severe fractures of the lower limb.

#176: True/Lok Hexapod for severe deformity correction and occurrence of second adjustments on patients prescription: analysis of twenty five cases

Richard Luzzi (Brazil),
Fernando Ferraz Faria, Carlos Eduardo Miers

Question: Complex deformity correction procedures are becoming more common with the development of frames based on six axis analysis. Mostly of these corrections are guided by softwares, and, if data are acquired properly, precision to correct is high. However, many times, even respecting what was prescribed, there is a need to recalculate because the aim was not reached completely.

Method: We review patients submitted to elective lower limb deformity correction procedures, operated from May 2014 to May 2015 with the new True/Lok Hexapod (TLHEX, Orthofix, Bussolengo, Verona, Italy). The deformity parameters used for analysis was the amount of angular deformity (in any plane), translation (in any plane), torsional deformity (in any direction), and axial translation (shortening or lengthening). Statistical analysis was performed using SSPSSS (15.0 for Windows Evaluation Version, New York, IBM), and results processed through T-Test for independent parametric variables and Pearson Chi-Square for non-parametric variables.

Results: This is a case series of 25 patients, 13 patients had on level deformity corrected, 4 of these patients had two level correction deformities, and 8 patients had deformities in two or more segments, forming a group of 36 deformities. Thirty one deformities had an angulation component [angular deformity average: 14.28; 8.99 (0-32)], 16 had torsional component [average 9.28; 12.68; (0-40)], 16 had translational component [average: 4,92 mm 8,28 mm (0-33 mm)] and 23 had a shortening or lengthening component [average: 15.03 mm 20.46 mm (0-72 mm)]. In 25 deformities, representing 69.4%, were used as a reference ring a full ring, and in 11 (30.6%) deformities were used a 5/8 ring. In 18 (50%) deformities a re-calculation were performed due pure additional lengthening in three cases, to correct angular deformity in two cases, to correct torsional deformities in three cases, and a combination of any above in ten ! cases. None of the deformity parameters proved to have an influence, statistically significant, with the recalculation event, neither was a double level correction or the type of ring used as reference ring.

Conclusion: In this case series, there is no evidence of relationship between the deformity, and frame parameters analyzed and the recalculation event. Additional studies maybe can answer this question.

#177: Hexapodal experience in tibial and femoral reconstruction: potentials and limits of multilevel techniques

Giovanni Lovisetti (Italy),
Francesco Sala

Question: Can multilevel hexapod-based system be used to accomplish tibial and femoral reconstruction for deformity, limb length discrepancy, non-unions and bone defects?

Methods: We retrospectively reviewed our experience using TSF and TL-Hex external fixation for tibial and femoral reconstruction in 14 consecutive patients between 2008 and 2014. The study population included 12 men and 2 women. The average age at surgery was 44.1 years (19-79 years). The locations were: femur (5), and tibia (9). Patients data were collected from medical records and radiographs. Complications encountered intra-operative and during treatment were grouped using Paleys Asami criteria.

Results: The mean follow-up period was 16 months (12 to 24). The mean bone transport lengthening was 7.96 cm (3.0 to 12.0), the mean external fixation time was 418 days (300 to 600). The mean lengthening index was 1.98 months/cm (1.05 to 4.0). Six cases were treated with bifocal techniques and eight patients had trifocal technique. In one case we employed a three level hexapode in a tibial frame. According to the ASAMI outcome: the final bone results were: excellent in 10 cases and good in 4. The final functional results were excellent 6 cases, and good in 8. A total of 7 difficulties were encountered in this study. There were problems, obstacles and minor complications.

Conclusion: TSF and TL-Hex external fixators allow six axes deformity correction to restore the normal alignment of limb axis. The almost complete control of any axis deviation helped bone transport procedures, and eliminated the need of guide wires for transporting bone segments to the docking site. With ultra short hexapode struts it has been possible to place rings at a minimum distance of 40 mm, consenting up to three levels of hexapod fixation in tibia.

#178: Lengthening and deformity correction using fixator assisted internal fixation

Miliind M Chaudhary (India)

Can fixator assisted internal fixation reduce duration of external fixation and reliably achieve lengthening and deformity correction?

Methods: We have treated 126 patients with fixator assisted lengthening and deformity correction of 149 segments. Lengthening alone was performed in 71 tibiae and 19 Femora (total 90 segments). Deformity correction was performed alone in 39 Tibiae and 20 Femora (59 segments). Of these FAP (Fixator assisted Plating) was performed in 40 segments with 36 tibiae and 4 femora. 36 tibiae were operated upon for a high tibial osteotomy and 4 femora had a supracondylar osteotomy which was assisted by an intra-operative fixator and fixed with a locking plate. 16 patients had fixator assisted nailing of 20 segments (3 tibiae and 17 Femora). 11 had varus bowing correction, 5 genu valgus and one had procurvatum correction. The tibiae had one valgus, one varus and one procurvatum each. Here the fixator was used as an intra-op alignment tool. 5 of the femora had a double level osteotomy to correct a proximal procurvatum. Average correction of deformity was 21 degrees 14 patients had lengthening along with deformity correction, 4 in the tibia and 11 in the femur. The average length they achieved was 3.5 cm. The average fixator duration was 7 weeks ( range 4 to 9 weeks) and early removal of fixator enabled early resumption of ROM. 48 patients had lengthening of 41 Tibiae and 7 Femora mainly for length equalization and achieved a mean of 4.7 cm of length( 1.8 cm to 9 cm) The mean fixator duration was 111 days( 31 to 224 days). The Operative technique consisted of specially designed straight nails, poller screws and straight rigid cannulated reamers. These are especially helpful in correcting juxta-articular deformities with or without lengthening.

Results: Accuracy of deformity correction was more than 90%. Target length was achieved in 86 of 90 segments. External fixation duration was reduced by almost 60% in those who needed lengthening. This helped in patient comfort and early resumption of Knee ROM. in societies where the cost of implantable lengthening devices is prohibitive, fixator assisted internal fixation using special nails and locking plates can reduce exfix duration and achieve reliable accuracy of lengthening and deformity correction.

Conclusion: Fixator assisted Nailing and Plating have the advantages of the Ilizarov method and its accuracy but not its disadvantage of prolonged external device usage. However, it comes at a higher price in terms of special equipment, instruments and implants and a steeper learning curve. It carries a small but real risk of infection (4% in our series) a special feature of this method is that double level correction is possible with modified IM mails in which at one level deformity correction is done and at another lengthening is performed. This is not possible even with Implantable lengthening nails.

#179: Centralization of the foot in Tibial and Fibular hemimelia

Nabil Ahmed Elmoghazi (Egypt),
Wael Ali Maher, Mohamed Magdy Elbatouty, Tamer Abdel Mawla Abdel Gawad

Question: Is it possible to achieve centralized and plantigrade foot by acute correction of severe foot deformities associated with Tibial and Fibular hemimelia without vascular compromise?

Methods: Ten patients with severe foot deformities due to congenital limb deficiency with average age 2.6 years (range 2-4 years),8 patients with severe equinovarus deformity due to Tibial hemimelia( Jones type Ib in 2 cases, type II in 4 cases and type IV in 2 cases) and 2 patients with severe equinovalgus deformity due to fibular hemimelia (type III). Through a long anterolateral incision , we did a one stage Tibiofibular synostosis ( in Jones type II and IV) with centralization of the fibula in the ankle( in Jones type Ib) with talectomy and resection of 2 cm segment from the fibula to decrease tension and allow correction of a severely deformed foot, then preparation of a trough in the calcaneus where the centralized fibula was fixed by a trans- calcaneal fibular K wire to keep it in its centralized position and to fix the osteotomized fibula too. In case of Fibular hemimelia , we did the same technique with tibial shortening , talectomy and centraliz! ation of the tibia in a trough created in the calcaneus then a transcalcaneal Tibial K wire was inserted. Lastely, closure of the wound with excision of the redundant skin. Centralization of the fibula in the knee in 2 cases (Jones type Ib), lengthening of 5 cm of centralized fibula in 1 case, previous failed soft tissue surgery with failure to centralize the tibia in 1 case with Fibular hemimelia.

Results: The average follow up was 2.3 years (range 1-3 years). Plantigrade foot and stable ankle achieved in 8 cases, 2 cases developed residual equinus deformity which was treated by posterior soft tissue release . skin sloughing occurred in 3 cases and treated by debridement and frequent dressing and healed by 2ry intension. Poor regenerate was seen in 1 case of fibular hemimelia and required bone graft and eventually healed . residual valgus deformity of the proximal tibia in 1 fibular hemimelia case and planned to be corrected in the next lengthening . mild flexion deformity of the knee ( 10 degrees) in one case of tibila hemimelia( Jones type Ib). All patients and families were satisfied with the foot correction procedures.

Conclusion: Combined Tibiofibular synostosis and centralization of the foot by talectomy and tibial or fibular shortening can adequetly correct severe foot deformity associated with tibial and fibular hemimelia and lead to plantigrade foot.

#180: Femoral head reshaping and distal trochantric transfert intreatment of hinged abduction in perths disease

Nabil Ahmed Elmoghazi (Egypt),
Wael Ali Maher

Question: Does femoral head osteochondroplasty and greater trochanter transfer improve head sphericity, containment and relive pain and improve hip function in perths disease (LCPS) with aspherical head and hinged abduction?

Methods: Fifteen patients with severe head asphericity due to LCPD with hinged abduction were treated with a planned reshaping of the femoral head by osteochondroplasty of the femoral head via safe surgical dislocation hip approach according to Ganz with distal and lateral transfer of the greater trochanter. Patients were assessed clinically and radiologically . Clinical assessments included range of motion, limb length measurements, pain and limping with evaluation using Harris hip score (HHS). Radiological assessment were done by plain x-ray and CT of the hip, head morphology was classified by stulberg classifications, femoral head sphericity was evaluated with head sphericity index and containment was assessed using shenton line, extrusion index and lateral center-edge angle (LCE angle).

Results: The mean follow up was 3.4 years (range 1-5 years). The mean HHS improved from 54.8 preoperatively to 92 at the last follow up. The mean femoral head sphericity improved from 68 (range 61 to 76) preoperatively to 86 (range 77 to 96). The mean preoperative LCE angle was 3 degrees corrected to 25 postoperatively. There is increase in the mean abduction, internal rotation and external rotation to 35, 25 and 32 degrees respectively. The normal trochanteric height restored in 87.6% of cases. No avascular necrosis of the femoral head or trochanteric nonunion.

Conclusion: Reshaping of the femoral head in LCP by osteochodroplasty and greater trochanter transfer can lead to improved head sphericity, containment and decrease hip pain and improve hip function.

#181: Femoral and tibial deformity correction: Use of gait analysis as an adjunct to conventional pre operative planning

Amir Qureshi (UK),
Daniel Marsland

Question: Is a static assessment of gait adequate in planning deformity correction.

Methods: We obtained formal gait analysis (Robert Jones & Agnes Hunt Hospital, Oswestry, UK) including the use of a force plate and clinical assessment, as well as anti-gravity devices to simulate normal body mass index when required.

Results: Formal gait analysis allows a dynamic assessment of the deformity, predicts the functional benefit of deformity correction and also the degree of correction required to optimise gait. It can also help select those patients that would not benefit significantly from deformity correction, thereby reducing unnecessary surgical intervention and potential risk.

Conclusion: For complex lower limb deformity, formal gait analysis is invaluable, both for planning correction in the appropriate planes and identifying those patients in which surgery would be of no benefit. We would advocate close links to be developed with gait analysis laboratories. Wepresent illustrative cases fromour practice.

#182: Comparison of fixator assisted nailing and fixator assist plate with distal femur osteotomy

Shengsong Yang (China),
Lei Huang


#183: Gradual correction of High Tibial Osteotomy using magnetactivated lengthening intramedullary nail in patients with varusMalalignment and Symptomatic Medial Osteoarthritis

Mohammed Jalal Al Sayyad (Saudia Arabia)

To prospectively assess the effectiveness of magnet activated lengthening intramedullary nails in achieving gradual correction of high tibial osteotomy to correct varus malalignment in patients with medial knee osteoarthritis.

Methods: Magnet activated lengthening intramedullary nails were used to gain gradual correction of a high tibial osteotomy. Inclusion criteria were identified. Clinical and subjective evaluations were performed. Complications of the procedure were studied. Radiographic evaluation included long-standing AP lower limb, standard lateral, Rosenberg and Merchant views.

Results: A total of 4 knees (4 patients; mean age, 40 years; age range, 28 to 45 years) were included. Clinical evaluation showed no patient with instability or a range-of-motion deficit worst than pre-operatively. After gradual correction, the mechanical axis was on average 5 valgus; anatomical axis 7 valgus; the Mikulicz' line crossed the tibial plateau on average at 64% of the width of the tibial plateau measured from medial.

Conclusion: HTO with gradual correction using magnet activated lengthening intramedullary nail is effective in gaining accurate correction of varus malalignment in patients with symptomatic medial osteoarthritis with high accuracy.

#184: An aged case of tibia vara with Blount's disease, corrected by intra-articular osteotomy with hemicallotasis

Jun Nakasone (Japan),
Shohei Higuchi

Question: A 64-year-old woman was under treatment for rheumatoid arthritis. She was suffering from pain of the left knee when aged 58, and right knee when aged 61. The pain was gradually increased, so she sustained a walking discomfort. On examination, there was bilateral tibia vara and lateral thrust motion in gait.

Methods: About the cause of painful tibia vara, we judged that it was not owing to rheumatoid arthritis and osteoarthritis because of preservation of the knee joint space on radiological examination. And furthermore, it reveals bilateral step and beak formation at medial metaphysis, so we concluded that the varus deformity by Blountfs disease remained. We tried to correct deformity by intra-articular osteotomy, such as tibial condylar valgus osteotomy, for the reason that an improvement of joint congruency would lead her to relief from pain in this case.

Results: We performed oblique osteotomy from medial metaphysis to intra-lateral joint of the right knee, and fixed using external fixation device (Orthofix, DAF self-aligning articulated body) for correction by hemicallotasis. Postoperatively, distraction was performed from at 1 week to at 5 weeks after operation, and external fixator was removed at 5 months after operation with consolidation of the callus. 1 year and 3 months later, we performed operation to the left knee by almost same procedure. At present, 4 years have passed since the first operation performed, she has little pain and lateral thrust motion in free gait. Radiographic findings achieve improvement of joint congruency.

Conclusion: We think that intra-articular osteotomy with hemicallotasis has possibility of improvement of joint congruency of tibia vara.

#185: Open Wedge Distal Femoral Osteotomy: Accuracy of Correction and Outcome

Osama Elattar (USA),
Lam A, Nguyen J, Austin F, Robert R.

Question: With renewed interest in knee joint preservation, Osteotomies around the knee are important techniques to unload the affected joint compartment. The clinical benefits are pain reduction, delay in progression of arthritis, and improved aesthetics. Distal femoral osteotomy (DFO) has been used to treat valgus knee malalignment when the apex of deformity is located in the distal femur. Furthermore, valgus knee deformity is sometimes associated with patella subluxation. Since the DFO also serves to medialize the patella tendon insertion, when DFO is combined with a lateral retinacular release, it also serves to realign the patella. Few studies have evaluated the open wedge DFO for accuracy of femur and patello femoral deformity correction as well as pain and functional improvement. Purposes: (1) How accurate is deformity correction (femur valgus, and patella subluxation) using radiographic parameters? (2) What are the clinical outcomes? (3) Do patients with patella malalignment benefit from DFO?.

Methods: We retrospectively reviewed the clinical charts and radiographs of 28 consecutive patients with a mean age of 44 years (range, 22-72) having undergone 41 DFOs (15 unilateral and 13 staged bilateral). All patients were diagnosed with symptomatic genu valgum deformity. Exclusion criteria included advanced osteoarthritis. All patients were treated with the lateral opening wedge DFO and 8 patients had concomitant sagittal plane correction using a locked titanium plate and screws. Bone graft substitutes were used in all patients. Four patients had concomitant tibial osteotomy for simultaneous correction of valgus tibial deformity using a circular hexapod frame. Lateral patellar retinacular release (9 out of 41 procedures) was added in patients with lateral patellar subluxation diagnosed clinically and radiographically using the Merchant knee x-ray. Three patients had concomitant knee arthroscopy and 2 had concomitant tibial tubercle transfer for patell! a realignment. The preoperative and postoperative radiographs were evaluated for mechanical axis deviation (MAD), lateral distal femoral angle (LDFA) and the patella congruence angle (PCA) to assess the accuracy of deformity correction. Clinical outcomes were assessed with SF-36, lower limb module (LLM), and Oxford knee scores.

Result: The mean follow up was 26 months (range, 12-57). All patients achieved bony union, and the mean time to union was 3.2 months (range, 2.5-6). The accuracy of deformity correction was 95% (range, 33.3%-100%).

Conclusion: Opening wedge DFO with locked plate fixation is a reliable procedure for the treatment of valgus knee malalignment and lateral patellar subluxation with or without arthritic changes in the lateral compartment. Deformity correction is accurate and patient reported outcomes reveal significant improvement from the treatment. Longer follow up is needed to access the survivorship of this procedure.

#186: Low dose upright assessment of lower limb deformity

Saba Pasha (USA),
Victor Ho-Fung, Richard Davidson

Question: The question was whether the clinical measurements of the Lower limb deformity on the plain X-rays are affected by the alignment of the bone with respect to the X-ray scanner. We further explored the application of the 3D modeling of the bone on clinical assessment of the lower limbs bone deformity and compared it to CT scans.

Method: Anterior-posterior and lateral X-ray images of 6 femur and tibia Sawbone models with angular and rotational deformities were taken in a stereoradiography slot scanning machine (EOS imaging). These images were taken in 0,15, and 30 degrees of axial rotation and 0,10, and 20 degrees of tilt. A CT scan of each bone registered. 2D length and deformity angles were measured on 2D X-rays and 3D reconstruction of the CT scans. A 3D reconstruction of each model was generated in SterEOS software. A MATLAB code was developed to align the posterior aspects of the femoral condyles and tibial plateau of the 3D models with the true frontal plane in all the X-ray scans. The deformity angles and lengths were then calculated using the 3D coordinates of the femur and tibia anatomical landmarks. These measurements were compared with the CT scans of the bone.

Results: 2D length measurements varied significantly for different degrees of knee flexion angles (0.05). Anterior-posterior deformity of the femur and tibia was significantly different between the 2D and 3D methods.

Conclusion: The developed software provided a reliable technique in clinical assessment of the lower limb deformity. The accuracy of this measurement technique were comparable to CT scans while exposes the patients to lower ionized ration dose.

#187: Case review of 15 consecutive deformity cases to evaluate the new

TL-Hex systemSean Pretorius (South Africa)

What was the clinical outcome of our first 15 deformity cases using the TL-Hex system with regard to deformity correction and ability to maintain the reduction.

Method: 15 Consecutive cases with different deformities where corrected using the Hexapod frame. These patients where then evaluated with xrays and clinically to ascertain whether the deformities where in fact corrected and how many attempts did it take with the software to correct the deformity.

Results: All cases, except one tibia case, where corrected with one software correction. Joint deformity cases all had a second correction to close down the joint space that was purposefully distracted as part of the deformity. One frame had wire breakage on 2 occasions but this did not affect the maintenance of the deformity. No major infections have been noted at the pin sites.

Conclusion: The TL-Hex System is very effective for deformity correction in the lower limb and is almost 100% accurate. The system is also very stable for maintenance of deformities with excellent union rates.

#188: Below Tuberosity Osteotomy Causes Lesser Change of Patellar Position than Above Tuberosity Osteotomy in Medial Opening-Wedge High Tibial Osteotomy- A Cohort Study Based on CT Scans

Keun Jung Ryu (Korea),
Dong Hoon Lee, Hyun Woo Kim, Jin Ho Hwang

Question: Medial opening-wedge high tibial osteotomy is an established surgical procedure for correcting proximal tibialvarus deformity with various surgical techniques identified. Although, above tuberosity osteotomy is utilized in a conventional medial opening-wedge high tibial osteotomy technique, it can cause patellar infra by infero-lateral displacement of the tibial tuberosity. Recently, a new technique with above tuberosity osteotomy was reported to prevent a decrease in patellar height. However, comprehensive analysis on changes of patellar position between the two techniques (above tuberosity osteotomy vs below tuberosity osteotomy) has not been fully explored. We aimed to investigate the effect of below tuberosity osteotomy on changes of patellar position including lateral patellar displacement, patellar tilt, and patellar height, compared to above tuberosity osteotomy in medial opening-wedge high tibial osteotomy.

Methods: This is a prospective cohort study. From March 2009 to June 2014, we evaluated 96 segments of bones undergoing medial opening-wedge osteotomy for proximal tibialvarus deformity which met pre-specified inclusion criteria. All patients underwent fixator-assisted medial opening-wedge high tibial osteotomy for idiopathic proximal tibia vara or osteoarthritic knee with proximal tibia vara. Bi-planar osteotomy was performed for all patients with one of the two osteotomy techniques (above tuberosity vs below tuberosity). The author switched the osteotomy techniques from above tuberosity to below on the middle of the study period. The only difference on surgical technique is the direction of osteotomy to the tibial tuberosity. The two groups (above tuberosity osteotomy group, n = 30 vs below tuberosity osteotomy group, n = 66) were compared on changes of patellar position after the index surgery; (1) lateral patellar displacement via lateral patellar displacement index (LPDI) and tibial tuberosity trochlear groove distance (TTTG-D), (2) patellar tilt via patellar tilt angle (PTA) and congruence angle (CA) and (3) patellar height via patellar height index (PHI) and Blackburn-Peel index (BPI). Evaluation on patellar position was based on axial and sagittal CT scans with knee flexed to 30 degrees, performed pre - a0 nd post-operatively. The mean age was 338 years in above tuberosity osteotomy group and 3210 years in below osteotomy with no significant difference (p=0.45). Female-to-male ratio, body mass index, and the degree of deformity corrected such as differences of medial proximal tibial angle and mechanical femoro-tibial angle showed no significant differences between the two groups.

The two groups showed no significant differences on changes of LPDI (p=0.145), TTTG-D (p=.126), PTA (p=.566), and CA (p=.617). However, below tuberosity osteotomy group showed significantly lesser change of PHI

Conclusion: Below tuberosity osteotomy technique in medial opening-wedge high tibial osteotomy causes lesser changes of patellar height when compared to above tuberosity osteotomy technique. And it causes and lesser changes of lateral patellar displacement and patellar tilt as well for the amount of correction greater than 7 degrees of femoro-tibial angle.

#189: Fixator-Assisted Intramedullary Nailing with Dome Osteotomy for Correcting Proximal Tibial Valgus Deformity

Keun Jung Ryu (Korea),
Dong Hoon Lee, Jin Ho Hwang, Hyun Woo Kim

Question: Proximal tibial valgus is a relatively uncommon deformity which presents in genu valgum. Although they often requires surgical treatment, a less-invasive technique designed for minimizing complications from extensive soft tissue exposure has not been tested in the setting of correcting such proximal tibial valgus deformity. We aimed to (1) investigate the ability of fixator-assisted less-invasive intramedullary nailing technique in the treatment of proximal tibial valgus deformity to achieve desired alignment correction, and (2) assess the complications associated with this technique, and (3) assess the complications associated with immediate full weight bearing with this technique.

Methods: From January 2011 to December2014, a total of 38 segments of tibia undergoing proximal tibial osteotomy with our fixator-assisted less-invasive technique for proximal tibial valgus deformity were evaluated. No limbs were excluded. During the period in question, no other techniques were used for the same deformity. The surgical procedures included application of a temporary mono-external fixator, dome-shaped proximal tibial osteotomy, correction of deformity, temporary fixation using external fixator, and final fixation with intramedullary nailing. Radiographic review to confirm osseous union and alignment was performed by two of the authors not involved in clinical care of the patient. Complications were assessed by chart review and the alignment in both coronal and sagittal planes was compared pre - And postoperatively. Delayed union was described as union occurring later than 4 months. Full weight bearing was allowed to all patients after surgery.

Results: In the coronal plane, the difference in mechanical axis between the amount of real correction and the amount of target correction was 1.0 0.8 degrees. In the sagittal plane, the difference between pre - And postoperative posterior proximal tibial angle was 0.4 0.6 degrees. Overall, five segments out of 38 tibiae (13%) showed complications, all of which turned out to be mild anterior knee pain which resolved without leaving any sequel. There was no soft tissue infection. All osteotomies healed within 4 months with no delayed or nonunion. There was no complication associated with immediate full weight bearing.

Conclusion: Fixator-assisted technique with dome osteotomy is a valid option for correcting proximal tibial valgus deformity with good coronal and sagittal alignment controls and immediate full weight-bearing. However, future studies should compare it with the other techniques in order to clarify advantages or disadvantages of this technique.

#190: Fixator-Assisted Technique Enables Less-Invasive Plate Osteosynthesis after Correction of Distal Femoral Deformities

Keun Jung Ryu (Korea),
Dong Hoon Lee, Hyun Woo Kim, Jin Ho Hwang

Question: A conventional plating technique to correct distal femoral deformities requires extensive soft tissue exposure. We introduce a less-invasive plate osteosynthesis using fixator-assisted technique for femoral varization, valgization, or derotation osteotomy. We aimed to (1) investigate the ability of this technique to achieve desired alignment correction, and (2) assess the complications associated with use of this technique.

Methods: From January 2011 to December2014, a total of 54 segments of femur undergoing distal femoral osteotomy with fixator-assisted plating technique for distal femoral valgus (36 segments), varus (4 segments), flexion (2 segments), torsional (8 segments), and two-plane (4 segments) deformities were evaluated. No limbs were excluded. During the period in question, no other techniques were used for the same deformities. The surgical procedures included application of a temporary mono-external fixator, dome-shaped or transverse distal femoral osteotomy, correction of deformity, temporary fixation using external fixator and final fixation with a plate. Radiographic review to confirm osseous union and alignment was performed by two of the authors not involved in clinical care of the patient. Complications were assessed by chart review and the alignment in both coronal and sagittal planes was compared pre - And postoperatively. Immediate full weight-bearing was done for all patients with dome-shape osteotomy and partial weight bearing was done for 6 weeks postoperatively for all patients with transverse osteotomy.

Results: In the coronal plane, the difference of the mechanical axis between the amount of real correction and the amount of target correction was 1.0-0.5 degrees. In the sagittal plane, the difference between pre - And postoperative posterior distal femoral angle was 0.- 0.3 degrees. Overall, nine segments out of 54 femurs (16%) showed complications; eight turned out to be mild discomfort at the distal iliotibial band which resolved with removal of the plate without leaving any sequel and one periprosthetic fracture. There was no soft tissue infection, delayed union or nonunion. All osteotomies healed within 4 months with no delayed or nonunion.

Conclusion: Fixator-assisted technique is a valid option for correcting various distal femoral deformities which enables less-invasive surgery with good coronal, sagittal and rotational controls. However, futurestudies should compare it with the other techniques in order to clarify advantages or disadvantages of this technique.

#191: High Tibial Osteotomy using Mini External Fixation

Ghassan Salameh (Germany)
, Michael Schmidt

Question : This study show using of advanced external fixation device Salamehfix to treat medial compartment osteoarthritis of knee joints with varus alignment and ability of treatment a various severity, ability for correction with angle correction and translation of bone fragments just distal to tibia tuberosity with a high stability of fixation, it can have more advantages with external fixation over classic methods in mobility, restoring length and less complications. Method : 42 Patients treated with various severity of medial compartment osteoarthritis and medial alignment from 10 to 15 degrees on standing X-rays and the age is from 45 yrs. to 74 yrs. All cases achieved over correction from 3 to 5 degrees valgus, the external fixation device was used is Salamehfix, which consist of two arcs deference diameters and perimeters to take the shape of leg, so that small fixation device with stable fixation which allows early weight bearing and adapted hinges which allows simultaneous correction and translation in order to make perfect alignment of the knee axis. There was also a preoperative planning, so the fixator was assembled prior to the surgery with hinges are shifted and angulated as the needed amount of correction. Clinical outcomes, lower limb measurements LEM, Radiographic outcomes including Resnick grades, pre-and post-correction limb alignment and tibial slope measurement are considered.

Results : Complete correction was carried out on the operation table, few of them residual correction was carried out gradually after two weeks and corrected in 10 days, mostly done by dome shaped osteotomy, time in the frame from 12 to 16 weeks depends of amount of correction even some cases after subluxation of knee was corrected, Radiographic correction goal was achieved in all patients . Complications where mostly superficial pin infection and treated locally.

Conclusion : Good advantages of using Salamehfix fixator in simultaneous angulation-translation correction of medial compartment osteoarthritis with high stability allowing early mobility and weight bearing with a good tolerance to the fixator.

#192: Sequential Use of External Fixation and Nailing in Long Bone Deformity Correction and Non-union Healing

Elena A. Shchepkina (Russia)
, Leonid N Solomin, Ivan V Lebedkov, Pavel N. Kulesh

Question : Analyze results and complications in the Sequential External Fixation and Nailing (SEFaN) in lower limbs long-bone deformity correction and non union healing.

Method : SEFaN was used in 30 cases (31 segments: femur 16, lower leg - 15) in deformities (11), non-unions (18), delayed union (2). Varus deformity of lower limb was in 17 cases (MAD: +15.718.93 mm); valgus deformity - 14 (MAD: 12.2510.8). Rate of deformity correction was 1 mm per 24 hours. In addition to well-known methods extracortical clamp devices were used (http://orthosuv. org). In the cases of formation the distraction regenerate we used the static scheme of nailing and recommended full foot-step after formation of cortical plate around of regenerates diameter. In treatment of non-unions we used dynamic scheme of nailing. The results we were assimilate with the group of patients treated with external fixation (femur - 76, lower leg 82). Varus deformity of the femur was in the 41 cases (MAD: +34.520.3 mm), lower leg 39 (MAD: +24.657.13 mm). Valgus deformity of the femur was in the 35 cases (MAD:-5.511.6 mm), lower leg 43 (MAD: -19.415.92 mm).

Results : In SEFaN group time of deformity correction and ExFix period was 43.2 days (in ExFix group ExFix index 124.6 days). After treatment MAD was 3.453.85 in the cases of varus deformity, 2.223.72 mm in the cases of valgus deformity. In ExFix group after treatment MAD was 7.16.8 mm in the cases of varus femur deformity, 3.453.85 mm in the cases of varus tibia deformity, 7.36.5 in the cases of valgus femur deformity, 2.223.72 in the cases of valgus tibia deformity. The complications in SEFaN group were observed in 7 cases (22.5%): pin-tract infection 3.2% (in ExFix-11.8%), breakage of transosseous element 3.2% (in ExFix-5.9%), non-union 0% (in ExFix-4.6%), secondary deformation 0 (in ExFix-2.4%), joint stiffness 3.2% (in ExFix-8.3%), neuropathy 3.2%, premature consolidation 3.2%, exacerbation of osteomyelitis - 6.5% (in ExFix-2.2%). In X-ray and CT examination we observed significant periosteal component of regenerate in SEFaN group.

Conclusion : SEFaN decrease period of external fixation by 2.9 times. It improves the quality of patients life, decreases the number of pin-tract infection, joint stiffness, secondary deformation of regenerate as well. The main disadvantage of this method is risk of the recurrence of chronic osteomyelitis.

#193: Tibiotalar and tibiocalcaneal arthrodesis using the Ilizarov technique in the presence of infected nonunions of ankle joints

Lei Huang (China)

: The salvage for infected fracture nonunions of distal tibial, talar or calcaneal is still a challenging work. After eradication of infectious tissues, we must confront with how to create a painless, stable and plantigrade feet.

Answer : 4-6 weeks after radical debridement of the infectious tissues, tibio-talar or tibio-calcaneal arthrodesis was performed either directly with hybrid external fixators or after docking secondary to proximal tibial osteotomy and bone transportation.

Results : A retrospective review of 26 patients undertaken either tibiotalar arthrdesis or tibiocalcaneal arthodesis with hybrid external fixators for infected nonunions of distal tibia, talaus and calcaneus. 8 of 26 patients fused without any further procedures . The other 18 patients were undertaken debridement at the docking sites, and 11 of them had autogenous bone grafting. There was a mean following-up of 32 months (22 ~ 41 months). All patients had successful fusions and satisfactory outcomes. There was no recurrence of infections. There were no amputations. Two patients had 6 degrees of varus deformity at the docking site.

Conclusion : Tibiotalar or tibiocalcaneal arthrodesis using the Ilizarov technique is a reliable alternative in patients with infected nonunions, especially if there is a large bone loss of the tibias, talus and calcaneus fractures.

#194: Reconstruction of Soft Tissue Defects with Nonunion of an Infected Tibia by Applying Intentional Shortening and Deformation Using the Taylor Spatial Frame: A Report of three Cases

Shogo Shimbashi (Japan)
, Hidenori Matsubara, Yasuhisa Yoshida, Shuhei Ugaji, Hiroyuki Tsuchiya

Question : Soft tissue reconstruction involves the application of flaps, grafts, and acute leg shortening and lengthening. With this technique, additional intentional deformation and malalignment correction after healing of the soft tissue has been performed in cases when shortening alone could not close the soft tissue. We present three cases of soft tissue defect with nonunion of the infected tibia that were reconstructed by applying intentional shortening and deformation with the Taylor spatial frame (TSF).

Method : Case 1 was a 48-year-old man who incurred an injury due to left lower leg open fracture (Gustilo IIIC) during work. The popliteal artery in the distal trifurcation area was torn. The tibia was shortened by 3 cm by using Hoffmannfs external fixator, and the popliteal artery was sutured onto the posterior tibial and fibular arteries. However, the wound was infected with methicillin-susceptible Staphylococcus aureus and an ulcer developed in a tibial anterior area. The infected tibia resulted in nonunion. Case 2 was a 55-year-old man who incurred an injury due to left lower leg closed fracture (pilon fracture) during a fall. Osteosynthesis with plates was performed. However, the wound was infected with methicillin-resistant Staphylococcus aureus, and the metals were removed. The fracture did not heal and developed ulcers in the anterior and lateral parts of the lower leg. Case 3 was a 21-year-old man who incurred an injury due to left lower leg open fracture (Gustilo IIIB) during a motorbike crash. He had a 7-cm bone defect in the tibial shaft and a 10- ~ 8-cm soft tissue defect. A cement spacer was inserted, and negative pressure wound therapy was performed. However, the soft tissue defect was not closed and was further infected with Pseudomonas aeruginosa.

Results : We performed soft tissue reconstruction for the three cases by applying intentional shortening and posterior convex deformation with the TSF. For case 1, debridement, osteotomy (proximal; 0.5 cm, distal; 1 cm into an anterior wedge), and TSF application with a 35 apical-posterior deformation were performed. Furthermore, a tibial shaft osteotomy was performed for lengthening. Deformity correction and lengthening were achieved in 3 months, and then plate conversion was performed. He returned to his original occupation at 18 months after the operation. For cases 2 and 3, we used the same technique. Posterior convex angle was 25 and 8 (V varus), respectively. Ankle arthrodesis was additionally performed in case 2, and the bone defect was reconstructed with bone transport in case 3.

Conclusion : Soft tissue reconstruction involves the application of flaps, grafts, and acute leg shortening and lengthening. Whereas, in all the cases, the soft tissue defects were healed without no additional soft tissue operation and the infection were subsided. We treated the soft tissue defects and nonunion by applying intentional shortening and deformation by using the TSF without any flaps. We believe that this is a useful technique for soft tissue reconstruction with nonunion due to an infected tibia.

#195: Masquelet: Treatment option in septic non union of distal tibia fracture

Carlomagno Cardenas-Nylander (Spain),
Miquel Videla Ces , Joan Giros Torres, Vanesa Vega ocaa, Anna Isart Torruella

Question: The Masquelet induced membrane technique allows treating major bony defect in tibia with good results.

Methods: 60yo patient, who suffers fall from 2 meters with a left open distal tibia fracture ( Gustilo grade I) with suprasyndesmotic fibular fracture . First treated by means of debridement of fracture and external fixator plus antibiotic coverage for 10 days.

Results: Without fibular fracture fixation, fracture was valgus and soft tissue condition worsened, necessitating a second surgery to realign the joint, fibular ORIF and noninvasive negative pressure system to improve the process of wound healing. At 4 months of the fracture, negative pressure system was removed, there was a fistula, so a bone scan was performed that reported a septic active nonunion on medial distal margin of tibial fracture. Bacterial investigation was negative. Masquelet technique was performed, fistulectomy, osteotomy at infection site and antibiotic spacer placement with vancomycin and gentamicin, a fasciocutaneous reverse flow sural flap was done plus a cutaneous free autograft from contralateral thigh and new external fixator. Intraoperative cultures were positive for MARSA starting immediately ATB treatment for 8 weeks. At 4 months second procedure was performed, the formation of a pseudosynovial membrane was noted, cement spacer was removed a fracture site curetage was done and filled with mesenchymal cells extracted from iliac crest aspirate, posterior iliac crest autograft and tricalcium phosphate, achieving alignment and stability using a medial LCP plate. One month after the last surgery patient performed partial load. At 6 months bone callus formation. At 9 months walking without crutches. Currently it has good ankle mobility.

Conclusion: The physeal defects can be treated with bone transport, pappineau, vascularized fibular autograft , RIA or Masquelet that favor revascularization, bone formation and consolidation , preventing reabsorption in early stages.

#196: Treatment of MRSA infected nonunion of the femur after lengthening in the patient with a fibular hemimelia. A case report

Hiroyuki Kaneko (Japan)

The treatment of MRSA infected nonuinion is difficult. I would like to present the usefulness of the Ilizarov external fixator in the treatment of MRSA infected nonuinion.

Methods: In a14 year-old-boy with 4 cm discrepancy in limb length due to a fibular hemimelia, his right femur was lengthened in 4 cm, using the Ilizarov external fixator at the previous hospital. Five months after the first operation, the Ilizarov external fixator was removed, and at the same time, a fracture at the distal end of the lengthened area was seen. The internal fixation by a locking plate was done. Another fracture happened at the proximal end of the lengthening area, and another locking plate was added. A subcutaneous MRSA infection happened in his right femur, 2 months after the last operation. The debridement and washing was done, but the infection was not controlled. He was introduced to my hospital 2 weeks after the last operation. MRI and a bacteriological examination showed MRSA infected nonuinion in the second fracture area of his femur. Both plates were removed with the infected bone resection, the debridemen tof infected soft tissue, the washing, and the wet dressing. And the Ilizarov external fixator was applied. Vancomycin was administered intravenously for 7 days. The wet dressing was changed every day. MRSA infection was controlled and the bone was united. The Ilizarov external fixator was removed, 1 year after the last operation. He enjoys his high school life, and has no recurrence.

Results: The Ilizarov external fixator might stabilize the lengthened bone, rigidly. Therefore, the infection might be controlled and the bone union might be obtained.

Conclusion: The Ilizarov external fixator is seemed useful in the treatment of an MRSA osteomyelitis after limb lengthening in the patient with a fibular hemimelia.

#197: Taylor Spatial Frame Stacked Transport for Tibial Infected Nonunions with Bone Loss: Analysis of Use of Adjuvant Stability

Joshua K Napora (USA),
Douglas S Weinberg, John K Sontich

Question: Limb salvage of acute and chronic tibial bone defects presents as a complex problem. The stacked Taylor Spatial Frame (TSF) bone transport technique is an effective treatment for infected tibial nonunions with bone loss. The purpose of this study was to evaluate risk factors for adjuvant stability either at time of removal or after removal of TSF. A secondary aim was to determine predictors of eventual below knee amputation (BKA). We hypothesized that TSF stacked transport would be an efficient technique in infected tibial nonunion that eradicates infection, improves alignment without compromising on regenerate healing, and produces improved functional outcomes over time.

Methods: Between 2000 and 2014, 77 patients were treated for infected nonunions with bone loss using stacked TSF transport by a single surgeon at a level one trauma center. Patients were treated with resection of nonunion with application of TSF for bone transport followed by a second surgery to bone graft the nonunion site. Parameters measured included bone defect size, length in frame, external fixation index, use of a free flap, number of surgeries, and delayed intervention after removal of TSF. Outcomes recorded included: removal of frame with no additional intervention, BKA, adjuvant stability with intramedullary nail, plate fixation, or reapplication of TSF. Short musculoskeletal functional assessment (MFA) is currently in the process of collection and analysis.

Results: The average patient age was 46 ± 12 years, 59 (77%) patients were male, 9 (12%) were diabetic, and 34 (44%) were smokers. 34 (42%) had soft tissue defects that required a free flap performed by plastic surgery. The mean size of the defect was 5.4 cm. The mean external fixator index was 1.8 month/cm and mean length in frame was 9.6 months. The average number of orthopaedic surgeries once transported was 4.0. 29 (37.6%) of patients had delayed intervention, which we defined as additional stability or BKA after removal of TSF. 40 patients had removal of frame with no additional operative intervention, 9 patients required additional stability at time of removal of TSF with intramedullary nail or plate fixation at time of removal, 23 patients required delayed additional stability after TSF removal with intramedullary nail, plate fixation, or reapplication of the TSF, and 5 patients underwent below knee amputation (BKA). 1 patient had removal of frame with delayed union treated with immobilization cast. Infected was eradicated and union was achieved in all patients that did not undergo BKA. The time spent in the TSF (p = 0.003), number of surgeries (p < 0.001), and use of a free flap (p = 0.036) predicted risk for delayed intervention. Analysis of addition stability with plate, fixation, intramedullary nail, or reapplication of TSF regardless of timing demonstrated length in frame (p = 0.038) to be significant and use of a free flap to approaching significance (p = 0.069). Sub-analysis showed that risk factors for BKA were approaching significance with length in frame (p = 0.083), size of bone defect (p = 0.068), need for free flap (p = 0.071), and number of surgeries was significant (p = 0.001). MFA results from a previous study using the same cohort of patients indicate functional improvement over 1 to 3 years after removal of TSF.

Conclusion: Our study suggests that the use of Taylor Spatial Frame for the infected tibial nonunions with bone loss is an effective method for achieving union and eradicating infection in a difficult orthopedic patient population. This data provides insight for counseling patients on outcome and expectations, and highlights potential risk factors for need of additional stability as an adjuvant therapy to TSF. Future direction will focus on MFA data from this patient population to provide needed long-term limb salvage outcome potential to help council patients and physicians in this difficult process.

#198: Clinical Outcome of Combined Ilizarov External Fixator with Local Pedicle Flap for the Treatment of Infectious Non-union in Tibia

Hengsheng Shu (China)
, Heng Shao

Question: To evaluate the clinical outcome of Ilizarov external fixation technique combined with local pedicle flap for the treatment of infectious nonunion in tibia with accompanying soft tissue defects.

Method : A retrospective study was done from July 2005 to June 2013. A clinical data of 30 patients including 21 males and 9 females with infectious non-union of tibia with accompanying soft tissue defects. The age ranged from 20 to 65 years with mean age of 43 years. The initial cause of injury was open fractures in 26 cases and closed fracture with soft tissue injury in 4 cases. Duration of their initial treatment to final admission to our hospital was 8 to 42 months. 3 cases had undergone single previous surgery; two times surgeries in seven cases and multiple surgeries (3 times) were done in 20 cases. All cases were presented with different degrees of skin and soft tissue defects, wound with exposed bones, discharging sinuses and adhesive scar around bones. Flap area ranged from 6 cm 5 cm ~ 16 cm 10 cm. 25 (83.3%) cases underwent local flap surgery and external fixation. In 5 cases, staged reconstruction surgery with flap delayed technique was done. The results were analyzed by using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria of scoring system.

Results : All of 30 patients were followed up (12 to 36 months) with an average of 18 months. Out of 30 cases, flap transfer survived in 27 (90%) cases with no recurrence of infection and successfully healed without any major complications. 3 (10%) cases had flap edge necrosis and recurrent inflammation after surgery so that they needed further treatment. Average Limb shortening of 0.8 cm (ranging from 0 to 2 cm) was observed. 5 (16.6%) cases of patients with delayed flap surgery, 100% flap survival rate were achieved. The average duration for tibial fracture healing was 7 months. The average acceptance time for Ilizarov fixation was 8 months. According to ASAMI criteria of scoring system, the bone assessment results were excellent in 28 (93.3%) cases and good in 2 (6.6%) cases. Functional assessment scores were excellent in 25 (83.3%) cases, good in 3 (10%) cases and fair in 2 (6.6%) cases.

Conclusion : Ilizarov method combined with pedicle flap transfer can effective treatment of tibial nonunion with bone and soft tissue defects. For the elderly, smokers accompanied with diabetes, peripheral and vascular disease, we recommend the flap delay technique, which can effectively enhance the flap survival rate.

#199: Mechano-biology in the management of mobile atrophic and oligotrophic tibial non-unions

Nando Ferreira (South Africa),
Leonard Charles Marais, Colleen Aldous

Question: Can mechano-biological stimulation achieve union in mobile atrophic and oligotrophic tibial non-unions without the need for routine bone graft?

Methods: We performed a retrospective review of all patients with mobile atrophic and oligotrophic tibial non-unions treated with circular external fixation between January 2010 and January 2014. 38 consecutive patients with mobile atrophic and oligotrophic tibial non-unions were treated with fine wire circular external fixation and functional rehabilitation. All patients were followed-up clinically and radiologically for a minimum of six months after frame removal. Three patients were excluded because they did not complete the treatment process. All patients underwent partial fibula resection, mechanical realignment and compression across the non-union site. Eight patients underwent autogenous bone graft procedures. These were performed if the non-union site had a diameter less than 50% of the normal bone diameter or during formal docking after bone transport.

Results : Bony union was achieved after the initial surgery in 33 (94.2%) tibias. Two persistent non-unions were successfully treated with repeat circular external fixation without bone graft. This resulted in final bony union in 35 (100%) tibias.

Conclusion: Mechano-biological stimulation of mobile atrophic and oligotrophic tibial non-unions through fine wire circular external fixation and functional rehabilitation can create a local environment conducive to bone formation even if the biological activity/potential appear to be low.

#200: Hexapod external fixation closed distraction in the management of stiff hypertrophic and oligotrophic tibial non-unions

Nando Ferreira (South Africa),
Leonard Charles Marais

Question: Can closed distraction with hexapod circular external fixation effectively treat stiff hypertrophic and oligitrophic tibial non-unions?

Methods: We performed a retrospective review ofall stiff hypertrophic and oligotrophic tibial non-unions treated by hexapod closed distraction between January 2010 and January 2014.

Results: 46 hypertrophic and oligotrophic tibialnon-unions were included. No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after theinitial surgery in 41 (89.1%) tibias. Four persistent non-unions united after repeat treatment with closed hexapod distraction. This resulted in final bony union in 45 (97.8%) tibias. Leg length was equalized to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5 degrees of normal in 42 (91.3%) tibias.

Conclusion: Closed distractionof stiff tibial non-unions can produce predictable union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb length discrepancies.

#201: The Health Burden of Living with Below Knee Amputation: A Utility Outcomes Score Assessment

Asim Makhdom (Canada),
Hani Sinno, Adam Cota, Abdulaziz Aljuryaan, Edward Harvey

Question: Complex lower extremity fractures that involve extensive soft tissue damage continue to pose a management dilemma to both surgeons and patients when considering whether to salvage injured limbs or perform surgical amputation. Our aim was to objectively measure the perceived health burden of living with a unilateral below knee amputation (BKA).

Methods: Validated utility outcome measures were used to quantify the health burden of BKA in 116 prospective subjects. These subjects were from a sample of healthy population recruited to complete a survey to determine the utility outcome score of BKA, single eye blindness and double eye blindness. To minimize any particular weakness of any individual tool, we used three different utility outcome measures. These include visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) test. Student t test and liner regression analysis were used for statistical analysis.

Results: The VAS, TTO, and SG scores for a unilateral BKA were 0.57 ± 0.16, 0.75 ± 0.2 and 0.78 ± 0.18, respectively. These were lower than the corresponding scores of single eye blindness VAS (0.61 ± 0.16, P = 0.02) and TTO (0.79 ± 0.19, P = 0.002) tests and the SG measure (0.8 ± 0.17, P = 0.09). Age, gender, race, income, and education were not statistically significant independent predictors of the utility scores for BKA.

Conclusion: Utility score assessment of the perceived impact of living with a unilateral BKA demonstrated lower scores than living with single eye blindness. In our sample population, when faced with a BKA as a treatment outcome, individuals would choose to undergo a reconstructive procedure with a theoretical mortality risk of 22% and would be willing to trade 9 years of life for such a treatment to avoid a BKA. These data can be helpful to potentially change health care allocation resources particularly for prevention measures, reconstructive procedures and cosmetic prosthesis - As well as to better understand how patients perceive their potential disability.

#202: Pelvic hip support in patients with spina bifida

Sergio Nossa (Columbia),
Juan Serpa

Question: What is the outcome in patients with spina bifida and symptomatic hip dislocation treated with pelvic hip support?

Methods: Two female patients with spina bifida who had the ability to walk with help of crutches, presented with painful unilateral hip dislocation. They were not considered candidates for hip arthroplasty because of the neurologic status and were managed with pelvic hip support and lengthening assisted with external fixation.

Results: Patient 1: Is a 17 year-old female with diagnosis of spina bifida who was evaluated for painful right hip dislocation, she could walk with the use of crutches. X-ray of the pelvis showed right hip dislocation with formation of neoacetabulum. In the physical exam: gait with the support of crutches, positive right Trendelenburg sign, ROM of the right hip with flexion of 40 degrees & 0 of internal and external rotation, muscular strength of 3+/5 for knee extension, anesthesia at L5 level. At short follow up the patient significantly improve her limping and range of motion, and is now without any pain.

Patient 2: A 16 year-old female with diagnosis of spina bifida, presented with pain in the left hip, x-ray of the pelvis revealed bilateral coxa magna, dislocation of the left hip with formation of neoacetabulum with severe secondary osteoarthritis. The physical exam evidenced gait with crutches, left hip with flexion deformity of 20 degrees; and adduction deformity of 5 degrees & 0 of internal and external rotation, muscular strength for hip flexion 3+/5 and knee extension 3+/5. We had to make at the time of the pelvic support a Girdlestone procedure to improve its motion. At short follow up this patient continue with LLD of four cm because the bone quality did not aloud us to make more lengthening, we have to protect the lengthening and surgery with a plate. But she is now without pain and now she has a better range of motion.

Conclusion: Pelvic hip support is an option for patients with spina bifida who have a painful hip dislocation, improves the range of motion, provides a complete pain relive at short follow up and improve the ability to walk with crutches.

#203: Sclerostin depletion in fracture healing

Mohammad M Alzahrani (Canada),
Asim Makhdom, Reggie C Hamdy

Question: Is sclerostin depletion through systemic administration of sclerotin antibody as effective as complete depletion through complete knockout of the sclerotin gene?

Methods: 10-week-old male SOST knockout (KO) (N = 20) and Wild-type (WT) (N = 40) mice underwent insertion of a tibial intramedullary pin after which a mid-shaft tibial osteotomy was performed. The mice were divided into three groups: SOST KO (N = 20), WT with Scl-Ab injection (N = 20) and WT with saline injection (N = 20). The Scl-Ab group received an intravenous dose of 100mg/kg weekly starting on day 7. Each group was managed and sacrificed according to the specified protocol. For data analysis, one-way ANOVA (Analysis Of Variance) was performed followed by Tukey's post hoc test at each time point. P values < 0.05 were considered statistically significant.

Results: Both Scl-Ab and KO groups showed significantly increased trabecular BV/TV (bone volume/total volume) at the fracture site (mid-shaft of the tibia) compared to the saline group at all time points and also showed no significant difference between them at all time points (except at 28 days postoperative) On biomechanical testing the Scl-Ab and KO groups showed significant increased strength in stiffness at days 14, 28 and 35 compared to the saline group. Concerning ultimate force and work to failure the KO group showed significant increase in the force required compared to both the Scl-Ab and saline groups at 21,28 and 35 days. While the Scl-Ab group showed increased forced required to fracture the callus compared to the saline group at these time points, but this was only significant for work to failure at 28 days.

Conclusion : Scl-Ab injections showed promising results, which were comparable to the complete depletion of sclerostin, especially at earlier stages of the healing process. In addition, our results indicate that sclerostin antibody exerts its greatest effect in the earlier stages of fracture healing (days 14 and 21), after which the healing process plateaus and thus completing this process at an earlier time point. Further research into accurate dosage and adequate timing of administration is required before these promising results can be implicated as a modality for accelerating fracture healing in humans and management of delayed/nonunion.

#204: The myth of the prophylactic anterior compartment fasciotomy for elective tibial osteotomy

John E. Herzenberg (USA),
Richard Luzzi, Ahmed I. Hammouda

Question : Acute compartment syndrome (ACS) is a clinical emergency that requires prompt diagnosis and treatment to reduce the potential for catastrophic disability. ACS commonly occurs after tibial fractures, but also after elective osteotomies. Prophylactic fasciotomy of the anterior tibial compartment in elective tibial osteotomy is frequently recommended to prevent ACS. Can we assume that a prophylactic fasciotomy will eliminate the possibility of ACS in elective tibial osteotomies?

Method : This is a case series of four patients (3 females and 1 male) from one hospital who underwent elective tibial osteotomy for acute valgus deformity corrections. All four developed ACS, despite having undergone prophylactic anterior compartment fasciotomy. The technique for the fasciotomy consisted of a 3 cm skin incision over the anterior compartment, a longitudinal, complete release of the deep fascia from knee to ankle, and a small transverse (cruciate) fasciotomy from the tibia to the lateral compartment. The skin was closed per primum. The four patients all had deformity correction with fixator assisted nailing technique. Average age of the patients was 22.5 years (range, 16 to 32 years). The etiology was tibial valgus deformity (3 cases) and valgus mal-nonunion of lengthening regenerate (1 case). Intracompartmental pressures were measured with a compartment pressure monitor.

Results : Patients developed clinical manifestations of ACS 0-36 hours post-operative. Based on intracompartmental pressure measurements, ACS was diagnosed and urgent decompression (dermotomy) was performed. All the muscles were healthy, bled, and contracted in response to stimulus, except for one patient with partial muscle necrosis of the upper third of the anterior compartment. The intracompartmental pressures dropped down immediately after release. Shoe lace (vessel loop) technique and/or vacuum assisted closure system was used to gradually close the wounds. Delayed primary closure was performed 3-9 days post-therapeutic fasciotomy in three patients. One patient required multiple debridements, a rotational muscle flap and split thickness skin graft.

Conclusion : There are two kinds of fasciotomy: prophylactic (fascia only left open) and therapeutic (fascia and skin both left open). It is a myth to think that a prophylactic fasciotomy provides absolute protection against ACS. Once ACS is diagnosed in the patient who already has a prophylactic fasciotomy, urgent dermotomy must be performed to relieve the high pressure. Prophylactic tibial anterior compartment fasciotomy might prevent some, but not all ACS. The careful surgeon is advised to maintain a high level of suspicion and careful post-operative observation for ACS, even in patients who have underwent a prophylactic anterior compartment fasciotomy. Valgus to varus correction may be a particular risk factor, as the anterior compartment is stretched.

#205: Deformity correction and lengthening of the femur with retrograde motorized lengthening nails

Joachim Horn (Norway),
Stefan Huhnstock

Question : Limb lengthening with intramedullary motorized nails is a relatively new method. The use of retrograde femoral nails allows for intraoperative axis correction close to the knee joint. The purpose of this study was to see if a retrograde femoral lengthening nail is a reliable construct for limb lengthening and deformity correction.

Method : We performed 20 femoral lengthening in 20 patients using a retrograde femoral nail. The patients mean age at time of correction was 28 (15-61) years, 10 were female and 10 male. Diagnoses were: 12 cases of posttraumatic deformity, 4 congenital femoral deficiencies and 4 hypoplasias of the femur. Initial deformities included shortening in all patients; mean 38 (25-65) mm. 9 patients had an additional valgus deformity [mean 7 (3-17)] and 5 patients had a varus deformity [mean 9 (3-16)]. 1 patient had a procurvatum deformity of 26 and 5 patients had no initial deformity besides shortening. In 15 patients we used the Fitbone device and in 5 patients the PRECICE lengthening nail. Preoperative planning and controlled intraoperative correction of malalignment and potential torsional deformities were done based on the reverse planning method as described by Baumgart (2009). The method includes the use of rigid, straight reamers, and the use of blocking screws to guide the reamers intraoperatively and to maintain the acutely performed deformity correction.

Results : The planned amount of lengthening was achieved in all patients. No loss of length was found during follow-up. All patients consolidated without further interventions, consolidation index was mean 1.4 (0.8-2.5) months/cm. 5 patients showed residual axis deviation when lengthening was completed and long standing radiographs could be obtained. 3 of these patients had residual varus deformity with 3, 4 and 5 of varus respectively; and 1 patient had residual valgus deformity of 10. 1 patient developed a procurvatum deformity of 7 degrees during the course of lengthening. 3 patients had to be revised due to migration of locking screws, and 1 patient due to insufficient connection of the receiver in a Fitbone nail. No other obstacles or complications occurred.

Conclusion : Controlled axis correction and lengthening can be achieved with motorized retrograde femoral nails. However, a thorough preoperative planning and intraoperative control of alignment are required in order to avoid residual deformity. The use of rigid, straight reamers and blocking screws are essential in order to achieve and maintain the acutely performed deformity correction.

#206: Radiographic analysis of hexapod external fixators fundamental differences between the Taylor Spatial Frame and the Truelok-Hex

Nando Ferreira (South Africa),
Franz Birkholtz

Question: How do the Taylor Spatial Frame and Truelok-Hex differ with regard to radiographic analysis for deformity correction planning?

Methods: A Sawbone model was created to simulate a midshaft-tibial fracture with deformity. A 180 mm ring was applied oblique to the proximal segment of the Sawbone model, in both the sagittal and coronal planes. Standard radiographs were taken of the model and analysed using the described Taylor Spatial Frame and Truelok-Hex methods.

Results: The Truelok-Hex software allows the surgeon the ability to program reference rings that are not orthogonally mounted. Apart from this software difference, the described analysis methods resulted in variation in all translational measurements for both deformity and mounting parameters.

Conclusion: The radiographic analysis of the Taylor Spatial Frame and Truelok-Hex are fundamentally different. These differences must be appreciated in order to use these systems effectively.

#207: Bifocal osteosynthesis for treatment of distal femoral deformity with shortening: Acute correction and gradual lengthening

Qinglin Kang (China),
Jia Xu, Yachao Jia

Question: Distal femoral deformity with shortening is a common orthopedic disease, which is less challengeable for surgical disposition. The traditional treatment is gradual correction and lengthening after monofocal femoral supracondylar osteotomy. However, it always results in knee stiffness and dysfunction of quadriceps. We described our experience of acute correction and gradual lengthening with bifocal osteosynthesis.

Methods: From July 2008 to August 2014, 18 cases with various distal femoral deformities with shortening were successfully treated by acute correction and gradual lengthening using bifocal osteosynthesis. There were 6 females and 12 males with a mean age of 19.6 years (range, 15 to 27 years). Types of deformities included 13 varum, 2 valgus, and 3 procurvatum ranging from 15 to 30 degree. The average length discrepancy of 30 femurs was 6.8 cm (range, 4 to 13 cm). Osteotomies were performed at the site of femoral supracondyle and middle or proximal shaft, and then orthofix LRS fixator were mounted. The distal femoral osteotomy was for acute deformity correction and midshaft osteotomy was for gradual lengthening.

Results: All patients achieved the desired angular correction and realigned the mechanical axis of involved limb. The average lengthening was 6.5 cm (range, 4 to 11 cm), and the postoperative ROM of affected knees in 18 cases was similar to preoperative. Frames were removed at an average of 8 months (range, 5 to 15 months). Complications of superficial pin-tract infections were observed in 4 patients, but they resolved over time.

Conclusion: On the basis of our preliminary experience, we believed that bifocal osteosynthesis would be a considerable procedure to prevent knee stiffness after femoral lengthening. Acute correction of distal femoral deformity by supracondyle osteotomy could hardly influence the ROM of knee joint, and gradual lengthening by midshaft osteotomy contributes to the rehabilitation of quadriceps after tension.

#208: Intra-articular osteotomy to correct the deformity around knee joint

Qinglin Kang (China),
Yachao Jia, Honghao Chen

Question: To explore and evaluate the outcomes and significance of intra-articular osteotomy for deformity correction around knee joint.

Methods : Between June 2011 and September 2014, 14 cases of intra-articular osteotomy for deformity correction around knee were undertaken in our institution. This group included 10 males and 4 females; the average age was 34.5 years (range, 18 to 54 years). The positions of intra-articular deformities consisted of 11 proximal tibias and 3 distal femurs. According to the preoperative X images and MAD measurements, the CORA and deformity origin around knee joint were determined, and then intra-articular osteotomies were performed to correct the deformities and achieve the normal JLCA. Additional osteotomies were simultaneously done in 12 cases to correct extra-articular deformities and LLD. Types of intra-articular osteotomy consisted of 7 medial and 4 lateral semi-plateaus elevation in proximal tibia, 3 lateral condyles splitting and distal displacement in distal femur. All intra-articular osteotomies were stabilized with full threaded cannular screws, and extra-articular deformities and LLD were corrected using external fixator.

Results: The mean follow-up was 2.3 years (range, 1 to 3 years). All patients achieved normal limb length and mechanical axis. Stability of knee restored into normal range. No patient complained obvious pain during follow-up. The average range of motion (ROM) of knee at last follow-up was 120° (range, 90° to 140°), which was similar to preoperative ROM.

Conclusion: Intra-articular osteotomy is a high technical demanding procedure, which can be applied successfully to correct various distinct intra-articular deformities around knee joint. It is a practical and powerful key technique in orthopedic surgery and should only be performed by experienced specialist.

#209: Use of Ilizarov External Fixator to correct lower limb severe deformities in sacral agenesis

Boatto Hilario (Brazil)
, Clinco Junior, Osvaldo Dias, Alexandre Rial, Silva Fabio de Assuno, Linhares Glauber Kazuo, Amorin, Thiago Bastos

Question: Severe lower limbs deformities in sacral agenesis can be corrected using External fixator device? (Case Report)

Methods: An 8 years old girl with sacral agenesis with bilateral 90 degrees knee flexion deformity, popliteal pterigium, flexion of the hips and equinus, adduction and supination of the feet was treated with circular external fixator device.

Results: The deformities were corrected using gradual distraction without soft tissue release. After the correction the patient could stand up and walk using braces.

Conclusion: The circular external fixator device is usefull to correct severe deformities in sacral agenesis.

#210: Correction of Limb Deformities in China: Current Status and Future Directions

Anhuai Yu (China),
Yue Guo, Weiming Wang, Xiaofei Tian, Jianwen Chen

Question: Limb deformities correction in China has progressed substantially in the past three decades. But the current status and future directions on this issue in China were not addressed clearly from an international perspective, for most related articles were published in Chinese.

Methods: We reviewed the following 9 major databases from their inception to 1 May 2015: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese Biomedical Literature Database (CBM), the Chinese Medical Current Content (CMCC), the Chinese Scientific Journal Database (VIP database), the Wan-Fang Database, the China National Knowledge Infrastructure (CNKI) and Citation Information by National Institute of Informatics (CiNii). All the related articles in English or Chinese without restriction of publication status were included.

Results: The current prevalence of specific disorders of limb deformities in China, the diagnosis, and the treatments with a focus on surgical interventions with external and internal fixation methods were explored and illustrated in detail. We also concluded some challenges and possible solutions, including the multidisciplinary methods for complex deformities in adults, limb lengthening and correction of deformities in children. Current situation, education and training of orthopedic surgeons for limb deformities correction in China are also introduced.

Conclusion: The percentage of ideal limb deformities correction in China is extremely low. Effective strategies should be implemented jointly by public, medical societies, government and international collaborations, with great effort, to promote limb health in China.

#211: Management of valgus or varus knee deformity with fixator assist nailing technique and distal femur osteotomy

Sheng Song Yang (China),
Lei Huang


#212: A challenging case of limb salvage requiring a combination of composite fixation and Masquelet technique to address significant segmental bone loss

Christopher Blair (USA),
Ashley Simela, Brian J. Cross

Question: Would the combined characteristics of the Masquelet technique and composite fixation effectively provide superior construct stability, while acting as a conduit for new bone growth, in a challenging case of segmental bone loss in an open femur fracture?

Methods: By combining the two-stage Masquelet technique with a titanium cage implant placed in the second stage to provide superior stability to the construct while awaiting new bone ingrowth in the area of the defect.

Results: Over seventeen (17) centimeters of new bone growth were achieved, effectively eliminating the considerable segmental defect of the metadiaphyseal femur.

Conclusion: Combining proven techniques of adult reconstruction in creative ways can be used to achieve impressive successes in overcoming bony voids in the trauma patient. Utilizing the characteristics of composite fixation along with the Masquelet technique is one means by which we have been able to demonstrate this success.

#213: Femoral version and tibial torsion are not associated with hip or knee arthritis in a large osteological collection

Douglas S. Weinberg (USA),
Paul J. Park, William Z. Morris, Raymond W. Liu

Question: Tibial torsion and femoral anteversion are common rotational abnormalities in children, and their courses are most often benign and self-resolving. While neither usually requires surgical treatment, the decision to perform a derotational osteotomy is usually based on the degree of functional impairment. Neither condition is thought to influence the development of osteoarthritis of the hip or knee; however, to date there have been no large scale studies confirming this. The aim of this study was to investigate the correlations between tibial torsion, femoral anteversion and osteoarthritis of the hip and knee.

Methods: Tibial torsion and femoral anteversion in 1,158 cadaveric tibiae and femora were measured using a camera setup based on previously described radiographic landmarks. Any specimens with obvious traumatic, rheumatic, or metabolic abnormalities were excluded. Degenerative joint disease of the hip and knee were each graded from 0 to 6. Correlations between tibial torsion, femoral anteversion, age, race, and gender with osteoarthritis of the hip and knee joints were evaluated with multiple regression analysis.

Results: The mean and standard deviations of tibial torsion and femoral anteversion were 7.9 8.8, and 11.4 12.0, respectively. African-Americans had significantly decreased external tibial torsion (5.1 8.7 vs. 9.2 8.5, P 0.05 for all).

Conclusion: This study confirmed previously reported differences in the rotational profiles between races and genders. However, neither tibial torsion nor femoral anteversion had a significant influence on the development of arthritis of the hip or knee. These results support the practice of treating tibial torsion and femoral anteversion based on the symptomatology of the patient. Parents of asymptomatic children can be reassured that long term consequences are unlikely.

#214: Association between Tibial Malunion Deformity Parameters and Degenerative Hip and Knee Disease

Douglas S. Weinberg (USA),
Paul J. Park, Raymond W. Liu

Question: Tibia fractures are the most common long bone fracture. Most injuries are managed surgically, although non-operative indications exist. Criteria for closed reduction are based on the amount of fracture shortening and angulation, with high success rates achieved if acceptable alignment is maintained. However, to our knowledge, there exists limited data available regarding the long-term consequences of specific deformation patterns.

Methods: The tibiae of 2899 cadaveric skeletons from the Hamann-Todd osteological collection were manually inspected for evidence of fracture. Specimens with midshaft fractures that formed obvious callous were included as candidates for study; fractures extending into either the proximal or distal joint surfaces were excluded. Fracture laterality, shortening, translation, and fracture angulation in the coronal and sagittal planes were measured using previously described techniques. Axial rotation (tibial torsion) was measured using a camera setup based on previously described radiographic landmarks. Degenerative joint disease of the knee and hip were graded from 0- 3. Correlations between fracture characteristic and osteoarthritis were evaluated with univariate and multivariate analyses.

Results: 37 tibia fractures were present in 36 skeletons, a 1.7% prevalence in this collection. There were 23 right (62%) and 14 left sided fractures. Fractures were shortened by an average of 16 11 mm compared to the contralateral side, with 25 tibiae shortened more than 10 mm. Fractures were translated by an average of 5 5 mm and 2 3 mm in the coronal and sagittal planes, respectively. The average coronal deformity was 6 6, with 18 specimens containing 5 or greater of coronal deformity. The average sagittal plane deformity was 7 7, with specimens containing 10 or greater of sagittal deformity. The average tibial torsion was 116, with 16 specimens containing greater than 10 of axial rotation. Tibial torsion was greater (increased external rotation) in fractured tibiae when compared to the contralateral side (11 10 versus 8 9, P = 0.020). In patients with tibia fractures, ipsilateral knee arthritis was greater than that of the contralateral side (2.2 0.7 versus 1.6 0.7, P 0.05 for all). Fractures with coronal plane deformity greater than 5 had more arthritis than fractures without (2.5 0.5 versus 1.9 0.7, P = 0.006). There were no differences in knee arthritis scores in fractures that had sagittal plane deformities greater than 10 (2.5 0.8 versus 2.2 0.6, P = 0.381). Knee arthritis was greater in specimens with greater than 10 of tibial torsion (2.0 0.6 versus 2.5 0.5, P = 0.004). Tibiae that were shortened by more than 10 mm had higher grades of ipsilateral hip arthritis compared to those without 10 mm of shortening (1.7 0.9 versus 1.3 0.7, P = 0.009). There was no difference in hip arthritis on the ipsilateral side compared to the contralateral side (1.6 0.9 versus 1.5 0.7, P = 0.149. There were no differences in hip arthritis scores for any other fracture characteristics (p 0.05 for all).

Conclusion: The results of this study suggest that shortening, coronal and axial plane malalignment are of the greatest consequence following fractures of the tibia. Sagittal plane deformity was not a significant predictor of greater arthritis at either the knee or the hip joints. The lower extremity may be better able to compensate through motion in this plane. These conclusions strengthen the recommendations of other authors who have emphasized restoring tibial length, and providing anatomic restoration in the coronal and axial planes.

#215: Outcome of Histraction Histeogenesis in Kienbock's Disease

D S Meena

Various modalities to treat kienbock's disease have been used since 1910. the controversy regarding superiority of conservative treatment over operative intervention exists in the literature. the results of distraction histeogenesis in perthes' disease has encouraged us to use the same principles in kienbock's disease.

Patients and Methods : The prospective study comprised of sixteen patients (six males and ten females) with mean age of 18.2 years (range 21-35 years) with clinico -radiological diagnosis of lichtman stage II (6) and III (10) kienbock's disease with a mean duration of symptoms for 6.6 months. The ulnar variance was neutral in six and was negative in ten cases. The cases were treated with biplanar joshi's external stabilisation system (jess) across the wrist joint. Gradual distraction was done at a rate of 0.5 mm/day in two fractions. After the distraction of 5-7 mm, the distraction was kept static for 3 weeks. The wrist was mobilised on hinge joints for 3 weeks. After removal of the fixator, short cock-up splint was used for 4 weeks.

Results : The mean follow-up period was 5 years (range from 2-10 years). The average duration of treatment was 5.3 months (4.5-6 months) and the duration of distraction (both static and hinged) was 8 weeks. Clinically all the patients were relieved of the symptoms with an increase in the range of movements at the wrist joint (ulnar deviation increased from 20 degrees to 29.5 degrees, radial deviation from 17.5 degrees to 21 degrees, dorsiflexion from 37.5 degrees to 52.5 degrees and palmar flexion from 38.3 degrees to 47.5 degrees). At the last follow-up, activities of daily living were found not affected and all the patients returned to their previous jobs. The average grip strength increased to 73.8% of normal. Radiologiclly the carpo-metacarpal ratio did not show any significant improvement but the density of lunate decreased.

Conclusion : Distraction osteogenesis when used in lichtman stage II and III kienbock's disease with negative or neutral ulnar variance gives good symptomatic relief allowing return to normal activities.

#216: Ilizarov technique for the treatment of ulna exostoses without resection of the osteochondroma

Rim Boussetta (Tunisia),
Rafik Elafram, Ismail Jerbi, Sami Bouchoucha, Walid Saied, Mohamed Nabil Nessib

Question: Multiple hereditary exostoses inhibit the growth of the ulna, lt leads to the development of limitations in the pronation-supination of the forearm, and cosmetic problems. The aim of this study is to evaluate the results of gradual ulnar correction and lengthening using the Ilizarov technique for the treatment of forearm exostoses without resection of the osteochondroma.

Methods: We retrospectively reviewed the cases of three patients who had deformities of the forearm and evaluated the radiologic and clinical results of gradual ulnar lengthening with an Ilizarov external fixator without excision of the osteochondromas from the ulna.

Results: Good clinical and radiological results were obtained after a mean follow-up of 05 years. During the clinical interview, post-operative functional status was significantly improved than pre-operative functional status. The X rays showed a total disparition of the osteochondroma by the pure lengthening of the ulna.

Conclusion: The pathogenesis of forearm deformities in patients with multiple hereditary exostoses is complex and not yet fully understood. However, there have been several hypotheses to explain this situation. Ulnar lengthening without resection of the osteochondroma was not described in the literature as we know. Treatment of three forearms from three patients by gradual lengthening of the ulna with an Ilizarov external fixator without excision of osteochondromas with leads to spontaneous reduction of the osteochondroma without the need for any additional operative intervention is a unique procedure non described in the literature.

#217: Minimally invasive treatment of Type III acromioclavicular joint dislocation using self-design coracoclavicular guidance equipment with endobutton plates system.

Liu Ming (China),
Tang Jian, Zhu Zhenan

Question: AC (acromioclavicular) joint dislocations are a common injury. The treatment of type III acromioclavicular injuries is controversial. Conservative treatment has been reported to achieve good outcomes. However, many patients experienced chronic pain or a fatigue sensation in an elevated posture, and therefore surgical treatment ensuring the stability of the acromioclavicular joint is crucial for more active patients. The present study offers a novel minimally invasive treatment using self-design coracoclavicular guidance equipment with endobutton plates system in order to reduce incision, bleeding volume, operative time and complications in intraoperation and postoperation.

Methods: Twenty-four patients with acute type III acromioclavicular joint dislocations (mean age 34 years) were enrolled from 2010-2013. The average time between the injury and the surgery was 4 days. All patients were evaluated both preoperatively and postoperatively by radiographs, visual analog scale and Constant score. Self-design coracoclavicular guidance equipment with endobutton plates system was used in all cases.

Results: Three small incisions about 1.5 cm were seperatively adopted at clavicle, coracoid and AC joint. Operative time was about 20 minutes. Intraoperative bleeding volum was not over 20ml. The average follow-up is 24 months. Visual analog scale score of was 0.93 (range 0-3), while mean constant score was 93.35 (range 90-99) and 95% of patient were happy with their functiont. One patient had a slight re-dislocation in radiograph 2 years after surgery. At the last follow-up, no major complications were recorded.

Conclusion: It is a more simple, more effective and safer surgical method using self C design coracoid-clavicle guidance device with endobutton plates system to treat type III acromioclavicular dislocation.

#218: Replacement of a complete infected defect of forearm by lengthened humerus: case report and literature review

Qin Chenghe (China)
, Yu bin, Xulei, Hu yanjun

Question: Long bone defect caused by refractory infection is a common complication in open comminuted limb fractures. Although bone graft and free fibular transplantation have long been the hallmark of skeletal defect management, their efficacy is limited. Bone transport which utilizes Ilizarov methodology has been applied to address this limitation. However, the literature reporting humeral bone transport to treat forearm defect is limited, especially in open comminuted forearm fractures.

Methods: We present a 29-year-old man who suffered a severe open comminuted fracture at the right radius and ulna which was unsuccessfully treated by conventional debridement and bone graft at our institution. His postoperative refractory infection, accompanied by purulence, led to an inevitable secondary operation one month later. At the initial stage, after the infected and fractured radius and ulna were removed, the consequent long bone defect was filled with calcium sulfate (CaSO4) admixed with vancomycin and carefully fixated. Two months later when the infection was under control, the patient underwent distal osteotomy and bone transport of the right humerus to replace the absence of radius and ulna. Half a year later, the patient regained simple motion of the forearm. X-ray revealed the lengthened humerus was docked with the metacarpal bone perfectly. No reinfection or other complication was observed.

Results: The patients were followed up for 18 to 30 months (averagely, 23 months). Recurrence of infection was found in one patient, which responded to secondary debridement. Bone graft was conducted in another patient. Because of extensive defect at the calcaneus and lateral column, one patient received free fibular transplantation to compensate for the defect and support hind food and lateral column. In three cases, partial calcaneal defect and malformation were corrected by Ilizarov technique. According to the Mayo Hindfoot-Ankle Scoring System, foot functional recovery was excellent in 19 cases, good in 3 cases and poor in 1 case.

Conclusion: Humeral lengthening to preserve basic function and profile of the forearm may a last alternative for cases like ours where resection of the ulna and radius is inevitable to treat refractory infection.

#219: PIP Contracture treated with Ilizarov minifixatorZhi

Hong Tong (China),
WeiFeng Zeng, Gavish Awotar

Question: Injury through trauma or surgical intervention tothe intricate system of the hand is often accompanied by contractures. Flexion contractures are more common and disabling and show significantresistance to treatment and rate of recurrence. Surgical procedures varywith severity of contracture and the patients age. To correct thecontracture of the PIP joint , we report a case where we used the Ilizarovminifixator, the treatment results and the problems we encountered.

Methods: The 23-year old patient suffered trauma byelectric saw to the little finger of the right hand, two wounds on thedorsal of it. The superficial and deep flexor tendon were cut into threeparts with partial amputation as well as the artery. He underwent emergencysurgical intervention with repair of the artery and of fifth flexordigitorium tendon. Thankfully, the finger was saved. However, 3 weekspost-operatively, contracture of the fifth PIP occurred. The contracturewas gauged as very serious as it affected the function of the hand. Thus, treatment was sought. Afterproper aseptic preparation, the fifth fingerwas milked out of blood and a tourniquet was applied for hemostatic control. A 1 cm incision was made at the proximal interphalangeal joint andsurrounding tissues were carefully dissected to isolate the tendon. Thejoint capsule, volar plate and collateral ligaents were released and whenadequate joint space was provided, adhesions were carefully released. Then, an oblique incision was made to the tendon to free the contracture and wasthen re-approximated and fixed with non-absorbable sutures. The finger wasstabilized in an extended position with the insertion of 4 K-Wires and theIlizarovminifixator. The latter was kept fixed for 1 week of traction for1 millimeter. After which the finger in full extension. For the next 2 weeks thereafter, the screws were loosened up and the PIP was moved thricedaily. Three weeks post-operatively, the instrument was removed andrehabilitation was started.

Results: The slow, sustained, stable tension provided by theIlizarovminifixator allowed a successful full extension of the finger. Furthermore, with meticulous care given to minimize intraoperative traumaand blood spillage, regeneration was also facilitated with properrehabilitation. Care is given to avoid direct friction of the articularcartilage. Upon each follow-up with the rehabilitation team, post-operativefunctional exercise were performed and taught to the patient for dailypractice. In subsequent follow-ups, the joint was successfully extended with no associated complications or decrease range of flexion and extension. No other complications were also reported.

Conclusion: With a dedicated microsurgical team with amultidisciplinary approach, proper surgical technique and carefulrehabilitation, such type of contracture using the Ilizarovminifixator canbe used for efficient results

#220: Fixator-assisted Nailing in the Treatment of Fractures and Varus Malunions of the Proximal Humerus

Alexander Cheinokov (Russia),
Ekaterina Lavrukova

Question: Fractures and malunions of the proximal humerus lead to functional impairment, especially limitation of abduction. Our aim was to develop a mini-invasive technique of correction of typical varus deformity providing easy closed nailing.

Methods: 52 patients with 2-part fractures (37/52) and malunions of the proximal humerus (15/52) were operated. The technique featured a small wire temporary external frame with two k-wires in the humeral head for spatial control, and one k-wire in the distal humerus in frontal plane. In case of acute fracture it allowed to reach alignment and proper length. In case of malunions percutaneous osteotomy of the surgical neck was performed prior to fixator application, and alignment was reached acutely by the fixator. Then closed intramedullary nailing was then performed through a stab wound, and the fixator was dismounted after locking of the nail.

Results: The technique allowed to restore anatomy of the proximal humerus and avoid varus malalignment. Mini-invasive approach and stable fixation provided rapid functional recovery. 41/52 patients were available for follow-up in 1 year. 39/41 fractures and osteotomies healed, in two nonunions exchange nailing was performed. Patients demonstrated significantly increased shoulder function and quality of life.

Conclusion: The presented technique provides reliable, easy and reproducible way of mini-invasive restoration of anatomy of the proximal humerus in two part fractures and varus malunions. It results with low complication rate and good functional outcomes. Its feasibility in more complex injury patterns requires further research.

#221: PIP Contracture treated with Ilizarov minifixator

ZhiHong Tong (China),
WeiFeng Zeng, Gavish Awotar

Question: Injury through trauma or surgical intervention to the intricate system of the hand is often accompanied by contractures. Flexion contractures are more common and disabling and show significant resistance to treatment and rate of recurrence. Surgical procedures vary with severity of contracture and the patients age. To correct the contracture of the PIP joint, we report a case where we used the Ilizarov minifixator, the treatment results and the problems we encountered.

Method: The 23-year old patient suffered trauma by electric saw to the little finger of the right hand, two wounds on the dorsal of it. The superficial and deep flexor tendon were cut into three parts with partial amputation as well as the artery. He underwent emergency surgical intervention with repair of the artery and of fifth flexor digitorium tendon. Thankfully, the finger was saved. However, 3 weeks post-operatively, contracture of the fifth PIP occurred. The contracture was gauged as very serious as it affected the function of the hand. Thus, treatment was sought. After proper aseptic preparation, the fifth finger was milked out of blood and a tourniquet was applied for hemostatic control. A 1 cm incision was made at the proximal interphalangeal joint and surrounding tissues were carefully dissected to isolate the tendon. The joint capsule, volar plate and collateral ligaents were released and when adequate joint space was provided, adhesions were carefully released. Then, an oblique incision was made to the tendon to free the contracture and was then re-approximated and fixed with non-absorbable sutures. The finger was stabilized in an extended position with the insertion of 4 K-Wires and the Ilizarov minifixator. The latter was kept fixed for 1 week of traction for 1 millimeter. After which the finger in full extension. For the next 2 weeks thereafter, the screws were loosened up and the PIP was moved thrice daily. Three weeks post-operatively, the instrument was removed and rehabilitation was started.

Results: The slow, sustained, stable tension provided by the Ilizarov minifixator allowed a successful full extension of the finger. Furthermore, with meticulous care given to minimize intraoperative trauma and blood spillage, regeneration was also facilitated with proper rehabilitation. Care is given to avoid direct friction of the articular cartilage. Upon each follow-up with the rehabilitation team, post-operative functional exercise were performed and taught to the patient for daily practice. In subsequent follow-ups, the joint was successfully extended with no associated complications or decrease range of flexion and extension. No other complications were also reported.

Conclusion: With a dedicated microsurgical team with a multidisciplinary approach, proper surgical technique and careful rehabilitation, such type of contracture using the Ilizarov minifixator can be used for efficient results.

#222: Humeral lengthening with monolateral external fixator

Milud Shadi (Poland)
, Pawe Koczewsk, Barosz Musielak

Question : Upper extremity lengthening is indicated in limited instances in comparison to lower limb lengthening because a moderate shortening of the upper limb do not usually produce significant functional or cosmetic problem. However, there are still numerous situations in which the upper extremity lengthening is advisable due to the functional, cosmetic or psychological aspects. The aim of the study: To evaluate the clinical outcome and complications of humeral lengthening with monolateral external fixator.

Method : Twenty-one patients (10 female and 11 male) at the age of 12.1 to 22.1 years (mean 16.3) with a total number of 31 humeral lengthening procedures performed at our institution from 2000 to 2012 were evaluated. In each subject the same surgical procedure was performed with the use of monolateral external fixator as a lengthening device. 13 patients (15 humeri) were lengthened because of post septic shortening, with its range from 5 to 13.8 cm (mean 10 cm), while in 8 patients (16 humeri) lengthening was done bilaterally because of achondroplasia. Mean follow up was 6 years (1 to 12). In all cases the monolateral external fixator (Pumed -21, Orthofix-7, Stryker -3) was fixed to the humerus by 4 Schanz screws, open humeral distraction osteotomy was done below the insertion of deltoid muscle. Only in one case 15 of anteflexion was corrected intraoperatively. Distraction begun at 5-6 th day postoperatively with the rate of 1 mm/day. In hypertrophic bone regenerate formation the distraction rate was increased up to 1.5 mm/day.

Results : 4 to 10.3 cm of lengthening was achieved (mean 7.8). The average time of fixator application was 7 months and the lengthening index ranged from 0.7 to 1.3 months/cm (mean 0.88). Most of the patients experienced pin tract infection, which were successfully managed conservatively. The most serious complication was mechanical injury of the radial nerve with 5 cm loss of its length at the level of distal Schanz half pin. This subject needed reconstruction using cable graft from sural nerve and no lengthening was carried out at that stage. Complete nerve function restoration was achieved after 10 months. This was the only unsatisfied result. No shoulder or elbow joint range of motion deterioration was observed on the last follow up. Axial deviation in 4 segments (treated with acute correction), fixator instability in 2 cases, and premature consolidation in 2 cases were noted. One case of humeral fracture after hardware removal was also observed. Transient neuropraxia in two cases was neutralized with the temporary stop of the distraction.

Conclusions : Humerus lengthening using monolateral external fixator is an effective and reliable method of treatment, with relatively low lengthening index but needs strict technique attention in half pins insertion as well as precise osteotomy technique of bone. Hipertrophic regenerate formation is unique feature of humeral lengthening. The monolateral external fixators are well tolerated by patients. Most monolateral devices have no ability of gradual axial correction that may result in secondary axial deformity as a complication.

#223: Lateral external fixator for treatment of supracondylar humerus fractures in children

Matias Sepulveda (Chile)
, Macarena Morovic, Estefania Birrer

Question : To analyze the clinical and radiological results of the use of a modular lateral external fixator as a treatment alternative in displaced supracondylar fractures of the humerus in children.

Method : Retrospetive study involving patients with supracondylar fractures of the humerus under 15 years treated with modular lateral external fixator in between September 2008 and September 2014. It conducted a descriptive analysis of the injuries. Treatment outcome was analyzed clinically and radiologically.

Results : Between 2008 and 2014, 32 patients with supracondylar fracture of humerus were treated with a lateral external fixator, with an average of 5.8 years old. The main indications were difficult reduction and important displaced (Gartland type III and IV). Average duration of surgery was 35 minutes. 95% of cases resulted with an anatomic clinical axis. Baumann angle was 74 degrees in average. There were no cases of cubitus varus.

Conclusion : In our series, the results of using a modular lateral external fixator in the treatment of displaced supracondylar fractures are valid and reproducible option, with excellent functional and clinical results and no complications.

#224: Elbow arthrodesis for posttraumatic sequelae: Surgical tactics using the Ilizarov frame

Francesco Sala (Italy)
, Maurizio Catagni, Federico Bove, Daniele Pili, Paolo Capitani, Rosario Spagnolo

Question: Elbow arthrodesis (EA) is a rarely performed procedure still considered a salvage approach. Ulno-humeral arthrodesis is difficult to perform because of the peculiar bony anatomy of the elbow. Radio-humeral arthrodesis is even more challenging when a large ulnar defect occurs as for failed total elbow replacement (TER).

Methods: Circular frames constructed by combining half pins with the conventional Ilizarov wires in a special multidirectional configuration provide a minimally invasive skeletal stabilization and control in all three planes. This configuration can provide gradual horizontal compression at the level of the EA and can be used to perform EA.

Results : Complete union was obtained in 3 EA (75%) at an average of 23 weeks. Fusion angles ranged from 90° to 120°. One patient required amputation above the elbow due to persistent infection and chronic pain after patenting the reconstruction with distraction osteogenesis for infected TER. The average length of follow-up after EA was 33 months (range, 18-60 months). At final follow-up the median QuickDASH score was 42.4 (27.3 to 52.2).

Conclusion : EA is not a common orthopedic procedure and the Ilizarov technique provides a reproducible and reliable way in achieving solid fusion with the desired angle.

#225: Complications in forearm lengthening by combined technique uniting Ilizarov method and flexible intramedullary nailing

Popkov Dmitry (Russia),
Popkov Arnold, Grebenyuk Eugeny

Question: Application of combined osteosynthesis (circular external fixator and flexible intramedullary nailing) in bone lengthening allows to reduce considerably the duration of external fixation, to decrease the number of complications (Lascombes et al., 2010; Jager et al., 2012). However, it should be noticed that the combined method requires expertise and familiarity with both bone lengthening techniques and flexibleintramedullary nailing (FIN). The aim of this retrospective study was to evaluate the complications occurred in use of the combined technique (ExFix + FIN) in forearm lengthening.

Method: Results of 31 forearm lengthenings (2008-2011) in 26 children (mean age 9.5 y. o) were retrospectively analyzed. All the children presented congenital malformations : 19 radial club hand and 12 ulnar club hand combined with dislocation of the radial head. The combined technique (ExFix + FIN) was applied for forearm lengthening and deformity correction. Outcomes of treatment were evaluated according to criteria of Lascombess classification of results (2012) taking into consideration amount of lengthening and deformity correction, duration of treatment, functional outcome, possible complications.

Results: In average, amount of lengthening was 4.61.9 cm (27.9%). The complications observed: local sepsis problems (in 5 cases), joint stiffness (3 cases of interphalangeal and/or metacarpophalangeal joints, 2 cases of pronosupination stiffness, 1 case of elbow flexum joint), irritation of sensitive branch of n. radialis (1 case), premature bone consolidation (1 case). The bone union delay (Healing Index HI - over 45 d/cm) was observed in 3 cases. This complication was caused by chirurgical errors: nailing through the osteotomy site (1 pt), intramedullary osteosynthesis of ulna only without nailing of radius (2pts). The outcomes were distributed according to Lascombess classification : I = 19, IIa = 4, IIb = 3, IIIa = 2, IIIb = 2, IVa = 1, IVb = 0. Discussion. The advantages of use of the combined technique in limb lengthening are well known : reduction of HI and decrease of number of complications (Popkov et al, 2010). Intramedullary nails guide the regenerate formation and contribute to prevent secondary displacement of bone fragments during period of distraction. Moreover, FIN decreases the risk of deformities and fractures after frame removal. In our series, all the complications related to use of FIN were caused by surgical technique or tactic errors.

Conclusion: Only correct application of the Ilizarov/FIN method provides excellent and good results of treatment without complications and sequelae caused by surgical technique and tactic errors.

#226: Humerus lengthening over a nail

Minoo Patel (Australia)

Humerus shortening can be traumatic or developmental, the common aetiologies being open fracture with bone loss, traumatic or post-infection growth arrest, multiple diaplyseal aclasia, and achondroplasia. We describe a new technique for humerus lengthening and present a series ofour initial ten cases.

Method: The surgical technique consists of distraction through an osteotomy using a monolateral external fixator rail, which acts as the distraction motor. An intramedullary nail is locked proximally, and acts as a guide rail. Once the distraction phase is complete and necessary length obtained, the nail is locked distally, thus maintain the distraction, while the regenerate bone consolidates. The time in external fixation is thus cut by almost 60% . An adult or paediatric rail is applied with 2 proximal half-pins, posterior to the medullary canal proximally and distal to the intra-medullary nail distally. The preferred osteotomy site is just distal to the deltoid tuberosity. A tuberosity entry humerus nail is inserted and locked proximally.

Results: Of the ten patients, one had bilateral lengthening for achondroplasia. Of the others, there were 3 open fractures (healed with shortening; one with a varus deformity), two post infection shortening, 2 with diaplyseal aclasia and one with idiopathic humerus shortening. The average length obtained was 4.38 cm (range 2.8 cm-11.2 cm). The average time in fixator was 1.4 weeks/cm. The average healing time was 3.8 weeks/cm. There were five minor pin site infections. There was temporary elbow flexion restriction in two cases. There were no neurological or vascular complications. The average DASH score at 12 months post frame removal was 6.

Conclusion: Lengthening over a nail is a safe reproducible technique for humerus lengthening.

#227: The Use of Tumor Prosthesis for Salvage of Non-ncologic Complex Distal Femur Fractures: A Case Series

Robert Carlton Palmer (USA),
Loren J Hudspeth, Bedford Hud Berrey

Question: Treatment of segmental loss of bone about the distal femur due to trauma or infection is a challenge in modern orthopedics. Multiple treatment strategies have been developed to address these issues, including: bone transport, large segmental allografts, bulk non-structural bone graft, amputation and tumor prosthesis. The successful use of tumor prosthesis and megaprosthesis in tumor reconstruction and joint arthroplasty have been well documented in the literature. These modalities are often considered the final option for limb salvage and failure often leads to amputation. The traumatically injured patients with segmental bone loss or infection present similar difficulties for which tumor prosthesis and megaprosthesis were also designed. The use of a tumor prosthesis may provide satisfactory reconstruction of the limb equal to or superior to the above-mentioned methods. The utility of tumor prosthesis used in this application was investigated to determine if the early use of these implants can provide superior patient outcomes with decreased socioeconomic impact. The ability to achieve limb salvage coupled with functional ability for patients to return to the work force quickly could provide a valuable advance in orthopedic trauma surgery. The purpose of this case series is to establish the use of a tumor prosthesis in non-oncologic conditions with loss of bone due to trauma or infection as a viable alternative to current methods of limb integrity restoration.

Method: A retrospective chart review was conducted utilizing the electronic medical record at an academic, regional level I trauma tertiary care facility. The review included male and female patients greater than age 18 who underwent definitive reconstruction of the distal femur with a tumor prosthesis for segmental bone loss due to trauma or infection from 2004 to 2015. There were no exclusion criteria and the operations were performed by a single surgeon. Time to index fixation, time to failure of fixation, number of revisions prior to salvage, time to salvage, post salvage procedure knee range of motion and ambulation status, and patient outcomes were documented.

Results: The investigation yielded a total of 8 patients. There were 5 males and 3 females and the ages ranged from 28-79 years old. The majority of original injuries were due to traumatic open fractures. Patients underwent an average of 2 surgeries prior to the placement of the tumor prosthesis and the time to placement from the patients index surgery ranged from 4 days to 26 months. 3 patients were non-ambulatory prior to surgery and 2 patients regained ambulatory status following the operation. Average follow-up time was 22 months and the average knee range of motion recorded for 7 of the patients at last follow-up visit was 1.4 to 108 degrees. One patient underwent a scheduled amputation due to persistent infection. Otherwise, 6 of the 7 remaining patients showed bony ingrowth about the hardware at the last recorded clinic visit and only 1 patient had a pain free mal-union due to hardware failure of the proximal aspect of the prosthesis.

Conclusion: Patients who have failed fracture fixation due to nonunion of complex distal femur fractures are problematic and present significant challenges to achieve a stable functional limb. Resection of the distal femoral segment for non-union or very comminuted distal femoral fracutres in the elderly or adjacent to prior total knee arthroplasty is a viable option to fracture fixation. Salvage of the extremities requires eradication of any infection, complete resection of the distal femoral segment and fibrotic soft tissue. The use of tumor prosthesis for complex distal femur injuries is a viable salvage option that offers an alternative to amputation which may decrease long-term healthcare costs, morbidity and disability. Future research is warranted to provide further support of the tumor megaprosthesis for non-oncologic, complex distal femur fractures.

#228: The use of Illizrov metod in reconstruction of bone defects after bone tumour resection

Wiktor Orzechowski (Poland),
Szymon Dragan, Piotr Morasiewicz, Szymon Lukasz Dragan.

Question: Thqestion was is the Ilizarov method suitable for the treatment of bone defects in patients after bone resection in course of bone tumours such as giant cell tumour and aneurysmal bone cyst.

Method: In our meterial of patients we have three patients after resection of giant cel tumour and two after resection of aneurysmal cyst. In four of them the resection was performed within proximal metaphysis of the tibia and in remaining one within distal metaphysis of the radius. All of them were stabilized in Ilizarov external stabilizator and after resection of bone tumour we performed a bone transport.

Results: In three cases we achieved a bony consolidation without any addtional procedures within a dockig place. In two of them we were forced for the revison of docking place because of soft tissue obstacle, preventing bony consolidation.

Conclusion: The Ilizarow method of bone trasport is an efficient and very usefull method in the treatment of bone defects after bone tumour resection as limb salvage procedure.

#229: Ilizarov Applications to Benign Bone Tumors

Mofakhkhrul Bari (Bangladesh)

Is there any usefulness of Ilizarov external fixator for the treatment of benign bone tumors?

Methods: We treated 29 limbs of 27 patients with deformity and different LLD due to benign bone tumor. There were 20 males and 7 female with a mean age of 11 years. We used Ilizarov of different bone tumors. The etiologies were osteochondroma in 9 patients, Olliers disease in 5 patients, fibrous dysplasia in 8 patients and GCT in 5 patients.

Results: The outcomes of the results were satisfactory in case of all these benign bone tumors.

Conclusion: Preservation and bone degeneration by means of distraction osteogenesis constitutes a highly conservative limb saving surgery. Patients with good defects of less than 10 cm, a great deal of preserve healthy tissue and good prognosis are good candidates for these methods.

#230: Limb lengthening using Ilizarov apparatus for the survivors with osteosarcoma around the knee

Seungcheol Kang (South Korea),
Soo-Sung Park

Question: Osteosarcoma is the most common primary malignant bone tumor in children, and often cause limb-length discrepancy (LLD). The aim of the study is to report the results of limb lengthening using Ilizarov apparatus for the patients with osteosarcoma who underwent limb salvage surgery (LSS) before their skeletal maturity.

Methods: We targeted only the patients who underwent LSS (wide excision and arthrodesis) for their stage II conventional osteosarcoma around the knee (proximal tibia or distal femur). The patients who were not followed-up until their skeletal maturity were excluded. Among them, 11 patients who underwent limb lengthening (soft tissue lengthening, STL) using Ilizarov apparatus from September 2006 to January 2012 were finally reviewed. There were 6 males and 5 females. The mean duration of STL was 64.727.7 days (35-112), the mean duration from LSS to STL was 3.51.1 years (2.1-5.4). The mean total follow-up duration was 7.82.0 years (5.4-10.1), and the mean follow-up duration from STL to final follow-up was 4.32.3 years (1.6-7.9).

Results: The mean age was 15.41.4 years (12.6-16.9) when the STL was performed, and the mean preoperative LLD was 5.92.8 cm (2.2-10.4). After STL, 6 patients underwent arthroplasty and 5 patients underwent arthrodesis, and the mean residual LLD was 0.71.0 cm (-1.1-2.0), therefore, the mean gain of length was 5.22.3 cm (1.7-8.9). There was no major surgical complication such as permanent neurologic deficit or deep infection. After skeletal maturity, the final LLD was 1.72.3 cm (-1-6.8).

Conclusion: For the patient with LLD caused by osteosarcoma around the knee, the results of limb lengthening using Ilizarov apparatus seem to be satisfactory.

#231: Distraction osteogenesis for managing residual leg length discrepancy in post-malignant bone tumor salvage procedures

Changhoon Jeong (Korea),
Chang-Kyun Park, Kwang-Won Park, Hae-Ryong Song.

Question: 1) if the use of distraction osteogenesis with an external fixator can address the problem of residual leg length discrepancy in patients with osteosarcoma previously treated with limb salvage procedures and 2) the complications that arise from this procedure.

Methods: The medical records and radiographs of 5 osteosarcoma patients who underwent limb lengthening were reviewed for this study. The amount of lengthening, mean external fixator index (EFI), and related complications were evaluated.

Results: For these patients, the mean amount of lengthening was 6.3 cm (range, 5.6-7.8 cm) and the mean EFI was 1.4 months/cm (range, 0.9-2.2 months/cm), planned lengthening was thus achieved. Postoperative complications included superficial pin track infection, equinus deformity, hardware failure, premature consolidation, re-fracture and prosthetic dislocation.

Conclusion: The use of distraction osteogenesis with an external fixator has potential benefits in the treatment of residual LLD in patients who have undergone limb salvage surgeries for malignant bone tumors. However, treating physicians should be very cautious because complications related with this procedure are common.

#232: Distraction osteogenesis for failed sarcoma allografts

Mark T. Dahl (USA),
Russell A. McGill

Question: To present seven cases of late reconstruction of residual sarcoma tumor defects with distraction osteogenesis. Patients with bone sarcoma allograft surgery presenting with infection, nonunion, and limb length discrepancy can have severe limb shortening and/or large bone defects. Debridement surgery for infection requires complete implant removal and extensive debridement, often with temporary antibiotic cement spacers to maintain stability and assist in control of infection. These implants are not suitable as a long term solution to the skeletal defect. Reconstruction options for such defects once infection is eradicated include; 1) repeat allograft replacement with internal fixation, 3) vascularized autologous fibular grafting with internal fixation, 4) reconstruction using tumor prostheses, 5) membrane induced repair with massive bone grafting and internal fixation, 6) distraction osteogenesis reconstruction with external fixation or internal fixation, and 7) amputation.

Methods: This is a retrospective chart and x-ray review of seven patients referred for treatment of deep infection of a segmental allograft repair for femoral or tibial sarcoma. Each patient had completed limb salvage surgery and adjunctive chemotherapy for sarcoma (four osteosarcoma and three Ewings sarcoma) before presenting to the tumor surgeon with infection. Presentation to the limb reconstruction surgeon was 2-6 years after the diagnosis of bone tumor. The reconstruction differed based on the defect size, location, bacteriology and adjacent joint involvement.

Results: No sarcomas or infections recurred. All patients are ambulatory without assistive devices at one to twenty-three years post distraction osteogenesis treatment. Each patient had staged reconstruction consisting of: 1) radical debridement of infection with complete removal of all foreign material, local antibiotic cement bead implantation, and intravenous antibiotic therapy, 2) circular external fixation until infection was eradicated. Two patients had hip fusion nonunion repair with double plating and no bone grafting. Each of these patients also had deformity correction and lengthening with circular external fixation first and later had motorized internal limb lengthening. Two patients had double level tibial bone transports of 13 and 22 cm. Three lengthening of 4, 6, and 8 cm were performed using implanted motorized lengthening nails. All patients have completed treatment and are a full weight bearing without assistive devices at follow up of 12 months to twenty-three years (mean follow up was 36 months, range 6-110 months. The mean age at limb reconstruction was 16 years (range 12-19 years). The mean total lengthening achieved was 14.4 cm (range 8- 23 cm). The mean healing index was 0.8 months/cm (range 0.4 1.5 months/cm). The length discrepancy was corrected to within 20 mm in all cases (mean 7 mm). Mechanical axis correction was within 6 degrees in all cases. Range of motion at the knee was within 10 degrees of the opposite knee in 5 of 7 cases (range 110-135 degrees with no flexion contractures measured).

Conclusion: An autologous biological solution to segmental defects resulting from infected allografts used in diaphyseal sarcoma patients can result from the use of methods of distraction osteogenesis. The limb length and deformity reconstruction can be considered a possible resource for the tumor surgeon presented with such a problem.

#234: Guided growth for correction of anterolateral tibial bow in congenital tibial dysplasia

Mark T. Dahl (USA),
Elizabeth Weber, Jennifer Laine

Question: Congenital Pseudarthrosis of the Tibia (CPT) is a rare condition affecting one in 250,000 children. It may present either as a fracture or as an incipient form known as Congenital Tibial Dysplasia (CTD). CPT cases presenting with fracture have poor union rates ranging from less than 50% with grafting and pinning, to 90% with grafting and ring fixators, yet any union achieved may be tenuous, and plagued with refractures, deformity, LLD, and ankle stiffness. The incipient (CTD) form may progress to a fracture despite bracing. Even if the tibia does not fracture, the deformity may lead to permanent foot and ankle deformity. Elective tibial-fibular osteotomy may lead to nonunion. A method to avoid a fracture by preventative correction is desirable. We report five cases of ankle alignment correction using guided growth in Congenital Tibial Dysplasia.

Methods: This is a retrospective, case series with chart and x-ray review. Five patients diagnosed with anterolateral bow of the tibia and congenital tibial dysplasia was treated with an anterolateral distal tibial guided growth plate until neutral mechanical axis was achieved. A 15 mm incision used and 8-plate inserted on an outpatient basis. No immobilization was used other than the previous ankle foot-orthosis (AFO). Each case required exchange plating in mid-correction, as the distal epiphyseal screw began to approach physeal contact.

Results: In each case, frontal plane ankle and tibial mechanical alignment was corrected to neutral. No fractures or growth arrest occurred, and no deformity recurred. Each tibia and fibula showed increasing corticalization, remodeling, and recanalization over time.

Conclusion: Anterolateral bow of the unfractured tibia associated with neurofibromatosis, Congenital Dysplasia of the Tibia, was corrected by guided growth of the distal tibia. The technique corrects the distal tibial joint alignment. This technique does not address the underlying bone pathology, but improvement in cystic changes and increased cortilization occurred in each case. Further long term follow up will help clarify the role of this simple intervention in prefracture Congenital Tibial Dysplasia.

#235: Bioexpandable Prostheses after resection of malignant tumors in children

Rainer Baumgart (Germany)

Expandable endoprostheses could be an option after resection of malignant bone tumors of the lower extremities in children and adolescents not only to bridge the defect but also to overcome limb length discrepancy. To achieve equal limb length at maturity new concepts of expandable endoprosthesis are now available. Which results can be expected?

Methods: One option is to lengthen the prosthesis with an internal power unit but especially in cases of a huge demand of lengthening the relationship from prosthesis to the remaining bone becomes worse. As consequence a new idea was to lengthen not the prosthesis but the remaining bone as it is performed frequently in cases of congenital or posttraumatic limb length discrepancies. Both systems (MUTARS Xpand and MUTARS BioXpand, implantcast, Buxtehude, Germany) are equipped with a motor drive which gets its energy wireless from outside by electromagnetic waves. After surgery the skin is closed completely. In case of bone lengthening with the bioexpandable endoprosthesis, the relationship of the prosthesis length compared to leg length develops in favour of the remaining bone.

Results: 5 patients (3 male, 2 female) were treated with the BioXpand. In 4 cases the femur and in 1 case the tibia was lengthened after resection of an osteosarcoma (3) or an Ewings-sarcoma (2). The mean age of the patients was 16,8 years and the mean amount of lengthening was 78 mm. In all cases limb length equality could be achieved, in one case lengthening was performed in 2 steps. There was no infection and lengthening could be finished in all cases. The bone regenerate in the tibia case was poor so that bone grafting had to be performed from the iliac crest. In one cases a temporarily contracture of the knee joint was observed which recovered completely after finishing lengthening. In one case a breakage of the nail occurred 2 years after lengthening just before the replacement to the final prosthesis was planed.

Conclusion: The bioexpandable prosthesis is a favourable option for children after tumour resection. The device is safe and offers the same advantages as in congenital or posttraumatic shortenings and better long term stability of the prosthesis can be expected. The small diameter and the length of the remaining bone as well as stress shielding are basic problems; also the repeated operative interventions are a challenge for further developments

#236: Bone reconstruction after malignant tumour in adolescents using a bone transport and lengthening motorized intramedullary nail

Franck Accadbled (France),
Camille Thevenin Lemoine, Jrme Sales de Gauzy

Question: Bone reconstruction after excision of malignant bone tumour of the limbs remains a challenge. The Fitbone* fully implantable intramedullary motorized nail has provides satisfactory results in limblengthening according to the literature. We aimed at evaluating this device as a transport and lengthening nail.

Methods: Three male adolescents aged 12, 13 and 15, diagnosed consecutively with osteosarcoma of the distal femur, underwent large epiphyseal-sparing bone excision (respectively 13, 21 and 24 cm). The first step of reconstruction combined the use of a methyl methacrylate spacer and a femoral locking nail allowing to bear weight. The second step was performed and average 8 months later, when chemotherapy was over. In 2 cases it consisted in large cancelous bone auto and allografting (Induced membrane technique). Subsequent non union and length discrepancy were managed in a third step using a transport and lengthening nail. The third case was managed with a transport and lengthening nail and a 4 cm allograft of the distal metaphysis as the second step.

Results: Bone transport was 6,3 and 4 cm, followed by 4 cm bone lengthening in the 2 last cases. Bone union was obtained in all 3 cases after an average 10 months (Healing index 50 days/cm). One patient required a nail exchange then a further bone autograft. One patient had a locking screw replaced.

Conclusion: Bone transport and lengthening using the fully implantable Fitbone* intramedullary motorized nail provided satisfactory and encouraging preliminary results in this challenging situation.

#237: Treatment Of Legg-Calve-Perthes. Comparative Study Between Arthrodiastasis And Intertrochanteric Osteotomy And Fixation With Plate And Screws.

Nuno Craveiro-Lopes (Portugal),
Carolina Escalda.

Question: The late onset Perthes disease usually has a poor prognosis. It is common to see a patient with increased pain, decreased range of motion and a lateral subluxation of a collapsed femoral head, called "hinged hip ", which is a contraindication for classic containment by femoral varus osteotomy or pelvic osteotomy. In those cases, hip arthrodiastasis can be a valuable tool for treatment. In this paper the authors compare the results of a group of 14 patients treated by arthrodiastasis with Ilizarov fixator (ADT) with a group of 11 patients treated by femoral intertrochanteric osteotomy stabilized with plate and screws (OTM).

Methods: The ADT group was treated between 2000 and 2010 and consisted of 11 boys and three girls . Mean follow-up was 5 years. The OTM group consisted of 10 boys and 1 girl and was operated between 1979 and 1989, with a mean of 6 years. To proceed to the arthrodiastasis, we used a external fixator with 2 Ilizarov arches fixed with three 4.5 mm pins in the supra-acetabular zone and three in the proximal femur , maintaining a joint distraction of 8-10 mm for an average of 4 months. Patients were subject to arthodiastasis on average 6 months after TNHT (4 to 9) and used the fixator for an average of 13 weeks (10 to 16). The intertrochanteric osteotomy and plate fixation technique included a varus, flexion and medial rotation effect of the proximal segment, and was stabilized with a blade-plate for children (Synthes).

Results: The difference between the severity of injury in both groups, in all cases Herring group B and C, was not statistically significant (P = 0.33), the operative time was statistically much lower in the ADT group (P < 0.0005), with an average of 28 minutes (20 to 40) compared with an average of 60 minutes (45 to 70) on the OTM group, as well as the blood loss, with an mean of 64.4cc on the ADT group (30 to 100) and 650cc on the OTM group (300 to 900). Time until walking with crutches, was also statistically very different, being lower in the ADT group, with a mean of 3 days (2 to 4) than in the OTM, on average 42 days (35 to 56). Patients were subject to arthodiastasis on average 6 months after TNHT (4 to 9) and used the fixator for an average of 13 weeks (10 to 16). Epiphyseal Index of the ADT group had mean value of 40% (25 to 41) and the OTM group, 31% (20 to 39.7), values that were statistically different (P = 0.013). The cervical index mean values for the 2 groups were 101% (67 to 191) and 97% (68 to 123) respectively, this difference was statistically not significant (P = 0.39). The epiphyseal angle, however, showed values with significant statistical difference (P = 0.03). The ADT group had a mean of 61° (42 to 80) and the OTM group, 49°(31 to 72). The mean acetabular angle showed also statistically significant differences in the 2 groups (P = 0.04), with 12° (7 to 15) and 16° (8 to 28) respectively. The angle of Wiberg (center-edge), had not statistically different values (P = 0.17), with 16° (13 to 28) and 20° (5 to 40) respectively. Measurement of leg length discrepancy showed a difference on the 2 groups, statistically very significant (P = 0.001), with the ADT group with residual leg length discrepancy of mean 0 mm (+8 to -9) and the OTM group with -21 mm (-10 to -38). 5 of those patients presented more than 20 mm of leg length discrepancy. The percentage of cases equal or greater than Stulberg type III in the ADT group was 20%, (two cases), while in the OTM group was 54% (six cases), with a statistically significant difference (P = 0.024). In all the patients that underwent arthodiastasis, the frame was removed in an outpatient basis with a mild sedation. The only problems encountered were superficial infections of the pins in 2 cases, treated with proper wound care and oral antibiotics at the outpatient clinic. All the patients in the group that underwent osteotomy required a second major procedure for hardware removal, under general anesthesia at the central operating room, with a mean stay in ward of 3 days. In this group, there were complications in 4 patients: 2 patients had a exaggerated varus osteotomy resulting in a limping gait, one case with Trendelenburg gait due to severe leg length discrepancy, coxa vara and breva, and one case of deep infection that required hospitalization for intravenous antibiotics and hardware removal at 8 weeks of the initial procedure, with healing of the infection. Final functional evaluation: The evaluation of the final functional outcome by the Harris Hip Score, showed for the ADT group an average score of 98% (96 to 100) and for the OTM group, 94% (88 to 100), values with statistically significant differences (P = 0.017).

Conclusion: This study demonstrated, with evidence based data that the ADT group: Had presented better congruence and sphericity of the femoral head. Showed less residual sequels, namely less varus deformity, Trendelenburg and leg length discrepancy. Had better functional assessment, using the "Harris Hip Score". Showed no complications or sequels that required new interventions in the short or medium term. The surgical procedure was faster, without blood loss, patients walked with weight bearing earlier and did not required a second surgery for removal of implants.

#238: Tibiotalocalcaneal fusion in bone reconstruction

Lukas Zak,
Gerarld E. Wozasek


#239: In vitro and in vivo evaluation of bone formation using solid freeform fabrication-based bone morphogenic protein-2 releasing PCL/PLGA scaffolds

Kyu-Sik, Shim (Republic of Korea)
, Tae-Hoon Kim, Young-Pil Yan, Sung Eun Kim, Hae-Ryong Song

Question : To test whether or not there are significant enhancements in bone formation upon the use of PCL/PLGA scaffolds those are capable of releasing BMP-2 growth factors at a sustained rate.

Method : We immobilized hep-DOPA conjugate onto the PCL/PLGA scaffolds before loading them with the growth factor, BMP-2. The Hep-DOPA increases the bonding affinity of BMP-2, allowing for the scaffold to hold the BMP-2 for a longer duration.

Results : The characterization and surface elemental composition of all scaffolds were evaluated by scanning electron microscope and x-ray photoelectron spectroscopy. The osteoblast activities on all scaffolds were assessed by cell proliferation, alkaline phosphatase (ALP) activity and calcium deposition in vitro. To demonstrate bone formation in vivo, plain radiograph, micro-computed tomography (micro-CT) evaluation and histological studies were performed after the implantation of all scaffolds on a rat femur defect. HepDOPA/PCL/PLGA had more controlled release of BMP-2, which was quantified by enzyme-linked immune sorbent assay, compared with Hep/PCL/PLGA.

Conclusion : This study demonstrated that HepDOPA/PCL/PLGA scaffolds gave more controlled release of BMP-2 compared with Hep/PCL/PLGA scaffolds. BMP-2/HepDOPA/PCL/PLGA scaffolds had enhanced osteoblast activity in vitro as well as bone formation/mineralization in vivo. Thus, this study suggested that a BMP-2-eluting HepDOPA/PCL/PLGA scaffold system would be a good and promising platform to develop the next generation of scaffolds for regenerating bone defects in the field of orthopedics.

#240: Can combined therapy with teriparatide and low-intensitypulsed ultrasound accelerate fracture healing with an Ilizarov externalfixator?

Koji Nozaka (Japan),
Yoichi Shimada, Naohisa Miyakoshi, Shin Yamada, Hidetomo Saito, Hiroaki Kijima

Question: Ilizarov external fixators have many advantages in the treatment of fractures. However, a disadvantage of the Ilizarov system is the relatively frequent incidence of pin infection. It is an advantage for orthopedic surgeons to remove an Ilizarov external fixator as early as possible after surgery. Although both teriparatide and low-intensity pulsed ultrasound (LIPUS) have been found to accelerate fracture-healing processes, the effect of the combination of teriparatide and LIPUS in clinical bone fracture management remains unclear. Therefore, a retrospective study comparing the treatment effects of use of an Ilizarov external fixator alone and that of an Ilizarov external fixator combined with teriparatide and LIPUS was performed among elderly patients with lower limb fractures.

Methods: From among 721 patients with a lower limb fracture on admission to our department who underwent surgical treatment for a lower limb fracture with an Ilizarov external fixator, 38 patients 60 years old were investigated. Patients were either treated with an Ilizarov external fixator alone (IEF alone, n = 20) or an Ilizarov external fixator combined with teriparatide and LIPUS (IEF combination, n = 18). The patients mean age was 64.1 years (range, 6079 years) in the IEF alone group and 67.2 years (range, 6083 years) in the IEF combination group. Teriparatide (20 g subcutaneous injection daily or 56.5 g subcutaneous injection once-weekly) and LIPUS (20 min/day) were started immediately after surgery for IEF combination group in an attempt to accelerate healing of the lower limb fracture with the Ilizarov external fixator.

Results: The mean duration of union was 111.9 days (range, 94175 days) for IEF alone and 72.1 days (range, 68141 days) for the IEF combination; it was significantly shorter with the IEF combination.

Conclusion: In elderly patients with lower limb fractures, combined therapy (teriparatide and LIPUS) showed a shorter mean duration of union than the Ilizarov external fixator alone. Combined therapy with teriparatide and LIPUS may become a useful option in the treatment of elderly patients with lower limb fractures.

#241: Validation of the multiplier method on a large contemporary European cohort and an assessment of the effect of physiological age on the multiplier physiological age?

James Aird (UK),
Fergal Monsell, Caroline Cheesman

Question: How accurate is the LLM (Leg length multiplier) and THM (total height multiplier) in predicting growth in the lower limbs in females. Is there anyway of improving the accuracy.

Methods: Using the ALSPAC (Avon Longitudinal Study of Parents and Children of the 90s) dataset we determined the accuracy of the Paley multiplier for predicting total height and leg length, and assessed whether if the date of first menses increased the accuracy of the multiplier. Female patients over the age of 8, with documented final height and final sub-ishial leg length over the age of 15 and a date of first menses were evaluated. Predicted final height was compared with actual final height at all data points. Males were excluded due to a shortage of high quality data above the age of 16

Results: There were 28332 data points in 3062 girls prior to skeletal maturity in the total height cohort and 8395 data points in 2300 girls in the leg length cohort. The average error in prediction depended on the time of assessment, and varied from 2.2 cm at age 7 to 1.3 at age 14, standard deviations ranged form 2-3. Correcting for skeletal age based on menarche, did not improve the accuracy however correcting for half the difference between skeletal age and chronological age did lead to an improvement in accuracy. A comparison of 2 patients of different chronological age but same physiological highlights why a full correction is inaccurate.

Conclusion: The accuracy of the multiplier only improves slightly as a child ages, it is therefore a very useful tool for planning a strategy for dealing with a leg length discrepancy in a children aged 4 to 8. For example, whether a patient need two lengthenings or 1 lengthening and epiphysiodesis. However when considering an epiphysiodesis it is important to appreciate that the multiplier can give significant errors, and it is important to have a strategy to deal with unexpected growth. The improvement seen when correcting for menarche, suggests that we can improve accuracy using skeletal age. This may improve the accuracy of the use of epiphysiodesis, however it does not remove the need for careful monitoring, and consideration of contralateral epiphysiodesis if required.

#242: Factors affecting torsional deformities treatment with the Ilizarov method.

Piotr Morasiewicz (Poland),
Jaroslaw Filipiak, Szymon Dragan, Wiktor Orzechowski

Question: Question was to determine clinical factors affecting torsional deformities treatment with the Ilizarov method. One of the many uses of the Ilizarov fixator is for torsional deformities correction. Rotational and translational bone displacement related to torsional deformities correction includes the additional tension stresses, which affect the biology of the regenerated bone. Understanding the clinical factors will assist in designing the optimal treatment strategy, thus possibly improving the outcomes.

Methods: It was case series retrospective study. The study examined 56 patients. The mean follow-up time was 5 years and 6 months. The mean age at the start of treatment was 19 years and 10 months. Patients underwent derotational corticotomies of distal metaphysis of the femur or proximal metaphysis of the tibia using the Ilizarov method. In these patients, following derotational corticotomies with the Ilizarov method, numerous variables were defined and their effect evaluated: the selected treatment strategy, the rate, size, type, and level of derotation on complications, the alignment index, the correction coefficient, the elongation index, and deformation correction factor.

Results: The differences in the values of alignment index and deformation correction factor in this study subgroups were not statistically significant. We found differences in the elongation index and correction coefficient in a number of subgroups.

Conclusion: In the case of correcting torsional deformation without significant elongation, acute correction and with a value of 30&#9702; does not significantly affect the results. Treatment strategy, type and level of derotation had no major influence on torsional deformities treatment.

#243: Does Patient Compliance with Weight Bearing Restrictions Improve with the use of Mobile Continuous Force Plate Measurement?

S. Robert Rozbruch (USA),
David C. Goral, Henry Daniecki

Question: Previous studies have demonstrated that orthopaedic inpatients ability to accurately reproduce partial weight bearing is poor. When told to perform partial weight bearing, patients tend to significantly overestimate how much weight they are putting on their leg. This can overload the bone during fracture and osteotomy healing and lead to failure and nonunion. While biofeedback does facilitate accurate training for partial weight bearing, the effects last only as long as feedback is available. We developed a customized thin film sensory insole (Soleforce) which is placed inside the footwear of a patient to register forces transmitted through a lower limb to provide continuous biofeedback for actual weight bearing with each step. Does patient compliance with weight bearing restrictions improve with the use of mobile continuous force plate measurement?

Methods: This sensory insole is connected via one connection to a small Foot Mounted Control Module (FMCM) and is mounted on the top surface of the footwear on the foot. The patients maximum allowed force (weight per step) is inputted into the device via a simple push button before use. As a patient takes a step, the FMCM interprets the input force the patient applies, and outputs this force to the user in real time. There is a display that displays the weight applied, as well as a linear array of lights that progressively illuminate based on the amount of force applied. As the user approaches their desired force target, the lights illuminate incrementally to guide the user to their goal. If the patient exceeds the maximum, warning lights illuminate as well as an audible alarm notifying the patient they have exceeded the maximum. Each and every step is stored in the FMCM for review at a later time. The information was uploaded to a computer. We prospectively evaluated 21 patients who had partial weight bearing restrictions after orthopedic surgery. Patients walked 20 steps with 2 crutches using Soleforce without feedback followed by 20 steps with feedback , and these were compared. The precision value was calculated utilizing an average force per step method. The maximum weight applied in each step was averaged to obtain an average force per step value, which was compared to the desired weight range and expressed as a percentage.

Results: The precision index improved from 0.57(range, 0-1.04) to 0.09 (range, 0-0.71) with feedback. With biofeedback, the average force per step improved from 57% to 9% away from the desired range. The proportion of patients who were within 25% of the allowed weight range improved from 10% to 95% with biofeedback. Furthermore, with feedback, 86% of the patients experienced a greater than 70% improvement in accuracy for being in the prescribed weight range.

Conclusion: Biofeedback using the Soleforce leads to improved precision for adhering to weight bearing restrictions. This should improve safety by empowering the patient to be more compliant with the physicians weight bearing prescription. Further research to test a larger number of subjects for longer periods of walking is underway.

#244: The Multiplier Method for Predicting Limb Length Discrepancy in Patients with Vascular Anomalies in the Lower Limb

Aresh Sepehri (Canada)
, Harpreet Chhina, Douglas Courtemanche, Anthony Cooper

Question : Patients with vascular anomalies of the lower limb will often demonstrate varying degrees of limb length discrepancies (LLD) at an early age that progresses until skeletal maturity. Klippel-Trenaunay syndrome is one type of vascular anomaly that has proven to be quite aggressive and can result in limb length discrepancies as large as 10 cm, although this is not always the case. In fact, vascular anomalies are highly variable in their effects on limbgrowth. Thus regular monitoring throughout childhood and the use of limb length discrepancy prediction tools are essential in the care of patients with lower limb vascular anomalies. The Paley Multiplier Method is a tool for predicting limb length and limb length discrepancy in patients that exhibit a Shapiro type one growth curve: upward slope pattern at a constant and proportionate rate. Due to the many mechanisms in which vascular anomalies affect limb growth, growth in the setting of a vascular anomaly is poorly characterized. Shapiro has observed vascular anomalies displaying growth patterns consistent with type one, two and three, while Lee et al. in their study have categorized vascular anomalies as type one. Orthopedic intervention often depends on the extent of limb length discrepancy at skeletal maturity. Thus the ability to accurately predict limb length discrepancy should allow for more confident prediction of the type and timing of orthopaedic intervention. To the best of our knowledge the Multiplier Method has not been formally tested in individuals exclusively with limb length discrepancy secondary to vascular anomalies. Our study aimed to answer the question: can the Paley Multiplier Method effectively predict leg length and leg length discrepancy at skeletal maturity for patients with a vascular anomaly of the lower limb?

Method : A retrospective review was performed from existing data from charts in the Vascular Anomalies Clinic at BC Children Hospital. Thirty-eight patients with a lower limb length discrepancy secondary to a vascular anomaly were identified. The age, limb lengths and discrepancy were recorded from each clinic visit (range two to eight visits, average 3.4). Predicted values for limb length and limb length discrepancies were calculated from earlier visits and compared to the more recent clinic visit measurements. The mean error was calculated for all patients by taking the average of the absolute values of the difference between the predicted values and actual measurements. The mean error was calculated for limb length and LLD predictions. The correlation between the actual and predicted limb lengths, as well as paired t test calculations between actual and predicted limb length discrepancies were performed to determine whether the Paley Multiplier Method could accurately predict the limb length discrepancy at future visits.

Results : When the Paley Multiplier Method was used to predict leg lengths for affected limbs, the predicted values were highly correlated with the actual measurements (R = 0.974). The average error in affected limb length predictions was 2.26 cm, with 83.3% of predictions being within four cm. However, it was observed that 70.1% of the predicted values over-estimated limb length (range 0.01-10.66 cm, average 2.51 cm). Despite this, the error in the affected limb was highly correlated with the error in the unaffected limb (R = 0.908). That is, when the Multiplier Method over-predicted leg length in the limb affected by a vascular anomaly, it over-predicted leg length in the unaffected limb as well. In addition, the mean error for the unaffected leg length predictions is 2.10 cm, comparable to the affected limb length error (See Table 1). The predicted limb length discrepancy, when compared to actual measurements, had a mean error of 0.66 cm, with 80.5% of predictions within one cm. Paired t test showed the difference in the predicted and actual LLD were insignificant (P = 0.122). The predicted LLD overestimated the discrepancy in 56.6% of cases. Similar results were found in patients specifically with KTS, where the predicted LLD, with a mean error of 0.69, showed no significant difference to the actual LLD (P = 0.187) (see Table 2).

Conclusion : Our study results show that the Paley Multiplier Method overestimates the leg length in both affected and unaffected limbs. However, due to the high correlation in error between the unaffected and affected limbs for length predictions, the error in the limb lengths did not affect the ability for the Multiplier Method to predict limb length discrepancy. Limitations to our study include a small sample size, the manual measurement of leg lengths rather than leg lengths calculated from CT imaging, and having only a few measurements at skeletal maturity. Ongoing data collection of new patients and current patients to skeletal maturity is required, but from the results collected, we conclude that the Multiplier Method is reliable and accurate in predicting leg length discrepancy for patients with a vascular anomaly of the lower limb.

#245: The double-line grid for intraoperative control of the Mikulicz-line

Rainer Baumgart (Germany),
Tillmann Baumgart

Question: Preoperative planning is mandatory to perform deformity corrections especially if internal devices are used. The question is how to transpose the planning to the patient on the operation table accurately. The cable of the electrocautery is very improper due to a high parallaxes failure. What can be an easy and cost effective alternative?

Methods: The Double-Line Grid is a plate with a thickness of 3 mm which can be placed on the operation table. It has the dimensions of 1282 × 376 mm while inside of the plate is a radiopaque grid with a line spacing of 50 × 50 mm. Two lines in the middle at a distance of 200 mm are double lines to improve the longitudinal orientation because with the image intensifier only a small sector is visible. Due to the fact, that the rotation of the hip joint is of great importance, the leg has to be moved in the correct rotated position and should not be moved during the measurements. Usually the patella is faced forward. The rotation should match the preoperative planning in frontal plain. The generator of image intensifier is positioned parallel to the operation table, allowing an orthogonal movement of the C-Arm in relation to the operation table. Depending on the side which has to be examined the right or rather the left double-Line has to be placed exactly into the center of the screen on the hip level by moving the C-Arm. After that the patient is moved until the femoral head is centrically placed on the Double-Line. The image intensifier is moved now parallel to the operation table to the level of the ankle. If the C-Arm and the generator is correctly placed (like described above) the Double-Line should be again approximately in the center of the screen. If not, small corrections can be made by adjusting the slide of the C-Arm. Now the ankle is also placed centrically on the Double-Line without changing the rotation of the leg. The last step is to verify the position of the knee. Therefore the image intensifier is moved now backwards parallel to the operation table to the knee joint, so that the Double-Line stays in the center of the screen. The position of the knee joint in relation to the Double-Line is evaluated.

Results: The Double-Line Grid was used in our Center successfully since 10 years in more than 1500 cases in the way described mostly for deformity corrections using the FITBONE-Device. The following sources of error were identified: The C-Arm (and the X-ray) is not vertical to the Grid-Plate The Double-Line is not in the center of the screen for each measurement The limb was moved during the measurement The limb was rotated during the measurement

Conclusion : If used in the right way, the Double-Line Grid is an accurate and cost effective tool to verifying the course of the Mikulicz-Line with an image intensifier during operative deformity correction. A smaller version (1282 × 186 mm) is available for the use on a trauma table where one leg is positioned aside

#246: Can Na18F PET/CT be used to study bone remodeling in patients with Taylor Spatial Frames

Henrik Lundblad (Sweden),
Gerald Q. Maguire Jr., Henrik Olivecrona, Cathrine Jonsson, Hans Jacobsson, Marilyn E. Noz, Michael Zeleznik, Lars Weidenhielm, Anders Sundin.

Question: Can Na18F PET/CT be used to study bone remodeling in patients with Taylor Spatial Frames?

Method: In all patients, the PET/CT volume alignment could be performed and was visually checked both by using coronal, sagittal, and axial projections (viewed side by side or superimposed) and by superimposing the two 3D volumes (viewed as 3D isosurfaces).

Result: The Na18F PET/CT examinations provided morphological as well as quantitative information regarding regional bone turnover (20, 21) that has a potential to substantially shorten ineffective treatments by earlier detection of a probable nonunion and may provide a means to monitor the distraction rate in bone lengthening.

Conclusion: To our knowledge this is the first study showing that Na18F PET/CT is applicable to assess treatment progression in patients being treated with a TSF.

#247: The Features of Organotypic Remodeling of Distraction Regenerate in Sequential Use of External Fixation and Intramedullary Nailing in Experiment (preliminary report)

Elena A. Shchepkina (Russia)
, Georgy I. Netylko, Leonid N. Soloin, Ivan V. Lebedkov

Question : To compare organotypic remodeling of distraction regenerate in the lower leg lengthening in rabbits by Ilizarov and in Sequential Use of External Fixation and intramedullary nailing (SEFaN) osteosynthesis.

Method : 36 rabbits Chinchilla were used for the experiment. In the control group after assembling the frame osteoclasy of the tibia was performed. Lengthening started on the 5 th day after the surgery and the rate of lengthening was 0.25 mm x 4 during 10 days. The fixation period was 30 days. In the experimental group was performed a modeling of SEFaN. For this after finishing of lengthening through an incision of 0.7 cm in the knee joint inside the medullary canal injected intramedullary wire 2 mm in diameter (that corresponds to the narrow part of the medullary canal of the tibia) to the level of distal ring of the frame. While insertion of this intramedullary wire the wires from the reductionally-fixing rings were removed. After x-ray control intramedullary wire was cut close to bone at place of insertion. The wires in basic rings were not removed as imitation of locking. The fixation period was 30 days. The x-ray control was performed on the 5-15-30 days of fixation.

Results : In the control and experimental groups to the 30 days of fixation in the regenerate site the cortical layer was formed along the entire circumference. According to the CT data the density of the cortical bone of regenerate corresponded to the density of the cortical layer of the bone in the adjacent zones, both in the control and the experimental group. The diameter of regenerate in the control group was 0.9-1.0 cm and 1.0-1.1 cm in the experimental group. The thickness of the cortical layer in the control group was 2 mm, in the experimental group - 3 mm. In the experimental group compared to control group in the entire circumference around the regenerate was present the area of periosteal regeneration with the length of 2.5-3 cm. In morphological study of the experimental group also clearly was identified the area of periosteal bone formation, which was not found in the control group. Around the intramedullary fixator was formed the capsule, between which and cortices during all the period of the study remained the area of endosteal bone formation along the entire length of the regenerate.

Conclusion : With this method of modeling of Sequential Use of External Fixation and intramedullary nailing was found the formation of periosteal osteogenesis with length exceeding the length of the regenerate in 3 times. Formation of cortical layer in density and morphological picture had no significant differences in comparison with the control group. Around the intramedullary fixator remained the area of endosteal bone formation along the entire length of the regenerate.

#248: The Correlation of Lower Extremity Proportions and Osteoarthritis

Douglas S. Weinberg (USA),
Raymond W. Liu

Question: When individuals with asymmetric lower extremities present for evaluation of limb length inequality, correction can occur at the tibia, femur, or in both bones. The aim of this study is to examine the normal ratio of tibia length/femur length and its relationship between osteoarthritis of the spine, hips and knees.

Methods: Bone lengths of 1,152 cadaveric femora and tibiae from the Hamann-Todd osteologic collection were measured. Each femur was measured from the superior aspect of the femoral head to the femoral condyles. Tibiae were measured from the lateral tibial plateau to the lateral tibial plafond. Degenerative disease was graded from 0 to 6 for the hip and knee, and from 0 to 4 for the spine. Specimens with obvious fracture, infection, or rheumatologic conditions were excluded from study. Correlations between the ratio of tibia/femur length and osteoarthritis were evaluated with multiple regression analysis.

Results: The average ratio of tibia to femur length (T/F), was 0.80 0.03. The average patient age was 56 10 years. There were 78 females and 498 males, 176 African-Americans, 398 Caucasians, and 2 other ethnicities. There was a strong correlation between age and arthritis at all sites, with standardized betas ranging from 0.44 to 0.57.

Conclusion: Increasing tibia length relative to femur length was found to be a significant predictor of ipsilateral hip and knee arthritis. Therefore, we recommend that when performing limb lengthening, surgical planning should lean towards recreating the normal ratio of 0.80. In circumstances where one bone is to be over-lengthened relative to the other, bias should be towards over-lengthening the femur. This same principle can be applied to limb-reduction surgery, where in certain circumstances, one may choose to preferentially shorten the tibia. This is the first study to report long-term consequences of lower-extremity segment disproportion.

#249: Do We Have to Tension Wires? A Biomechanical Study of Circular External Fixation using a Hindfoot Model.

Lane Wimberly (USA),
Lise Leveille, MD, David Ross, Bill Pierce, Mikhail Samchukov, Alex Cherkashin

Question: Thin tensioned wires used in circular external fixation for limb lengthening and deformity correction are well tolerated in the hindfoot; however, the placement of the wires may prolong surgical time, increase frame complexity, and cause frame deformation. The purpose of this study was to determine whether an increase in wire diameter can provide comparable stiffness in a foot model under axial (AX) compression, anterior-posterior (AP) bending (simulating dorsiflexion/plantar flexion), and medial-lateral (ML) bending (simulating pronation/supination) loads and eliminate the need for wire tensioning. We hypothesize that non-tensioned 2.8 mm diameter wires will be comparable in stiffness to tensioned 1.8 mm diameter wires.

Methods: A simulated foot model circular external fixator was constructed using a double row aluminum foot plate closed anteriorly with a half ring. A 38 mm diameter Delrin cylinder was used to simulate a foot. Four different frame configurations with differing calcaneal fixation were tested: 1) two crossed 1.8 mm diameter tensioned wires, 2) two parallel 1.8 mm diameter tensioned wires, 3) two crossed 2.8 mm non-tensioned wires, and 4) two parallel 2.8 mm diameter non-tensioned wires. The simulated forefoot was stabilized using a 4 mm diameter half pin. Each wire configuration was tested for five cycles under AX, AP bending, and ML bending loads. The linear region of the load-displacement curves were analyzed and average stiffness was calculated for each frame configuration in each loading mode.

Results: In all loading modes [Table 1], crossed and parallel frame configurations with two non-tensioned 2.8 mm diameter wires had statistically greater stiffness than the 1.8 mm diameter tensioned wire frame configurations.

Conclusion: Two non-tensioned 2.8 mm diameter wires provide significantly increased stiffness than two tensioned 1.8 mm diameter wires in axial compression, AP bending and ML bending. While these measures are statistically significant, the absolute measured difference in stiffness is unlikely to be of clinical significance. As such, the use of 2.8 mm non-tensioned wires may be clinically comparable for hindfoot fixation to 1.8 mm tensioned wires and reduce surgical time and complexity. Clinical relevance of the measured biomechanical differences should be tested.

#250: Biological regeneration of prolapse disc using spine Ilizarov under local anaesthesia

Ram Avtar Agrawal (India),
Rajat Agrawal

Question: Current treatment options in prolapse disc are excision of prolapse disc or disc replacement. But this is not an ideal treatment. Treatment should be to repair and regenerate the pathology. Is there any treatment by which we can repair or regenerate the prolapse disc instead of excising it ?

Methods: Ilizarov being a versatile fixator has been applied in Spine, one of the very few studies done in the world to the authors knowledge. Patient inclusion criteria was prolapse disc L4-L5 or L5-S1 with no significant clinical improvement by conservative treatment for 3 months. 5 mm pins under double C-Arm for simultaneous AP and Lateral view are applied in 14 patients in the pedicles percutaneously. 2 pins were applied in L4 and L5 each in L4-L5 prolapse disc and in L5 and S1 in L5-S1 disc prolapse. Distraction was done at the rate of 1 mm/day for an average of 10-12 days. Continuous neurological monitoring is done of the patient. Patient is asked to walk and do all daily activities throughout the procedure. To lie down supine, a square cut for the Ilizarov fixator is made in a thick foam in the bed. Spine Ilizarov is applied for an average 9 weeks.

Results: Clinical grading of radiating pain in lower limbs and backache were done a scale of 1 to 10. On day 1 as soon as fixator is applied and there is increase in spinal canal area even by 1-2 mm due to distaction, there is significant improvement in the radiating pain and backache. Pain grading improved continuously with continued distraction.

Conclusion: It is hypothesized that distraction causes mechanical offloading of the disc for an average of 9 weeks. Offloading gives the disc a chance to repair and regenerate which is seen as increased hydration in T2 images in MRI. The exact mechanism is not known but there is a definite clinical improvement in patients. This is one of the very few studies done till now and it is expected that further research will be done by many centers in the world to prove or disapprove the hypothesis.

#251: Use of external fixator for 5 th metatarsal basilar fracture

James C Wang (USA)

can external fixation be used for 5 th metatarsal base fractures.

Methods: by using external fixation for large avulsion fractures and jones fractures.

Results: good joint alignment and no non unions without immobilizing the foot and leg and allowing patients to walk right away.

Conclusion: that external fixation is a viable method to allow pts to walk right away without jeopardizing their result.

#252: Use of circular external fixation for tibial calcaneal fusions in charcot reconstruction

James C Wang (USA)

can circular external fixation be used in charcot salvage procedures.

Methods: yes by using it in tbial calcaneal fusions as a mean of preventing below the knee amputation.

Results : no one lost a leg in a 8 year follow up.

Conclusion: that circular external fixation should be used in charcot reconstruction

#253: Use of circular external fixation for calcaneal fractures

James C Wang (USA)

is there a better way to fix calcaneal fractures other than orif?.

Methods: using circular external fixation in a closed method to treat severe calcaneal.

Results: 48 patients underwent repair of severe calcaneal fractures without any open incisions, only one underwent stj fusion after 8 year of follow up.

Conclusion: that one should utilize circualr external fixation for severe calcaneal fractures

#254: Superior technique for brachymetarsia repair

James C Wang (USA)

Is there a better way to sx treat bracymetarsia?

Methods: By using a multi level external fixator to distract the metatarsal and the mtpj at the same time.

Results: 72 cases of brachymetarsia repair with no mtpj pathology.

Conclusion: that a multi level approach is the superior way to treat brachymetarsia

#255: New technique for treating hallux limitus utizling external fixation

James C. Wang (USA)

Is there a better way to treat hallux limitus other than deccompressive osteotomies and cheilectomy?

Methods: Focused on treating hallux limitus at the source, that being a hypermobile 1 st ray and stabilizing it and then peforming a concomitant joint distraction.

Results: 13 year follow up with 125 patients. All with improved range of motion and decreased pain.

Conclusion: That one should not treat the symptoms; at the 1 st mtpj and focus on the etiology at the 1 st metatarsal medial cuneiform joint and also performing a 1 st mtpj distraction

#256: Correction of supramalleolar deformities with an external fixator

Shuhei Ugaji (Japan),
Hidenori Matsubara, Yasuhisa Yoshida, Shogo Shinbashi, Hiroyuki Tsuchiya

Question: Supramalleolar osteotomy is a commonly used surgical procedure to correct deformity at distal tibia using internal fixators or sometimes external fixators. Anatomic specificities at distal tibia, which are less soft tissue coverage and poor potential of bone formation make supramalleolar correction different from the other site of correction. In this study we evaluated our series of supramalleolar correction and discussed the use of external fixator for it.

Methods: Corrections of supramalleolar deformities were performed in 14 limbs of 13 patients with Ilizarov external fixator (seven limbs) or Taylor Spatial Frame (seven limbs). The mean age was 22 years old (ranging 11-61). The etiologies were growth plate injury in three limbs, congenital disease in five, malunion after supramalleolar fracture in three, bone tumor in two, and malunion after ankle fusion in one. The mean angular deformity was 26.3 degrees (ranging 13-40) and one patients had a rotational malposition of 22 degrees. Acute correction was performed in 4 limbs, gradual correction in nine. Eight limbs were also needed lengthening of average 3.1 cm (ranging 1.7-4.4). The average follow-up time was 67.0 months (ranging 7.9-240).

Results: Anatomic correction was achieved in all patients without any complications. The average external fixation period (EEP) was 123 days (ranging 78-277) in no lengthening cases. The external fixation index (EFI) of lengthening cases was 83.4 days/cm (ranging 43.5-108).

Conclusion: Due to less soft tissue coverage at distal tibia, supramalleolar deformity correction using external fixator is very safe and useful method, especially for cases with complex deformity which cannot be corrected acutely or accompanying lengthening. However, from this study the EFI was much longer than our case series (n = 46) of deformity correction and lengthening at the tibial other sites (average 46.1 day/cm). Therefore it should be considered to perform lengthening at the proximal tibia while doing deformity correction with supramalleolar osteotomy.

#257: Ankle Alignment after Tibial Lengthening and Syndesmotic Fixation. A Comparison Study

Mihir Thacker (USA),
Oussama Abousamra, Maria del Pilar Duque Orozco, Kenneth J. Rogers, Christopher Iobst, L. Reid Nichols

Question: Proximal migration of the lateral malleolus can occur during tibial lengthening procedures. Syndesmotic fixation throughout the lengthening period is therefore recommended to prevent migration and any possible development of ankle valgus. The aim of this study is to compare two techniques of syndesmotic fixation in terms of preventing ankle malalignment secondary to tibial lengthening.

Methods: Records of all children with a tibial lengthening procedure, using a Taylor Spatial Frame, were reviewed. Two techniques of syndesmotic fixation were evaluated: transverse tricortical screws and oblique quadricortical screws. Only patients with tibial shortening or bowing, who had tibial lengthening of more than 20 mm, were included. Radiographs, taken before frame application and at frame removal, were reviewed. Tibial length, angular deformity, distal tibiofibular index (DTFI), proximal tibiofibular index (PTFI) and lateral distal tibial angle (LDTA) were measured. Malhotra grades, pre and post lengthening, were also recorded as was the duration of external fixation application.

Results: A total of 18 patients with 21 limbs were identified. Transverse screws were used in 15 limbs and oblique screws in 6 limbs. Age and gender distributions were similar for the two groups. There was no significant difference (p 0.05), between the two groups, in the amount of lengthening (40 mm in the transverse group and 35 mm in the oblique group), angular correction, lateral malleolar and fibular head migration, and LDTA change. External frame duration was similar as well. Comparing pre and post lengthening radiographs, significant migration.

Conclusion: Although migration of lateral malleolus was encountered in the transverse group, the amount of distal tibiofibular index change was similar to the oblique group. Moreover, no significant LDTA change was noted in either group. No advantage of one syndesmotic fixation method over the other was found in this study. Longer follow up is needed to detect any late changes.

#258: Treatment of articular fractures of the heel with external fixator: A multicenter study of 164 cases at 5 years follow-up

Tartaglia Nicola (Italy),
Corina Gianfranco, Mori Claudio, Noviello Chiara

Question: Treatment of fractures of the heel is still a controversial and much-debated subject today. Several different techniques have been used to treat complex articular or extra-articular fractures. It is widely believed that that the gold-standard is open reduction and internal fixation (ORIF) using plates and screws implanted laterally, less invasive techniques are gaining increasingly significant recognition, especially when patients show compromised soft tissues or local and/or systemic contraindications.

Methods: Since May 2009 to May 2012 authors (same protocol in five different hospitals in the South of Italy) have treated 164 complex calcaneum articular fractures with monolateral external fixator. The fractures were classified according to the Sanders fracture classification system. The Maryland Foot Score method was used to functionally evaluate the patients and x-rays and CT scans were performed at different stages of the treatment. We considered that external fixation was indicated for the treatment of Sanders type II, III and IV fractures. The procedure may be employed in patients with soft tissue disorders or general health conditions as diabetes mellitus or peripheral vascular disease. Osteoporosis was not regarded as a contraindication. Surgery was performed within 48 hours upon arrival after an x-ray and CT scan. Minimally-invasive percutaneous external fixation allowed early treatment because swelling and poor soft-tissue injury did not represent an absolute contraindication to operation. Patients were discharged within 48 hours after surgery and followed in outpatientclinic.

Results: Over a short period of time we are able to observe excellent functional results in most cases and patients were fully satisfied. None required further surgery. Clinical results were assessed at follow-up, according to the Maryland foot score, being excellent in 95 cases, good in 35, fair in 30 and poor in 4. The mean pre-operative Bhlers angle was 4 degrees avarage and the mean post-operative value was 26 degrees avarage. Regarding complications, we observed transient local post-traumatic osteoporosis, which resolved within four months, in 16 patients and 3 cases of superficial pin track infection. These were treated with local dressing and oral antibiotics for two weeks without requiring early removal of the pins. 5 cases of secondary arthritis were observed and 3 patients underwent an ankle fusion.

Conclusion: The main goal of treatment for displaced fractures of the calcaneum should be the restoration of the three dimensional structure, with emphasis on correct alignment in the coronal and axial planes and the height of the calcaneal body rather than anatomical reconstruction of the congruency of the subtalar articular fragments. The use of an external fixator appears to achieve this aim. The reduction is monitored by a stable fixation and the risk of major complications is reduced. Anatomical restoration of the subtalar joint facet is very difficult to achieve, particularly with percutaneous reduction and external fixation using two single pins to stabilize the articular fragments, as demonstrated by CT evaluation at follow-up. Some degree of stiffness and degenerative arthritis of the subtalar joint following a displaced articular fracture is usually unavoidable whatever the chosen treatment, owing to severe damage to the articular cartilage which almost always sustains high-energy axial load. The results of our series indicate that neither the subtalar mobil- ity nor the clinical outcome seem to be significantly affected by obtaining congruency of the subtalar facet when compared with the results reported with open forms of treatment which specifically aim to reduce the articular fragments anatomically, but correlate more with the results following early post-operative mobilisation and the restoration of Bhlerangle. In order to reduce the specific complications related to the external fixation, such as loose screws, infection and loss of reduction, it is important to monitor patients strictly, with weekly observations until the fixator is removed. In our series this regimen prevented early removal of the fixa- tor prior to consolidation of the fracture. Percutaneous eduction and external fixation proved to be a reliable technique for obtaining stable reconstruction of fractures of the os calcis. The clinical results appear to be comparable to those observed following open reduction and internal fixation. They are similar to a small series of calcaneal fractures treated by external fixation reported who obtained 92% of excellent and good outcomes using the Maryland foot score. The added advantages of minimally-invasive procedures are the considerably shortened operating time and hospital stay, and the reduced risk of complications related to surgical exposure. We therefore believe the surgical technique described to be an optimal solution for the treatment of calcaneum fractures.

#259: Foot deformity correction with hexapod external fixator, the Ortho-SUV Frame

Munetomo Takata (Japan),
Victor A Vilensky, Konstantin A Ukhanov, Hiroyuki Tsuchiya, Leonid N Solomin

Question: External fixators enable distraction osteogenesisand gradual foot deformity corrections. Hexapod fixators have become morepopular than the Ilizarov apparatus. The Ortho-SUV Frame (OSF), a hexapodthat was developed in 2006, allows flexible joint attachment such thatmultiple assemblies are available. We asked how large of reductioncapability the several assemblies of OSF exhibit.

Method: An artificial bone model with a 270-mm-long longitudinal foot was used. A 130-mm tibial full ring was attached 60-mmproximal to the ankle joint. A 140-mm, two-third ring forefoot was attachedperpendicular to the metatarsal bone axis. A 130-mm, two-third ring hindfootwas attached parallel to the tibial ring. A V-osteotomy, which was combinedwith 2 oblique osteotomies at the navicularcuboid bone and the calcaneus, was performed. The middle part of the foot, including the talus, wasconnected to the tibial ring. We assessed 5 types of forefoot applications and 4 types of hindfoot applications. The range of correction includedflexion/extension in the sagittal plane, adduction/abduction in thehorizontal plane, and pronation/supination in the coronal plane. Additionally, we reported the short-term results in 9 clinical cases.

Results: The forefoot applications in which the axis of theexapod was parallel to the axis of the metatarsal bones had good results, with 52/76 for flexion/extension, 48/53for adduction/abduction, and 43/51for pronation/supination. The hindfoot applications in which the hexapodencircled the ankle joint also had good results, with corresponding valuesof 47/58, 20/35, and 28/31. Clinically, all deformities were corrected asplanned.

Conclusion: Multiple assemblies and wide range ofcorrections are available with the OSF.

#260: Reconstruction of the osteoarthritis of the ankle joint after low tibial osteotomy

Motoyuki Takaki (Japan)
, Tsukasa Teramoto, Nobuyuki Takenaka, Narutaka Kato, Shota Harada, Takashi Matsushita

Question: The 50 years old women suffered from theosteoarthritis of the ankle joint. She had treated by low tibial closed-wedgeosteotomy 6 years ago at another hospital. Her tibia showed 20 degree valgusdeformity and 24 degree anterior apex deformity. Her fibula was osteotomizedand not united.

Methods: Since 1994, we treated the patients of theosteoarthritis of the ankle joint (ankle OA) with distal tibial osteotomy (DTOO). We think that the instability of the ankle joint is important factor of the cause of the ankle OA. DTOO is the osteotomy designed by Tsukasa Teramoto MD for improving stability of the ankle joint. Following our experiences of DTOO, we planed the osteotomy to improve stability for the patient. The tibia was osteotomized at deformity site, and realigned. The fibula was reduced by traction with ilizarov (we called Otsuka method). At this time the ankle joint was stabilized, we checked the stabilityby stress imaging. We fixed by ilizarov external fixator. 2 months after first operation, we perform the patient fibular osteotomy and then bone transported. 1 month later, fibular docking operation was performed. Ilizarov external fixator was removed after the osteotomy site of the tibia and theosteotomy and docking site of the fibula were united.

Results: The alignment of her leg and the stability of the ankle joint were improved. She could walk without pain after treatment. The range of motion of the ankle joint was kept.

Conclusion: We think the key of the reconstruction of theankle joint is not only alignment but stability.

#261: Use of circular external fixation for ankle arthrodesis

James C Wang (USA)

Can circualar exteranl fixation be used in ankle fusions.

Methods: Performed it on 102 patients.

Results: All fused without any delayed or nonunion and removed them on an average of 6.5 weeks.

Conclusion: That circualr external fixation can be an effective way to fuse ankle joints

#262: Influence of excessive femoral anteversion on the lower limb

Shohei Matsubayashi (Japan),
Makoto Osaki, Takashi Miyamoto, Tatsuya Fukushima, Kenji Taguchi

Question: Staheli indicated outward femoral osteotomy for excessive femoral anteversion for 8-year-old or older patients with marked cosmetic dysfunction, anteversion exceeding 50, internal rotation of 80 or greater, and external rotation of 10 or less. Most cases of excessive femoral anteversion may be asymptomatic. However, when the hip, knee, or ankle joint is in a pathological state, anteversion may not be compensated for and induce symptoms.

Methods: Investigation of symptoms induced by femoral excessive anteversion in 3 patients.

Results: [Case 1] A patient with excessive femoral anteversion who became unable to sit cross-legged after triple innominate osteotomy.

Medical record: The patient was a 13-year-old male with cerebral palsy. He was treated with soft-tissue release around the hip at 5 years old. Right hip joint dislocation aggravated thereafter. Open reduction of dislocation, varus derotation osteotomy of the femur, and triple innominate osteotomy were performed at 12 years old. He became unable to sit cross-legged after surgery. Since excessive femoral anteversion was present, outward femoral osteotomy was additionally performed. The bone fragment gradually moved after surgery, for which extension deformity was applied. Varus deformity was suggested due to the influence of outward rotation and extension deformity. The outward femoral osteotomy may have induced impingement and caused extension deformity. Summary: The entire lower limb was internally rotated due to excessive femoral anteversion and restriction of movement of the hip joint.

[Case 2] A patient with excessive femoral anteversion accompanied by patella dislocation. Medical record: The patient was a 12-year-old female with desbuquois dysplasia in whom the bilateral patellae were easily dislocated. The bilateral hip and knee joints were dislocated at birth and treated with a Pavlik harness. Open reduction of the right hip joint was performed at one year old, right patella stabilization was performed at 7 years old, hemiepiphysiodesis was performed for left varus knee at 11 years old, and bilateral outward femoral osteotomy was performed for excessive femoral anteversion at 12 years old. Dislocation of the right patella was resolved, but the left patella is still easily dislocated, for which left patella stabilization is planned. Summary: The patella was easily dislocated due to excessive femoral anteversion and instability of the knee joint. [Case 3] A patient with excessive femoral anteversion accompanied by an unstable knee joint. Medical record: The patient was a 16-year-old female with achondroplasia. Paralysis of the right upper and lower limbs developed at 10 months old due to compression of the medulla oblongata by the odontoid process. Right knee pain during walking developed at 14 years old, and excessive right femoral anteversion was observed, suggesting that, although femoral excessive anteversion should induce in-toeing gait, the lower leg was not internally rotated due to the equinus foot, and it was fixed on the ground in an externally rotated position, causing internal rotation of the femur alone. Moreover, the knee was unstable and unable to stop internal femoral rotation. Since the medial collateral ligament of the knee was loose, firstly, stabilization was applied. The knee instability was improved, but it may recur unless femoral excessive anteversion is corrected. Summary: The knee joint became unstable due to excessive femoral anteversion and equinus foot.

Conclusion: Since the hip is a ball joint, abnormal femoral rotation is compensated for to some extent. However, when another pathological condition concomitantly exists, such compensation will be lost.

#263: The response of the ipsilateral healthy femur to limb lengthe inequality in unilateral infantile and adolescent Blount disease is different

Marina Makarov (USA),
John Birch, Connor Smith, Taylor Jackson, Chanhee Jo

Question: Pediatric patients with asymmetric physeal growth disturbance of the medial proximal tibia associated with Blount disease frequently demonstrate secondary adaptive deformity in the adjacent femoral physis to ameliorate angular deformity. How the length of ipsilateral femur responds to associated progressive leg length discrepancy (LLD) has not been studied to our knowledge.

Methods: Of 232 patients treated surgically at our hospital for Blount disease between 2000 and 2014, 62 patients with unilateral involvement, adequate radiographs, and no limb lengthening procedures were included in the study. Charts and preoperative radiographs were retrospectively analyzed for evidence of acceleration or deceleration of the unaffected ipsilateral femur relative to the contralateral healthy leg. Femoral length differences between two limbs 0.5 cm was chosen as evidence of acceleration or deceleration phenomena.

Results: There were 31 patients in each group. Mean preoperative age of patients with infantile Blount was 9.8 years (range, 5.3-15.8); in the adolescent group, the mean age was 14.5 years (range, 9.8-18). African-American population was predominant in both groups (64 and 74%, respectively). The adolescent group was predominantly male (26:5, 84% male), whereas in the infantile group females were more common (18:13, 58% female). Patients with adolescent Blount disease presented with significantly greater LLD (3.2 cm vs. 1.7 cm).

Conclusion: Patients with unilateral infantile and adolescent Blount disease demonstrated completely different adaptation of the ipsilateral femur to associated LLD. Amelioration of LLD was typical in infantile Blount disease, evidenced by ipsilateral femur overgrowth. LLD in adolescent Blount disease was most commonly aggravated by ipsilateral femoral shortening compared to the contralateral femur. This observation would appear to confirm that infantile and adolescent Blount diseases are distinctly different entities, and raises intriguing questions regarding the relative significance of LLD and ipsilateral segmental disproportion, warranting further investigation.

#264: Factors Influencing Rotational Correction Rate in FemoralRotational Guided Growth: A Biomechanical Study

Ryan Li (USA),
Raymond Liu

Question: What are factors that influence the timing and total correction in rotational guided growth?

Methods: A mathematical model for rotational guided growth in the femur was adapted from Arami et. al. Plate length and orientation were found to influence rotational correction. Maximum rotational correction and progressive rotational correction over 1 mm increments of simulated growth were calculated for 12 and 24 mm plates at 30 and 60 degree offset angles. A biomechanical sawbones model was constructed to validate our mathematical model. Angular correction was assessed using guide pins placed on either side of a simulated growth plate. The femur was progressively lengthened at the growth plate to simulate growth. Progressive and maximal rotational correction were investigated for the conditions described. Intraclass correlation coefficient (ICC) was used to calculate agreement between mathematical and biomechanical models.

Results: Our mathematical model predicted that increased offset angle and plate length would increase rotational correction. Plates offset at 60 degrees from vertical had 1.75 times the rotational correction of 30 degree offset plates. Increases from 12 to 24 mm plates increased rotational correction by 2. Increasing both variables resulted in a 3.5 times increase in maximum rotational correction. Using the biomechanical model, 2.2 and 1.7 times maximal rotational correction were achieved with increases in plate offset and plate length respectively. Simultaneous increase in both resulted in a 4.1 times increase in maximal rotational correction. Both mathematical and biomechanical models predicted non-linear increase in rotational correction with growth. In both models, the rate of growth increased as plates achieved a more vertical orientation. There was a strong association between correction predicted by the mathematical model and that seen in the biomechanical model (ICC = 0.85).

Conclusion: This is the first study to validate the relationship between plate length with rotational correction, as well as the first study to propose a non-linear relationship between growth and correction in rotational guided growth. Further investigation is required to clarify these relationships prior to clinical application of this technique.

#265: Complex Reconstructions of overseen partly physeal arrest

Joachim Lauen Germany),
Christian vonRueden, Volker Buehren, Matthias Rueger

Question: A partly physeal arrest is rare and observed in follow up of traumatic physeal fractures and damages or on tumor and inflectional defects. The diagnostics mostly late based on a progressive deformity and length discrepancy.

Metods: We report on 7 cases with 13 surgical reconstructive procedures. Indications were complex deformities with a physeal bridging over 1/3 of physis and ages over 12, where a recovery of deformity after bar resection could not be expected and secondary deformities by growth adaption occurred. The surgical procedures include a complete epiphyseodesis, a complex angular deformity correction and lengthening. Generally used were external ring fixators, monolateral fixators or hybrid combinations. The additional secondary deformities of joint partners were addressed with osteotomies or in less deformity with growth guiding by 8 plate.

Results: The results correspond to the data of general deformity correction. A correction with physeal distraction reduced the mean healing time. Rotational and axial corrections could be done perfectly, the surfaces rejection by asymmetric restriction could not be addressed properly.

Conclusion: A follow up of epiphyseal fractures, damages orinfections is required to early detect physeal arrests and avoid secondary joint and axial deformities. Early detection opens up the possibility of resection and self-correction, but at least secondary deformities by growth adaptions.

#266: Femoral lengthening in children using a new hexapod fixator: preliminary results

Franck Launay (France)

The objective of the study is to report the first cases of femoral lengthening in children using a new hexapod fixator.

Methods: We carried out a retrospective study about cases of femoral lengthening done in 2013 and 2014 in our institution.

Results: Twelve lengthening were done during this period in 11 patients using the TL-Hex, a new hexapod fixator. The procedure was done in congenital bone in 10 cases and after a distal femoral epiphysiodesis in 2 cases. The mean age at surgery was 11,8 years. A lengthening was required in all patient and an axis correction was required in 8 of the 12 cases. The mean lengthening was 4,9 cm. The healing index was 43,5 day/cm (25,5-60). We noticed 2 fractures above the lengthening zone several months after the hardware removal, 2 knee stiffness, 6 local infections, and 1 broken half-pin. The goal of lengthening was reached in all cases. The goal of axis correction was reached in 87,5% of cases. Conclusion: The use of this new hexapod system allows to do accurate lengthening and axis correction, and is a reliable external fixator.

#267: Combination of Transphyseal Elevating Osteotomy, Epiphyseodesis and Meta-diaphyseal Osteotomy with Angular -Rotational Correction and Lengthening in Blounts Disease

Dr. med. Joachim Lauen (Germany),
Dr. Christian vonRueden, Prof. Dr. Volker Buehren, Dr. Matthias Rueger

Question: Blounts disease (tibia vara congenita) is characterized by a growth disorder of the medial part of the tibial physis, metaphysis and epiphysis. The growth deformity includes tibial plateau, meta- diaphyseal internal rotation-varus-recurvation, length discrepancy and secondary malformation of femoral condyles.

Methods: A transphyseal osteotomy with elevation of the medial tibia plateau and simultaneous epiphyseodesis was combined with a second tibial meta-diaphyseal closed wedge valgizational-derotational-antecurvation corticotomy and lengthening using monolateral external fixator. The transphyseal opening wedge osteotomy proximal to the MCL insertion tensioned the ligamentous laxity by acute distraction. The permanent growth arrest by epiphyseodesis stopped the deformity progression. The callus distraction corrected the length discrepancy.

Results: Five cases were treated with this method, the follow up 2-5 years. Uncomplicated surgeries could be reported, lengthening progress and consolidation time correspond to the data of general deformity correction.

Conclusion: The clinical and radiographic results showed the complex options of this combined double osteotomy procedure. Definitively a stable reconstruction of tibial plateau with a better realignment of knee joint, a correction of the secondary deformity and a length gain could be achieved in all cases.

#268: Recurrence after Surgical Intervention for Infantile Blount Disease and Assessment of a Novel Classification

Lauren LaMont (USA),
Jennifer Rodgers , John Birch , Amy McIntosh , Charles Johnston

Question: Does a novel classification better correlate with the risk of recurrence in infantile Blount disease after surgical intervention than the Langenskiold classification? Secondarily, does deformity and degree of overcorrection predict recurrence?

Methods: We reviewed the charts and radiographs of 82 patients and 115 limbs that underwent surgery for infantile Blount disease over a 22-year period (1990-2012). Patients were 10 years of age or younger and had at least two years of radiographic and clinical follow-up post-operatively. Demographic and radiographic data was collected on all patients prior to surgery, at initial post-operative visit and at final follow-up. Surgical data collected included all initial and subsequent procedures as well as surgical complications. Recurrence was defined as recurrent varus deformity that was indicated for corrective surgical intervention. Both the Langenskiold classification as well as the novel classification was applied to each pre-operative radiograph. The novel classification system that was applied to radiographs consisted of a 3 stage classification of types A, B and C [Figure 1]. The classification was based on the progressive deformity of the tibial metaphysis and the epiphysis. Type A had no significant epiphyseal changes; metaphyseal changes included medial beaking and lucency. In a Type B deformity, there is a down-sloping curvature of the metaphysis that projects medially. The epiphysis does not have significant down sloping. The most severe type C involved deformity of both the epiphysis and metaphysis. The metaphysis has down sloping distally with no curvature projecting medially. The deformity of the epiphysis in a type C is down sloping as well.

Results: There were 33 male and 49 female patients included in the study. 67 limbs did not develop recurrent deformity requiring operative intervention and 48 limbs required at least one repeat surgery for deformity correction. Pre-operative mechanical axis deviation (MAD), medial proximal tibial angle (MPTA), lateral distal tibial angle (LDTA) and BMI did not differ significantly between patients that developed recurrence and those that did not. The lateral distal femoral angle (LDFA) did differ significantly, patients with more varus distal femurs had less recurrence but this trend was also correlated to age related changes of the distal femur. Mean age at surgery was significantly different for those who developed recurrence compared with those who did not. Patients without recurrence were a mean of 4.3 years of age (range 2.4-10.3) compared with 6.2 years of age (range 2.9-10.1) for those who recurred. The degree of overcorrection did not significantly differ between those under four years of age compared with those with higher recurrence rate older than four. Of patients who developed recurrent deformity, there were significantly more patients with type C changes (71.7%, P = 0.0000) then either type A (22.5%) or type B (20.7%). When classified by Langenskiold there was a wider distribution of recurrence. High rates of recurrence were seen for both stage III (50%) as well as stage IV (69.6%).

Conclusion: Consistent with prior studies, the fifth year of life appears to be a critical transition in the risk for recurrent deformity after surgical correction of deformity. There was not a significant difference either in the pre-operative deformity or the degree of overcorrection between the older patients that recurred and the younger that did not. The only joint angle that differed significantly was the varus of the distal femur however that appeared to correlate with age related changes. The novel classification better stratified patients at risk for recurrence compared with the Langenskiold classification and is specific to infantile Blount disease.

#269: Percutaneous transphyseal screw epiphysiodesis efficacy and complications

Emily Dodwell (USA),
Elise Bixby, Matthew R. Garner, Roger Widmann

Question: Previous reports have identified a number of complications associated with percutaneous transphyseal screw epiphysiodesis (PETS), including implant failure, implant prominence, angular deformities, and delayed growth inhibition. The aim of this study was to assess the efficacy and complications associated with screw epiphysiodesis at a single tertiary care center.

Methods: Chart review identified all patients who underwent distal femoral and/or proximal tibial PETS between 2007 and 2013 inclusive. Complications including pain, knee effusion, angular deformity, unscheduled implant removal, infection and failed epiphysiodesis were recorded. For patients with complete pre - And post-operative calibrated imaging, total limb length and length of each tibial and femoral segment were recorded preoperatively and at skeletal maturity. The Multiplier Method was used to calculate expected length at maturity of each bone segment, and expected physeal inhibition for each bone segment. Efficacy (actual growth inhibition divided by expected growth inhibition) was calculated. Mean leg length discrepancy (LLD) was evaluated at maturity.

Results: Eighty-eight patients with 132 treated physes (69 distal femurs and 63 proximal tibias) were included. A total of 42 patients (48%) had complications including pain (N = 15, 17%), revision surgery (N = 3,3.4%), knee effusions (N=, 4.5%) and angular deformity (N = 5, 7.9%), defined as a change in mLDFA or MPTA &;#61619;5&#61616;. No angular deformities were severe enough to require revision. Thirty-five percent of patients underwent screw removal. Average LLD at maturity was 1.8 cm (range: 0.6 cm 3.5 cm). Overall, efficacy was 108%;106% for distal femur epiphysiodesis and 110% for proximal tibia epiphysiodesis, suggesting that PETS on average provided slightly more growth inhibition than calculated. Efficacy was also significantly correlated with BMI (r = 0.34, P = 0.02), but not with the number of screw threads crossing the physis (p 0.05).

Conclusion: PETS is an effective method of epiphysiodesis . Although 48% of patients experienced some form of complication, the majority were mild and transient, not requiring additional unplanned surgery. Contrary to previous reports, PETS in this series did not result in significant angular deformity, insufficient growth inhibition or other serious complications. Further comparative studies, such as a randomized controlled trial, could further elucidate the relative outcomes for this and other epiphysiodesis techniques.

#270: The sleeper plate: A technical note

John E. Herzenberg, (Baltimore USA),
Muayad Kadhim, Ahmed I. Hammouda

Question : Guided growth with tension band plates (TBP) is an effective treatment for lower limb angular deformities in children. Once the deformity is corrected, the TBP is removed to prevent overcorrection. If the deformity recurs, then the TBP must be re-implanted. The aim of this study was to describe a surgical technique to mitigate this problem by only removing the metaphyseal screw after correction is achieved. If the deformity recurs, the screw can be re-inserted as a percutaneous procedure. Is this technique an effective method to manage recurrence?

Method : This is a retrospective case series of patients who were treated with distal femoral and proximal tibial TBP for guided growth. After the correction was achieved, only the metaphyseal screw is removed, instead of removing the entire plate. The metaphyseal screw removal is done under fluoroscopy through a 1-cm incision without a tourniquet. A small periosteal elevator is used to elevate the plate from the bone to release adherent scar. Bone wax is injected in the empty plate hole to prevent bone growth into the hole. In case of recurrence of the deformity, we perform percutaneous re-insertion of the metaphyseal screw into the TBP.

Results : Five patients (9 lower limbs) were reviewed. Ages ranged from 7 to 13 years. The most common diagnosis was Blount disease. All patients underwent growth modulation with TBP and subsequent metaphyseal screw removal after deformity correction. Of the 5 patients, one needed to have the metaphyseal screw re-inserted because of deformity recurrence.

Conclusion : This technique removes only the metaphyseal screw instead of the entire TBP and both screws. The benefit of this technique is to allow an easy and minimally invasive procedure to re-insert the metaphyseal screw into the metaphyseal hole if the deformity recurs. We recommend this technique in young children who are at greater risk of relapse and in children who achieve correction from their TBP with more than 2 years of growth remaining.

#271: What are the indications for ilizarov`s methodology in children and adolescent patients?

Roberto Guarniero,
Rui Maciel de Godoy Junior, Nei Botter Montenegro, Jose Roberto Bevilacqua Guarniero

Question: What are the indications to use ilizarov's methodology in children and adolescents patients?

Methods: Doing a prospective cohort study of patients in the pediatric age group with some difficult and challenging deformities of the lower extremities using the Ilizarov's concepts for correction.

Results: The results are consistently good with no complications. When we follow all the rules for the usage of Ilizarov's methodology the results are very surprising and good.

Conclusion: The Ilizarov methodology with the usage of the circular external fixator is a good and safer way to treat challenging clinical situations in the pediatric patient population.

#272: Results of deformity correction in children with X-linked hereditary hypophosphatemic rickets by external fixation or combined technique

Dmitry Popkov (Russia),
Arnold Popkov

Question: X-linked hereditary hypophosphatemic rickets (XHPR) is the most common form of the hypophosphatemic rickets caused by renal phosphate wasting. The conservative treatment is not always successful. In such cases, operative procedures to correct multiplanar bone deformities may be indicated for prevention of secondary orthopedic complications. Different problems related to surgical correction were reported: an increased rate of non-union after osteotomies, delayed union, recurrent deformity, joint stiffness, deep intramedullary infection, refracture, nerve palsy, and pin tract infection. We used the Ilizarov device in association with flexible intramedullary nailing (FIN) with hydroxyapatite bioactive coating in children with XHPR. The aim of this retrospective study was comparison of results of correction in short and long term follow-up in children with XHPR who underwent the treatment with either the Ilizarov device alone or a combined technique: The Ilizarov fixator and FIN.

Method: We retrospectively analyzed 98 cases (children of age under 14 years) affected by XHPR. Simultaneous deformity correction in femur and tibia was performed with theIlizarov device (group I) or the combined method (group II).

Results: A monofocal bisegmental transosseous osteosynthesis was performed in group I on 24 limbs, a poly focal bisegmental transosseous osteosynthesis was performed in 20 cases. In group II the monofocal polysegmental transosseous osteosynthesis was performed on 30 extremities, the polyfocal bisegmental 20 limbs. The duration of external fixation is noted to be considerably shorter applying the combined technique: 124.714.9 days (group I) vs 87.413.2 days (group II). In both groups deformity correction was achieved with a proper alignment and normal orientation of the knee joint. Nevertheless, while a child keep on growing in long term follow-up, deviations of the mechanic axis from the center of the knee joint have been developing again and values of mLDFA, mMPTA have become pathologic in the most of cases. In group I location of a newly developed deformity resembled to a preoperative one: both, a diaphyseal and metaphyseal parts were deformed. Its worth of mentioning that in group II in all the cases an apex of deformity (CORA) was located in distal metadiaphyseal zone of the femur and proximal metadiaphyseal zone of the tibia. It is important that all of them in group II were out of zone of the intramedullary nail tracks which means that it is possible to prevent deformity recurrence with FIN.

Conclusion: The deformities of lower limbs in children with XLHR should be operatively corrected. Simultaneous correction of femoral and tibial deformities by means of circular external fixators is preferable. Application of a combined osteosynthesis (circular external fixator and FIN with bioactive coating) allows to considerably reduce the duration of external fixation, decrease the number of infectious complications, avoid secondary displacement of fragments during correction and deformities at the osteotomy level after frame removal. There were no recurrent deformities in parts of bone reinforced by intramedullary nails.

#273: Island nail flap in the treatment of foot macrodactyly of the first ray in children. Report of two cases.

Francisco Javier Downey-Carmon (Spain),
Araceli Lagares-Borrego, Jose Francisco Lirola, David M. Farrington

Question: What would be the optimal procedure to correct macrodactyly of the first ray of the foot?

Methods: We performed an island nail flap similar to those reported in other papers but the difference is that we performed an osteotomy of the distal phalanx that allowed us to transfer the whole nail complex with the dorsal portion of phalanx attached. In this manner we ensure the survival of the graft.

Results: We present two cases. In both we obtained satisfactory functional and cosmetic results. However, in one case, that was previously operated on, the nail complex was lost.

Conclusion: Along with additional surgeries, an island nail transfer obtains excellent results in first ray macrodactyly. The toe can be shortened as need since the nail complex, along with a portion of the distal phalanx, can be moved freely as desired. This leads to an rate of survival of the graft and, therefore, obtain better cosmetic results.

#274: A Study of Axial and Appendicular Body Proportions to Distinguish between Limb Reduction and Limb Hypertrophy

Douglas S. Weinberg (USA),
Raymond W. Liu, Samuel Li, James O. Sanders, Daniel R. Cooperman

Question: When children with irregular body proportions or asymmetric limbs present, it may be unclear where the pathology is located. An improved understanding of the clinical ratio between upper extremity, lower extremity and spine lengths may help elucidate whether there is an asymmetry between the trunk and limbs, and whether there is a reduction deficit of the shorter limb, versus hypertrophy of the longer limb.

Methods: We utilized the Brush Foundation study of child growth and development, which was a prospective, longitudinal study of healthy children between the 1930s through 1950s, and collected serial clinical measurements for 290 children at 3,326 total visits. Children ranged from 2 to 20 years during the study period. Linear and quadratic regression were used to construct nomographs and 95% confidence intervals for anthropometric body proportions.

The minimum sitting height/standing ratio occurred at 12.17 years in females, and 12.92 years in males. Overall, the ratio of arm length to sitting height was 0.759 (SD 0.066), the ratio of arm length to ASIS height was 0.755 (SD 0.034), and the ratio of ASIS height to sitting height was 0.984 (SD 0.128). The smallest variance between appendicular proportions was the arm length to ASIS height ratio.

Conclusion: We establish normative ratios of trunk to lower extremity length. The ratio of arm length to leg length (ASIS height) fluctuated less with age and had the least variance as compared to the ratio of either the arm or length with the spine (sitting height). We recommend comparisons between total arm length and ASIS height to distinguish limb reduction deficits from hemihypertrophy, with sitting height used only if combined upper and lower extremity discrepancy is noted. The tables and nomographs extrapolated from this study can be used to compare body proportions in Caucasian children to determine disproportion between the trunk and lower extremity, and to distinguish between hemihypertrophy and limb-reduction deficits.

#275: Reference positions in lower limb, the ideal directions forexternal pin insertion with less soft tissue displacement

Munetomo Takata (Japan)
, Hiroyuki Tsuchiya, Leonid N Solomin,

Question: The less displacement of the soft tissue at the pinsite is advisable for preventing contractures and pin-site infections. Butso far, no report has revealed soft tissue movement according to thedirections of the transosseous elements in the unified positioning method. We asked which direction at which level had less movement of the softtissue.

Methods: Fifteen cadavers were used. The longitudinal areawas divided into eight levels, and the transverse section at each level wasdivided into 12 radial positions similar to a clock-face. 12 wires arealigned radially on the examined ring, and are dyed in each point toward the soft tissue. The fixation ring was settled at the maximum far from theexamined level, and the two rings were firmly connected with rods. Each softtissue displacement was measured with marking the surface, before and afterthe certain joint motion. Range of motion included hip joint flexion/abduction, knee flexion, and ankle plantar flexion/dorsiflexion. Thesame procedures were done in three layers of skin, fascia, and muscle.

Results: Different amount of displacement was measured ineach position, at each joint motion. Larger movements were seen in thelevels near the moving joints, and in the directions parallel to the motion. Apart joint motion had the least influence. The curves in each levelexhibited bimodal with larger movements at the extension and flexiondirections. Three layers of skin, fascia and muscle, showed similar curve. The maximum motion in the femur was 58 mm in the muscle layer at the level 1/6 ofclock, during hip flexion. While, all the values were less than 5 mm atthe level 1/ 9 o'clock. The maximum motion in the tibia was 35 mm in theskin layer at the level 1/8 ofclock, during knee flexion. While, all thevalues were less than 5 mm at any level/1, 2, 3 and 12 o'clock, during all motions.

Conclusion: From the results, reference positions fortransosseous elements were defined in each level where the soft tissue movesless. Those might be useful in practice.

#276: Enhancing The Identification of Fluoroscopic Landmarks on Synthetic Bone Models Using High Density Paint: A Novel Technique

William F. Pientka II (USA),
Arvind Nana, Viktor Kosmopoulus

Question: Certain procedures rely heavily on fluoroscopy to ensure appropriate hardware placement. There are inconsistent reports on how to best confirm appropriate hardware placement in various anatomic locations. Can we create radiodense synthetic bone models to help identify improved fluoroscopic techniques for imaging specific bony landmarks.

Method: Synthetic bone models were painted with high density (blackboard) paint and evaluated radiographically as the first stage of a multiple stage study.

Results: We have identified a novel technique of creating radiographically visible synthetic bone models with specific anatomic landmarks painted with a radio-dense paint to allow for radiographic evaluation of specific bony landmarks.

Conclusion: We conclude that high density paint allows for the creation of synthetic bone models with radiodense anatomic landmarks.

#277: 3D Modelling, Printing, and Rapid Prototyping: ThePotential Value in Limb Reconstruction

Kevin Tetsworth (Australia)
, Nick Green, Vaida Glatt, Aidan Cleary, Peter Wong, Paul McEniery

Questions: 3D modelling, printing and rapid prototyping havebecome increasingly popular in the past few years, and there would appear tobe very real potential for applications across a wide range of surgicaldisciplines. However, there is little information currently available toobjectively demonstrate its benefit in orthopaedics and specifically limbreconstruction surgery. Is there a genuine benefit in the use of 3D technologies with respect to complex limb reconstruction cases?

Methods: Our hypothesis was that these 3D technologies areof greatest use for the most complex cases, with less benefit for simplercases. We further hypothesised that this technology requires a dedicatedservice to make the work flow most efficient, and to model the most cases. We expected the clinical benefits to vary widely between cases, dictated bythe specific nature of the pathology in each individual case. We conducted a retrospective review of a series of limb reconstruction casesto evaluate the different strategies employed under the 3D modelling andanalytics framework. These principally involved malunions and non-unions, including both upper and lower extremity pathology. Modelling and analyticswere performed either in house or outsourced to a commercial entity. Thespecific modality employed and the details of each case were recorded. A series of selected more complex cases were presented to a group oforthopaedic surgeons with varying levels of experience and expertise inmanaging limb reconstruction pathology. They then responded to a formal survey to evaluate their impressions of the benefit specifically attributedto 3D modelling and analytics for each individual case. Work flow was assessed to try to measure the efficiency of employing thistechnology. We compared the number of cases modelled across an 8-monthperiod without a dedicated unit to the following 8 months with a more formalunit.

Results: The data fully support the expectations of thestated hypothesis, that using 3D technologies was of significant benefit for preoperative planning of complex reconstructive osteotomies. Surgeons of alllevels of experience found 3D models of great benefit, as reflected in the survey responses. Demonstrating the actual clinical benefit in any rigorous way was moredifficult, and there were no specific metrics that could be easily employed. The pathology varied widely, and the numbers were too small to allow for meaningful numerical or statistical analysis. Although the value in eachindividual case was hard to define the surgeons involved universally believed the benefit was immediately apparent. More complex cases, including both intra-articular fractures and mal-unions, were evaluatedcomprehensively, allowing for definitive preoperative planning and optimalreconstruction. Our experience further confirms the expectations of our hypothesis, thathaving a more formal unit with dedicated staff would be a more efficientmeans to model the most cases. We were able to model and analyse many morecases in 8 months with dedicated staff than we were able to model in 8 months on an ad hoc basis.

Conclusion: 3D modelling and printing are useful developingtechnologies that have significant potential across a wide range of surgicaldisciplines. There are in fact genuine benefits within limb reconstruction surgery, tempered mainly by the constraints of time and finite resources. However, experienced surgeons did find these technologies useful for themost complex cases, with diminishing returns noted for less complex cases. Our data confirms a dedicated unit is the most efficient means to utilisethis technology fully, and that as local experience accumulates the benefitsbecome more obvious.

#278: Photometry as an objective method for clinical assessment of frontal plane lower limb alignment

Pawe Koczewski (Poland),
Anna Fryzowicz

Question: Clinical assessment of frontal plane lower limb alignment (FLLA) is highly subjective. Methods allowing for objective assessment are: full-length lower limb radiographs made in telemetric technique or CT scan. Though these methods have their relevant limitations: they require specialized equipment, they are connected to high costs and patients' exposure to X-rays. The purpose of presented study is to develop an objective system for clinical assessment of FLLA, based on new, objective photometric method.

Methods: Fifteen patients who had full-length lower limb radiographs in telemetric technique taken due to lower limbs malalignment participated in the study. In this group digital photography of lower limbs and pelvis in the same position were additionally made. Marking specific topographic points on patients lower limbs and pelvis preceded taking both pictures. Afterwards, based on markers localization on both pictures the analysis o relation between mechanical (radiography) and topographic axes (photometry) of femoral and tibial segments were carried out.

Results: Presented research shows constant relation of average value 3.7o between mechanical and topographic axes of femur and tibia. This fact allows for conducting an objective assessment of FLLA using only digital photography of lower limbs and pelvis.

Conclusion: The photometric method may by applied in: - screening tests in children and adults; - observation of natural history of FLLA deformity of different etiology; and monitoring the efficacy of the treatment of FLLA deformity.

#279: Radiostereometric analysis of growth after interventions at or around the growth-plate

Joachim Horn (Norway),
Harald Steen, Ragnhild Beate Gunderson

Question : Epiphysiodesis, hemi-epiphysiodesis and limb lengthening in children are common surgical methods. However, little is known about the actual behavior of the growth plate in relation to these procedures. Radiostereometric analysis is a well-established method for objective measurements of micromovements, and allows for registration of the three-dimensional dynamics of growth. The aim of our study was to use the RSA technique to monitor the behavior of the growth-plate during and after hemi-epiphysiodesis and limb lengthening, and after epiphysiodesis. Analysis of the distribution of growth related to (hemi-) epiphysiodesis will allow us to gain more knowledge about proper timing of the procedure, to demonstrate a pivot point during the correction, and to perform an exact analysis of growth after removal of the plate. Monitoring physeal growth during and after limb lengthening in children will help us to see if and when growth inhibition occurs.

Method : 25 children were included in this study. 20 were operated by percutaneous proximal tibial epiphysiodesis [mean age 13 (11-15) years, 14 males, 6 females], 4 received hemi-epiphysiodesis with an eight-plate [mean age 12.5 (12-14) years; 2 males, 2 females] and 1 child underwent leg lengthening with an Ilizarov external fixator (age 9 years; female). In all these patients six tantalum spheres (0.8 mm diameter) were inserted on each side of the growth-plate. Radiographs postoperatively and at each follow-up were obtained using a specially designed calibration cage made by the manufacturer (UmRSA Biomedical, Sweden). Further processing and final development of the x-rays was done with the RSA analysis program. The change in distance across the physis between two subsequent and the initial examinations was calculated. In the patient who underwent lengthening both the right and left proximal tibia growth plate were monitored by RSA.

Results : The mean growth 0-6 weeks after the epiphysiodesis procedure was 0.22 (0.01-0.60) mm, which corresponds to 30% of the normal growth rate. Between 6-12 weeks after the intervention the mean growth was 0.05 (0.00 -0.20) mm. From 12-24 weeks, no significant growth across the operated physis was observed. In hemi-epiphysiodesis mean growth 6 weeks after implantation of the eight-plate was 0.17 (0.06-0.28) mm/week under the plate and 0.23 (0.20-0.80) mm/week on the contra-lateral side. After 24 weeks and 36 weeks the growth under the plate was 0.09 (0.02-0.16) mm/week versus 0.31 (0.28-0.34) mm/week, and 0.08 (0.03-0-08) mm/week versus 0.33 (0.26-0.4) mm/week, respectively. In the patient undergoing tibial lengthening growth on the lengthened side was 0.09 mm at 6 weeks after completed lengthening, whereas growth on the contra-lateral side was 0.14 mm, indicating a growth reduction of about 50% on the operated side.

Conclusion : After percutaneous epipysiodesis actual growtharrest appears within 12 weeks after surgery. The RSA technique may be used routinely after epiphysiodesis as a quality control in order to detect asymmetrical growth after the procedure. In hemi-epiphysiodesis the technique is useful to analyze the actual growth pattern during the correction using different available implants. Furthermore, the technique allows for analyzing growth and possible rebound growth after removal of the implant. In limb lengthening the RSA technique can determine the degree of growth inhibition which may occur with lengthening in children, and from this more scientifically based recommendations may be established for the appropriate age to perform lengthening procedures, especially in achondroplastic patients.

#280: Evaluating length: The use of low dose biplanar radiography (EOS) and tantalum bead implantation

Emily Dodwell (USA)
, Matthew R. Garner, Matthew Dow, Elise Bixby, Douglas N. Mintz, Roger F. Widmann

Question: Low dose biplanar radiography (EOS) is an appealing imaging modality for use in children given its low radiation and ease of use. The goal of this study was to determine the accuracy and reliability of EOS compared with CT scanogram for measurement of total bone length and inter-bead distance after insertion of tantalum beads into lamb femurs.

Methods: Ten skeletally immature cadaveric lamb femurs were procured, and 0.8 mm tantalum beads were inserted into the cortex on the medial side both proximally and distally, and on the lateral side both proximally and distally. CT scanogram and EOS imaging were obtained. Measurements of total bone length and distance between each bead pair were recorded on AP and lateral views. Measurements were made by two orthopedic surgeons on two separate occasions. Repeat measures were made two weeks apart. EOS was compared to CT scanogram using pairwise Pearson correlations Intra - And inter-rater reliability was assessed using pairwise Pearson correlations. All analyses were performed using STATA 12.0.

Results: EOS measurements showed near perfect correlation to those of CT scanogram (r 0.96, P 0.98, P 0.99, P 0.98, P 0 0.99, p)

Conclusion: EOS is comparable to CT scanogram in the assessment of bone length and the distance between two radio-opaque markers. Reliability was excellent for all measurements. The combination of EOS imaging and tantalum bead implantation may be an effective way to evaluate physeal growth following procedures such as epiphysiodesis and physeal bar resection.

#281: Safety Profile of Three Guided Growth Implants: Body Weight Correlates with Implant Failure

Daniel W. Gren (USA),
Yong- Woon Shin, Tyler Uppstrom, Samir Trehan, Roger Widmann

The purpose of this study was to evaluate the safety profile of three types of guided growth plates that are used to correct lower extremity misalignment in the pediatric population.

Methods: A retrospective review of patients treated with implant guided growth plated was conducted. Consecutive patients treated by two surgeons between the years 2004 to 2014 were assessed for deformity correction and implant integrity. Patient medical records and post-operative radiographs were reviewed. Screw pull out defined as more than 5 mm was recorded. The rate of correction was determined for all cases that completed guided growth treatment.

Results: During the study period, 115 plates were implanted in 52 patients (24 males, 28 females). Of the 115 patients treated with plates, 30 received eight-plates, 63 received peanut-plates and 22 received hinged plates. The average age at implantation was 12.3 years (range: 4.3-16.5) in boys and 11.1 years (range: 6.4-15.0) in girls. The average length of follow-up was 18.4 months (range: 8-40). A total of four (6.3%) peanut-plates demonstrated an implant related complication: 3 (2.6%) cannulated screw breakages and 1 screw pull-out. Two (6.7%) eight-plates showed partial screw pull out and one (3.3%) eight plate showed partial screw pull-out with bending of the cannulated screw. There were no reported complications within the hinge plate group. Multivariate analysis demonstrated that increased body weight was significantly associated with implant-related complications (p = 0.046). There were no deep infections, premature growth arrests or plate breakages in this cohort.

Conclusion: Implant-mediated guided growth is a safe technique for pediatric lower extremity deformity correction with low rates of complications. However, obese patients had significantly higher rates of minor implant related complications in our cohort. Screw breakages were observed among those who received cannulated screws and the less flexible peanut-plates. This retrospective review comparing three guided growth implants demonstrated an increased implant related complication rate in obese patients. We recommend using solid, non-cannulated screws in older, obese children when using implant mediated guided growth techniques.

#282: Pedobarographic analysis of body weight distribution and balance after Ilizarov corticotomies.

Piotr Morasiewicz (Poland),
Szymon Dragan, Wiktor Orzechowski, Dragan Szymon, Lukas Pawik

Question: Symmetrical distribution of the load of the lower limbs and balance are among the determinants of proper biomechanics of the musculoskeletal system. So far, it has not been elucidated whether correction of the axis and the equalization of the length of the lower limbs length allows for achieving proper balance and load distribution. The aim of the present study was to compare load distribution and balance of patients who underwent Ilizarov method corticotomies with healthy controls.

Methods: The clinical studies evaluated 57 patients, who underwent corticotomy with the Ilizarov method. The control group consisted of 59 healthy volunteers. The evaluation assessed the distribution of the load of the lower limbs and balance using pedobarographic platform.

Results: In the study group operated limb bore 48.02% of the load on average, while the healthy limb 51.98%. These differences were not statistically significant. The average percentage of load in limbs in treated and control groups did not differ significantly. In the study group, the average length of path of the center of gravity was 145.47 cm. In the control group, the average length of path of the center of gravity was 112.69 cm. In the study group, the average area of the center of gravity was 7.54 cm2, while in the control group it was 5.19 cm2.

Conclusion: Ilizarov method corticotomy allows for obtainment value of the load distribution of the lower limbs in the study group not significantly different from those in a control group, but does not ensure the achievement of completely normal balance.

#283: Joint distraction attenuates osteoarthritis by reducing cartilage degeneration, subchondral bone aberrant change and secondary inflammation

Yuxin Sun (Hong Kong),
Yuanfeng Chen, Xiaohua Pan, Kiwai Ho, Gang Li

Question: Osteoarthritis is a progressive joint disorder characterized by cartilage degeneration, subchondral bone aberrant reconstruction and non-infectious inflammation. Recently, joint distraction was introduced to be a special surgical therapy to prevent the progression of osteoarthritis. In this study, treatment outcome of joint distraction and the probable underlying mechanisms were investigated through histology and imageology.

Method: Osteoarthritis was induced in the right knee joint by anterior cruciate ligament transaction and medial meniscus resection of rats. All the animals were randomized over three groups after a three-week induction. Two groups were treated with a custom-made external frame, one with and one without distraction. The third group was set as osteoarthritis control without a frame. After another three weeks; cartilage degeneration was assessed via histology (gross appearance, Safranin-O/Fast green stain) and immunohistochemistry (Matrix Metalloproteinases-13, Collagen type X); Subchondral bone aberrant changes was analyzed by micro-CT and immunohistochemistry (Nestin, Osterix). Interleukin-1 level were evaluated by ELISA.

Results: Characters of osteoarthritis were present in the osteoarthritis control group. Instead, cartilage could be found well protected in gross appearance in distraction group and histological finding also confirmed that cartilage degeneration was attenuated in lower histologic damage scores and higher percentage of Matrix Metalloproteinases-13 and Collagen type X positive chondrocytes after joint distraction. Subchondral bone abnormal change was also found reduced by down regulation of bone mineral density and bone volume/total volume through micro-CT in distraction group. Much larger number of Nestin and Osterix positive cells in the subchondral bone could be found in distraction group than that in other groups. Besides, as the sensitive marker of inflammation, Interleukin-1 level in serum was significantly decreased in distraction group. In addition, similar evidence of relief from osteoarthritis was found in the fixation group without distraction, less ! pronounced however.

Conclusion: In present study, we demonstrated that joint distraction could prevent the progression of osteoarthritis by reducing the cartilage degeneration and subchorndal bone aberrant reconstruction, as well as the potential secondary inflammation, giving the chance for prevention and intervention of osteoarthritis.

#284: Limb lengthening after internal hemipelvectomy with the FITBONE-system

Rainer Baumgart (Germany)

Internal hemipelvectomy after resection of malignant bone tumors of the pelvis is one option accepting a shortening of the leg which may be aggravated by the growth of the contralateral side in case of children, so that at maturity a huge limb length discrepancy results. The method of kallus distraction offers the potential of bone growth of high biological quality. Using fully implantable distraction nails (Fitbone), lengthening can be controlled wireless by an external control unit and the risk of infection is minimal. Exercises can be done without restrictions to prevent contractures, stiffness and subluxation of the adjacent joints which are set under high pressure. In cases of internal hemipelvectomy with or without arthroplasty, the neo-acetabulum is set under high load with an unknown risk of subluxation or even luxation if lengthening of the femur is performed. Would it be an option to use a fully implantable distraction nail also under these circumstances? Which perspective can be expected?

Methods: In 5 patients (2 male, 3 female) mean age 16,8 years, limb lengthening was performed with a fully implantable system (Fitbone) after resection of a malignant bone tumor of the pelvis which was treated by an internal hemipelvectomy. In all cases the lengthening nail was implanted retrograde through the knee joint. The osteotomy was performed about 9 cm proximal of the knee joint level. In 2 cases another distraction nail was implanted in the tibia and lengthening was performed simultaneously.

Results: The medial lengthening distance was 10,5 cm (femur 8 cm, tibia 3,6 cm). The medium follow up was 28 months (12/42) after finishing lengthening. No technical complication occurred. In all cases bone formation was circular and sufficient. The position of the hip joint/prosthesis and the functional use remained unchanged.

Conclusion: From our experiences limb lengthening of the femur and tibia with fully implantable distraction nails (Fitbone) seems to be suitable and effective even after internal hemipelvectomy with or without arthroplasty. If the joint was able to carry full load before for at least 2 years, the lengthening process do not increase the tendency of luxation.

#285: Reduction of high dislocation of the hip using a distraction nail before arthroplasty

Rainer Baumgart (Germany),
Stephan Horn, Werner Ploetz

Question : Treatment options for reduction of chronic proximal migration of the femoral head prior to total hip arthroplasty (THA) include acute lengthening, femoral shortening and continuous soft tissue distraction with external distractors. Acute lengthening is associated with a high risk of nerve palsy. Femoral shortening results in a limb length discrepancy and commonly in functional deficits. Distraction with external fixators may be complicated by the risk of deep infection due to contaminated pin tracts. Could it be an alternative to use a fully implantable distraction nail to distalize the femur?

Methods: The fully implantable distraction nail Fitbone has already been used frequently worldwide for leg lengthening in more than 2500 cases. For distalization of the femur the telescopic-active-actuator variant (TAA) can be placed into the proximal femoral cavity and finally locked in a way that the tip of the nail is pointing proximally out of the bone. The energy necessary for the distraction can be delivered wireless through the skin by an external power and control unit. A pelvic-support plate can be used which is stable enough to act as a counter bearing and allows a sufficient range of motion during distraction.

Results: 7 patients (5 male, 2 female) with a mean age of 38 years (20-59) were treated using a fully implantable distraction nail before arthroplasty. The mean lengthening amount was 52 mm (32-60). In an initial surgery the femoral head was resected and the cup of THA was placed into anatomic position with or without enhancement of the acetabulum. After surgery lengthening was started with 2-4 mm/day and was reduced depending on pain and function. In a second surgery the distraction nail was removed and the stem was inserted to complete the THA. In all patients the distalization of the femur was possible, so that THA could be performed in anatomic position. No infection was observed. During distraction 4 patients could be mobilized and complained of low pain. 3 patients need high dosage of analgesics and get temporarily contractures of the hip and the knee joint. In 2 patients neurological deficits were observed, one of them after initial acute stretching had a peroneal palsy which was not recovered completely one year after treatment.

Conclusion: The fully implantable distraction nail Fitbone is an option to reduce a hip dislocation before THA. Initial acute intraoperative stretching should be avoided while continues distraction immediately after the surgery with 3 mm/day seems to be an optimum

#286: Combined operative treatment of adult patients with congenital hip dislocation

Oleg Chegurov (Russia),
Boris Kamshylov, Dmitry Efimov

Question: Study of the effectiveness of rehabilitation of adult patients with untreated congenital hip dislocation by combined operative treatment. At the IIizarov Center for treatment of congenital hip dislocation in adult patients is used a technique of combined operative treatment combination of the transoseous osteosynthesis and reconstructive arthroplasty. At the first stage is carried out osteosynthesis of the pelvis and hip with the aim of its bringing down and reconstructive hip joint arthroplasty is performed at the second stage.

Methods: There was carried out analysis of treatment results of 20 patients (21 joint) with congenital hip dislocation aged from 18 to 53 years (35, 31,5 years). There were 13 women and 7 men. Average rating on the scale of Harris was 34, 33, 5 before treatment. The most significant clinical signs of the disease were lameness, limb shortening and pain. High hip dislocation, neoarthrosis, hip joint deficiency is defined radiologically. Dysplastic severity of symptoms was assessed by Crowe. At the hip dislocation it corresponded to Crowe IV.

Results: In the nearest observation period (up to 1 year) were studied results of all patients. The functional state of the hip joints was evaluated on a scale of Harris. Good results were obtained in 17 cases, fair- in 3 cases, poor- in 1 case. Positive results were 95, 2%. In the long-term follow ( from 1 to 5 years) were studied results in 15 patients (16 joints). Excellent results were obtained in 2 cases, good in 9 cases, fair in 4 cases, poor in 1 observation. Positive results were 93, 8%.

Conclusion: Operative treatment of adult patients with congenital hip dislocation is an urgent problem of restorative orthopedics. The use of combined technique of operative treatment (combination of the transoseous osteosynthesis and reconstructive arthroplasty) allows avoiding neurological complications and obtaining in the long-term observation positive anatomic and functional outcome of treatment in 93, 8% of cases.

#287: Treatment of late neglected adult dislocation of the hip with hybrid Ilizarov/monolateral distractor followed by total hip replacement.

Nuno Craveiro-Lopes (Portugal),
Carolina Escalda, Manuel Leo

Question: Treatment of late neglected hip dislocation on the adult patient has a difficult solution. Generally it is accepted that the best results are obtained when the total hip replacement (THR) is fitted on the original acetabulum. When more than 4 cm of overriding exists, diaphyseal resection, reconstruction of the proximal femur, grafting of the acetabulum and THR fitting, is the standard treatment.

Methods: Since this kind of treatment leads to a leg length discrepancy and is technically difficult, we develop a treatment protocol including a first stage of hip distraction utilizing a hybrid Ilizarov/monolateral distractor, allowing the fixation of two pair of heavy pins on the supra-acetabular region, two anterior and two posterior to the greater trochanter and two pair on the distal femur, obtaining this way a much more stable fixation, which permits a smooth hip distraction in an ambulatory basis.

Results: From 2002 to 2007 we have treated 7 female patients presenting neglected hip dislocations by congenital, septic or necrosis sequel, which were never treated before. 5 were Caucasians, 45 to 51 years old from Portugal and two Black, 17 and 24 years old from Angola, Leg length discrepancy was 4 cm to 6.8 cm. Treatment protocol included a Girdlestone type procedure and fitting of the hybrid Ilizarov/monolateral distractor. Then patient began gradual distraction in an ambulatory outpatient way, until the tip of the greater trochanter reaches the acetabular level. Then, the frame was removed and after 15 days in bed traction a standard Corail-Duraloc THR with HAC coating and ceramic-ceramic interface was fitted. Distraction period was 21 to 48 days and follow up is mean 6 years (3 to 8 years).

Conclusion: This methodology allowed on those 7 cases the precise correction of the leg length discrepancy, with the fitting of a standard THR on the original acetabulum, without technical difficulties or complications, namely neurological, infection or loosening of the implant

#288: Transosseous osteosynthesis for pelvic ring reconstruction

Alexander V. Gubin (Russia),
Alexei S. Zhdanov, Ivan I. Martel, Vladimir V. Shvedov, Seigei O. Ryabykh, Mikhail P. Teplenky

Question : Pelvic ring reconstruction is used for oncologic disorders congenital malformations and posttraumatic conditions. Even mild disorders in the shape of the pelvic ring can lead to serious problems, pains, disturbed gait, statodynamic disbalance. Treatment of patients with above conditions involves a procedure of a high risk and assistance from orthopaedic, vascular surgeons, neurosurgeons, spine surgeon, urologist, oncologist, proctologist. The diversity and rarity of the pathology entails specific difficulties with the choice of reconstruction technique and surgical instruments to correct and stabilize pelvic ring. Objective: To show possibilities and identify problems with application of various systems of transosseous osteosynthesis used for pelvic ring reconstruction.

Method : Retrospective review of 42 patients aged from 3 weeks to 50 years was conducted. All patients had severe deformity of pelvic ring that required correction. Etiologically the patients were divided into four groups, congenital malformation (n = 30), malignant pelvic involvement (n = 2), posttraumatic condition of sacrum and pelvic (n = 10). Open and closed techniques of anterior, median and posterior pelvic osteotomy either with plasty or without. External fixation devices, screws, plates transpedicular fixation systems were used as a reduction and fixation means.

Results : Functional improvement was achieved in all the cases. Neurological deficit ( palsy of peroneal nerve on the right developed in one case. Difficulties with instrumentation design, fixation and reduction were observed in all the cases. When using transpedicular fixation systems (TFS) techniques similar to those applied with external transosseous osteosynthesis appeared to be most effective. Advantages with TFS included possibilities of reduction regaining anatomical relations in the posterior pelvic arch with a long lever (like Shanz screws) and inversion to internal TFS fixation. Injury of the anterior pelvic arch entails thorough preoperative planning assessing amount of displacement, pelvic rigidness and determining a choice of surgical technique to be used including mobilizing method of osteotomy, application of stabilizing system with either Ilizarov external fixation or plating.

Conclusion : Transosseous external and internal osteosynthesis are perspective technique for pelvic ring reconstruction. 2. Effective application of external fixation includes the usage of multiplanar hinges to connect rods, and radio-noncontrast components. 3. Application of current transpedicular systems in pelvic surgery is based on the principles that are similar to those used in external transosseous osteosynthesis. 4. Engineering changes in spinal systems are needed fro wide and comfortable application in pelvic surgery.

#289: A Novel Technique for Hip Arthrodesis Using Multiplanar External Fixator And Trans-Articular Screws

Djuro Petkovic (CA),
Scott C. Nelson, John Herzenberg

Question: What are the results of performing hip arthrodesis through an anterior muscle sparing incision using a multi-planar external fixator with trans articular fixation?

Method: We studied a consecutive series of 10 patients who underwent hip arthrodesis by a single surgeon between November 2007 and December 2012. All operations were performed through an anterior Smith-Peterson approach. Multi-planar external fixation and trans-articular screws were used for stabilization. Operative parameters, radiographic and clinical results were analyzed for each patient.

Results: Mean age at time of surgery was 21.7 years (7/10 cases between 12 and 18 years). Mean estimated blood loss was 489 ml. Average follow-up was 47.5 months. At final follow up the average Harris hip score measured 83.4. Radiographic measurements included mean anatomic axis hip adduction 9; mean hip flexion 22; and mean leg length discrepancy 20 mm. There was a mean 8 external rotation measured on clinical exam. There was one non-union. Adduction drift of 8.3 was noted after fixator removal in spite of radiographic evidence of solid arthrodesis.

Conclusion: Hip arthrodesis using a multi-planar external fixator and trans-articular screws is a reliable method of achieving hip fusion within the desired parameters for positioning. Our technique is less invasive than other methods and has a favorable blood loss. Additional advantages of the technique are multi-planar stability, potential for adjustment of position post-operatively and perhaps most importantly it does not preclude future conversion to total hip arthroplasty. Adduction drift was an issue as seen in other studies, and this has to be accommodated for with proper positioning at the time of surgery.

#290: PAO and hip arthroscopy combined approach

Carlomagno Cardenas-Nylander (Spain),
Vittorio Bellotti , Emanuele Astarita, Federico de Meo, Esther Moya, Manel Ribas Fernandez

Question: Symptomatic young patients affected of low grade hip dysplasia are usually treated with pelvic redirection osteotomy being periacetabular osteotomy the most used. Several studies suggest that results in the medium and long term could be improved if other factors such as anesfericity of the femoral head and labral tears are addressed. The classic solutions to these problems were adding a capsulotmy the PAO, osteochondroplasty of the transition head neck junction and labral repair with anchors. The aim of this study is to assess the initial experience and safety of mini -invasive approach through transartorial PAO and hip arthroscopy in the treatment of low-grade dysplasia

Methods: Retrospective study of a sample of 21 grade I and grade II crowe dysplastic patients treated with transartorial PAO combined with hip arthroscopy to correct the CAM type deformity and treating intracompartmental injuries. We collected demographic data, surgical time, pre and postoperative measurements of radiological and MRI imaging variables, intraoperative findings and treatment performed , complications , transfusions and hospital stay

Results: All 21 patients presented intracompartmental fibrocartilaginous/labral disorder or bony deformity open to arthroscopic treatment, 16 hips in women and 5 men. The total surgical time lasted 88 minutes if we consider arthroscopy as an additional procedure. No increase in the number of transfusions, no severe complications, 14% femoral cutaneous lesions, 1 patient with pudendal nerve palsy, which resolved spontaneously after two weeks. In all cases alpha angle were corrected to normal range.

Conclusion: Transartorial c-arm guided PAO combined with arthroscopic intra-articular correction of defects associated with hip dysplasia has the potential to improve outcomes in this type of pathology, it is possible to treat a wide gamma of disorders without large incisions. Arthroscopy is feasible followed by the PAO without an increase in complication rate, we can consider this as a safe combination of procedures

#291: Hybrid technologies for treatment of severe spinal deformities

S. O. Ryabykh (Russia),
A. V. Gubin, O. G. Prudnikova, D. M. Savin, A. V. Burtsev, P. V. Ochirova

Question: Spinal deformity is a most common and leading syndrome of complicated vertebral pathology: congenital malformations of vertebrae and ribs, systemic and neuromuscular diseases, posttraumatic deformities, idiopathic scoliosis and their combination is quite often. Progression rate and extent of a curve can be considered as most important characteristics of the spinal deformity. They would influence a cosmetic and functional outcome and finally, quality of life and survival rate. Operative intervention is associated with high intraoperative risk and high complication rate during postoperative care in patients with curves measuring more than 100. All techniques that are used for spinal deformity correction can be subdivided into two groups, basic standard methods of acute correction applying widely known implants; and hybrid techniques combining mobilizing techniques (traction and vertebrotomy techniques) and techniques of distraction, derotation and reclination used for kyphosis with external and internal fixation systems. Objective: Review results and efficacy of combined surgical correction of severe spinal deformities of different etiology.

Methods: The review included 36 patients with progressing severe spinal deformity of different etiology. The deformity type, progression rate of the curves, and sharply deteriorating respiratory and cardiac function required staged surgical intervention. Two and more stages of surgical treatment were performed for 59 children and 25 adults. Depending on the technique used we subdivided patients into 2 groups. The first group was comprised of 25 patients with curves exceeding 100 who underwent four-staged correction within two surgical sessions. The first session included anterior multilevel vertebrotomy, spondylodesis with autograft, and closed osteosynthesis with external transpedicular fixation. The second session involved Smith-Petersen procedure, correction and stabilization of the curve with transpedicular CD instrumentation and posterior spondylodesis. The second group was comprised of 11 patients who underwent external fixation (halo-pelvic device, external transpedicular fixation and their combination) without anterior interventions to be followed by deformity correction with dorsal screw systems.

Results: The first group showed mean correction of 67%, mean correction loss of 6.3% at a long-term follow-up (more than 2 years), the mean blood loss of 46% of the total blood volume. The second group showed mean correction of 59%, correction loss of 7%, and the mean blood loss of 21% of the total blood volume.

Conclusion: The choice of tactics for operative correction of severe spinal deformity is to be tailored and determined by curve mobility. Mobilization of anterior and posterior portions combined with external traction is advocated for a rigid curve at any plane. External fixation systems showed to be most effective due to the possibility with gradual controlled correction either alone or to be followed by conversion to internal fixation or in combination with anterior release at the apex of the curve. However, the technique is rather demanding in terms of closed technique of screw placement, biomechanically substantiated assembly of the construct and postoperative control. Indications to surgical treatment should be viewed as life-threatening and hybrid techniques of treatment with staged usage of external fixation systems to be applied for spinal deformities complicated by infected soft tissues at the apex of the curve and severe functional disorders.

#292: Biological regeneration of prolapse disc using spine Ilizarov under local anaesthesia

Ram Avtar Agrawal (India)
, Rajat Agrawal

Question: Current treatment options in prolapse disc are excision of prolapse disc or disc replacement. But this is not an ideal treatment. Treatment should be to repair and regenerate the pathology. Is there any treatment by which we can repair or regenerate the prolapse disc instead of excising it?

Methods: Ilizarov being a versatile fixator has been applied in Spine, one of the very few studies done in the world to the authors knowledge. Patient inclusion criteria was prolapse disc L4-L5 or L5-S1 with no significant clinical improvement by conservative treatment for 3 months. 5 mm pins under double C-Arm for simultaneous AP and Lateral view are applied in 14 patients in the pedicles percutaneously. 2 pins were applied in L4 and L5 each in L4-L5 prolapse disc and in L5 and S1 in L5-S1 disc prolapse. Distraction was done at the rate of 1 mm/day for an average of 10-12 days. Continuous neurological monitoring is done of the patient. Patient is asked to walk and do all daily activities throughout the procedure. To lie down supine, a square cut for the Ilizarov fixator is made in a thick foam in the bed. Spine Ilizarov is applied for an average 9 weeks.

Results: Clinical grading of radiating pain in lower limbs and backache were done a scale of 1 to 10. On day 1 as soon as fixator is applied and there is increase in spinal canal area even by 1-2 mm due to distaction, there is significant improvement in the radiating pain and backache. Pain grading improved continuously with continued distraction.

Conclusion: It is hypothesized that distraction causes mechanical offloading of the disc for an average of 9 weeks. Offloading gives the disc a chance to repair and regenerate which is seen as increased hydration in T2 images in MRI. The exact mechanism is not known but there is a definite clinical improvement in patients. This is one of the very few studies done till now and it is expected that further research will be done by many centers in the world to prove or disapprove the hypothesis.

#293: Treatment of Congenital, Posttraumatic and Diabetic Foot Stump

Alexander Kirienko (Italy)

In Chopart and proximal to Lisfrank level post-traumatic, congenital e diabetic foot amputations the heel often deviates into equinus and varus, anterior and lateral wound dehiscence and ulceration may occur requiring higher-level amputation. The aim was demonstrate that distraction lengthening of the stump rebalancing leverage arms of the hind and forefoot, correct equinus, varus and prevent ulceration.

Methods: Ten patients with congenital (2 cases), post-traumatic (5), diabetics( 3) short foot stump were treated with percutaneous osteotomy of the anterior part of the calcaneus and neck of the talus, V osteotomy or midfoot osteotomy and application of circular external fixation and progressive distraction 1 mm per day started in the third day. Percutaneous Achilles tendon lengthening were added as needed. In the beginning longitudinal distraction for anterior lengthening was done, than the correction of equinus and varus deformity with the same frame and patients start partial weight bearing. After bony consolidation a total contact cast for 4 weeks.

Results: The It was achieved lengthening in mean 26 mm. Mean time of consolidation period was 69 days. The average age of the 4 women and 6 men was 41.9 years (range, 16-62). Postoperative complications included minor wound healing problems in 4 patients, wires breakage in one, wound breakdown requiring revision in 1. All 10 patients had successful soft tissue healing and new bone formation. The mean AmpuPro score was 108 points (of 120), and the mean Prosthesis Evaluation Questionnaire scale was 144 points (of 200)

Conclusion: This technique with the use of the Circular external fixator could be a salvage solution to the problems that often exist with postoperative short foot stump.

#294: An Anatomic Study on Whether the Immature Patella is Centered on an Anteroposterior Radiograph

James C. Kyriakedes (USA);
Raymond W. Liu

Questi on : In the operating room, after first obtaining a proper lateral radiograph with the condyles superimposed, a 90° rotation of the intraoperative fluoroscopy unit does not always produce an anteroposterior (AP) image with the patella centered. The orthogonality of these two views has not been well determined in children.

Methods: This study was comprised of a radiographic group (35 knees) and a cadaveric group (59 knees). Both cadaveric and clinical images were obtained by resting or positioning the femur with the posterior condyles overlapped, and then taking an orthogonal AP image. Centering of the patella was calculated and multiple regression analysis was performed to determine the relationship between patellar centering and age, gender, ethnicity, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), and contralateral centering.

Results: Mean patellar centering, expressed as the lateral position of the patella with respect to the total condylar width, was 0.08 ± 0.10 in the radiographic group and 0.06 ± 0.03 in the cadaveric group. Positive (lateral) patellar centering in one knee had a statistically significant correlation with positive patellar centering in the contralateral knee in both the radiographs and the cadavers. In the radiographic group, there was a statistically significant correlation between femoral varus and valgus deformities and positive patellar centering. In the cadaveric group, there was a statistically significant correlation between tibial valgus and negative (medial) patellar centering.

Conclusions: The patella in an immature knee is rarely perfectly centered on a true AP image, and is usually seated slightly laterally within the femoral condyles.

Clinical Relevance : Obtaining a true AP intraoperative radiograph is critical to analyzing and correcting valgus and varus deformities, and in the proper placement of implants. When addressing knee deformity one should consider obtaining an AP view orthogonal either to a perfect lateral of the knee or orthogonal to the flexion axis of the knee, particularly when evaluating distal femoral deformity.

#295: Management of hypertrophic nonunions with distraction osteosynthesis

Redento Mora (Italy)
, Luisella Pedrotti, Barbara Bertani, Gabriella Tuvo, Federica DeRosa

Question: Management of hypertrophic nonunions with compression-distraction techniques represents an evident improvement, especially considering the association of nonunion with axial deviation or shortening, that can be treated at the same time. The classic approach to nonunions is based on compression and rigid stabilization, and distraction is generally thought to be a predisposing factor for nonunion. However, in hypertrophic nonunions the tissue interposed between the bone fragments is biologically active and maintains its osteogenic potential, and gradual distraction acts as a strong stimulus towards consolidation; moreover, if the lack of bone consolidation is associated with axial deviation or shortening, they can be treated at the same time (Catagni et al., 1994; Rozbruch et al., 2002; Kocaoglu et al., 2003; Mora, 2006). Compression or contact between the bone fragments is not strictly required because the true missing component is an appropriate mechanical environment, provided by stable osteosynthesis. These concepts are based on Ilizarov's "tension stress" theory (Paley, 1990, Ilizarov, 1992).

Methods: The technique is simple and consists of providing adequate mechanical conditions to produce distraction osteogenesis. After a stable fixation with a circular external fixator, gradual distraction is administered at a rate of 1.0 mm per day until the shortening has been corrected. Subsequently, a further distraction of 0.5 mm every 10 days is performed in order to maintain the tension effect on the nonunion during the whole period of treatment. In cases without shortening only periodic distraction is carried out in order to produce and maintain the tension effect during the treatment. Where angular deformity or other deformities are associated, treatment is modified in order to correct them. This kind of treatment was started in 1986, and between 1986 and 2012 459 hyperthrophic noninfected nonunions of long bones were treated (with a follow-up of 2-28 years). There were 315 men and 144 women ranging in age from 20 to 68 years (average age 32 years). The nonunion site was at the humerus in 63 cases, femur in 85, and tibia in 311 cases. In 175 patients there was an open fracture. The time that had elapsed between the traumatic event and the treatment was from 5 to 49 months; 284 patients had previously received surgical treatment of the fracture; in the other patients the fracture had been treated conservatively. A shortening deformity of the involved bone was present in 310 cases (ranging from 0.5 to 2.5 mm, average 1.5 mm). In 91 of these casesthe shortening wasassociated with an angular deformity. Patients were treated with the "monofocal distraction osteosynthesis" technique combined with gradual correction of the angular deformity when required. In 427 cases a "classic" circular device and in 32 cases a "hexapod" device (TSF or SUV Frame) were employed. Patients were monitored by means of radiographic, ultrasonographic, and extensimetric evaluation, and whenever possible by means of microscopic investigation.

Results: The average time of treatment was 5 months (range 3-10). There were no intraoperative complications. During the postoperative period some patients presented with minor complications. Superficial infections at the transfixion points of wires or screws were seen in 142 cases (with rapid resolution after local dressing and specific antibiotic therapy). One patient had a transient paresis of the common peroneal nerve, which resolved after 2 months. In all but 6 patients consolidation was achieved. No angular deformity was observed at the end of treatment; a minimal residual shortening was seen in 12 patients (2-6 mm, average 3 mm). In some patients with femoral nonunions knee stiffness was seen during treatment, which gradually resolved with the help of kinesitherapy after removal of the fixator. In ten cases, material for histological examination of the nonunion site could be obtained at different time intervals from the beginning of distraction treatment. 4mm thick sections were stained with haematoxylin and eosin; 1 mm semithin sections were then stained with Rosenqvist silver stain. In the first phases, nonunion tissue is seen histologically as hypovascular fibrous or fibrocartilaginous tissue with very few capillaries and nearly always empty. The aspect of the nonunion tissue contrasts with the hypervascular bone ends on either side. Ten days after the beginning of distraction, there is a high proliferation of capillaries that form a vascular net and are filled by red blood cells. After 20 days there are fascicles of fibroblasts parallel to the the lines of distractional stress. In more advanced phases there is a gradual differentiation of osteoblasts that start to form osteoid tissue, and then deposits of calcium salt. Two months and half after after distracton is applied, the new bone trabeculae can be identified.

Conclusion: With this technique, intensive osteogenesis is achieved by means of a gradual distraction of the fibrous or fibrocartilaginous tissue at the nonunion site. This acts very similarly to the "interzone" located between the two ends of a corticotomy when bone lengthening is performed. The functional features of this kind of nonunion (hypertrophy and hypervascularity) are the main characteristics; as a consequence a fundamental preliminary assessment such as a bone scan is mandatory. Moreover, it is of utmost importance the maintenance of a constant degree of tension at the nonunion site even after the distraction is achieved. The results obtained in our series confirm that in hypertrophic nonunions of long bones the consolidation can be achieved by simple gradual distraction (maintaining a tension effect during the entire treatment period), with simultaneous correction of shortening and of other deformities if present. Therefore, distraction osteosynthesis has been shown to be a powerful stimulus towards bone consolidation. The morphologic study confirmed the intensive stimulus to neoangiogenesis (seen from the first days of the distraction treatment), and the absence of a cartilaginous stage between the initial tissue and the new bone, and so the process can be considered as a membranous ossification.

#297: A Review Of 45 Open Tibial Fractures Covered With Free Flaps. Analysis Of Complications, Microbiology And Prognostic Factors

Ulrik Kähler Olese (UK),
Claus Moser, Christian Torsten Bonde, Martin Mcnally, Henrik Eckardt

Question: Treatment of open fractures is complex and controversial. The purpose of the present study is to add evidence to the management of open tibial fractures, where tissue loss necessitates cover with a free flap. We identified factors that increase the risk of complications. We questioned whether early flap coverage improved the clinical outcome and whether we could improve our antibiotic treatment of open fractures.

Methods : From 2002 to 2013 we treated 56 patients with an open tibial fracture covered with a free flap. We reviewed patient records and databases for type of trauma, smoking, time to tissue cover, infection, amputations, flap loss and union of fracture. We identified factors thatincrease the risk of complications. We analyzed the organisms cultured from open fractures to propose the optimal antibiotic prophylaxis. Follow-up was minimum one year. Primary outcome was infection, bacterial sensitivity pattern, amputation, flap failure and union of the fracture.

Results : When soft tissue cover was delayed beyond 7 days, infection rate increased from 27% to 60% (p < 0.04). High-energy trauma patients had a higher risk of amputation, infection, flap failure and non-union. Smokers had a higher risk of non- union and flap failure. The bacteria found were often resistant to Cefuroxime, aminoglycosides or amoxicillin, but sensitive to Vancomycin or Meropenem.

Conclusions : Flap cover within one week is essential to avoid infection. High-energy trauma and smoking are important predictors of complications. We suggest antibiotic prophylaxis with Vancomycin and Meropenem until the wound is covered in these complex injuries.

#298: Treatment of infected non union of the distal (Juxta-articular) tibia

Halil Ibrahim Balci (Turkey)

Evaluate the effectiveness and complications for the treatment of infected nonunions at the distal tibia with distraction osteogenesis.

Methods: Between 1994 and 2009, 13 patients with a mean age of 50 years (range, 27-79) underwent distal tibial reconstruction for the treatment of infected nonunion with a mean bone loss of 4.8 cm (range, 1 to 7 cm). The mean number of previous operations was 1.77 (range, 1-4). We used bifocal compression and the distraction technique in five cases, compression with a circulair external fixator in five cases, with Taylor spatial frame in one case Radical debridement, temporary external fixation and antibiotic-impregnated cement were used for the first step in two cases because of the high grade infection. In addition, appropriate antibiotics were administered for six weeks . At the end of this period, when the sedimentation rate and C-RP values reverted to normal, reconstruction was performed with bone transport over an intramedullary nail. . At the last follow-up, functional and radiographic results were evaluated.

Results: The mean duration of follow-up was 36 months. The mean external fixation time was 198 days, and the mean external fixation index (EFI) was 29 days/cm. According to Paley's bone-scoring system, we had 10 excellent, two good, and 1 poor result (s); additionally, according to Paley's functional -scoring system, there were 5 excellent, 6 good, and 2 fair results. We had 11 problems, 5 obstacles and 1 sequela according to Paley's classification of complication. There was one persisting nonunion, which was reconstructed using a Taylor frame and underwent revision with a retrograde intramedullary nail.

Conclusion: External fixation techniques represent an appropriate solution to all of the problems encountered during the treatment period, and union was achieved in all patients without any discrepancy in limb length.

#299: Bone Transport for Postosteomyelitis Segmental Femoral Bone Defects With a Combined Retrograd IM Nail and Monolateral External Fixator.

Halil Ibrahim Balci (Turkey)

Treatment of osteomyelitis needs radical debridement that results in skeletal defects that can be treated via distraction osteogenesis. it is possible to replace or combine the external fixator with intramedullary locking nails during the consolidation phase to decrease the EFT. In our study we evaluated our cases on infected femur diaphyseal nonunion that we treated with combined technique.

Methods: Between 2003 and 2014, 17 ( 5 women and 12 men) patients with a. mean age of 39.3 years (range: 26 to 56 years) are operated with diagnosis of post debridement defect in femur. Age, gender, range of motion (ROM) of the affected knee and hip, previous surgeries, external fixation time, follow-up period were recorded from patient records retrospectively. The mean number of the previous surgeries were 2,4 (range 1 to 5). Bone and functional results were evaluated with use of the criteria of Paley et al. Complications were also classified according to Paley et al.

Results: All patients had full hip flexion and extension. There were no limb length discrepancy. Mean EFI time was 1.8 month/cm (range: 1.5-2.2 months/cm). Paley bone score was 11 excellent, 4 good, 2 fair. Paley function score was 10 excellent, 5 good, 2 fair. There were no reccurance of the infection. All of the distal compression sides are healed.

Conclusion: We recommend acute shortening and re-lengthening for femur osteomyelitis with bone loss in patients with no vascular circulation problem. The acute shortening and re-lengthening technique may provide greater patient satisfaction because of the shorter external fixator period, more stability and lower complication rates, especially combination of the short intramedullary locking nail with external fixator.

#300: Distraction Osteogenesis for Brachymetatarsia Percutaneous Metatarsal Osteotomy with External Fixation A Retrospective Study

Bradley M. Lamm (USA),
Monique C. Gourdine-Shaw, John E. Herzenberg, Jason George DeVries

Question: Brachymetatarsia has been successfully treated with distraction osteogenesis; however, metatarsophalangeal joint (MTPJ) stiffness after treatment continues to pose a problem. We evaluated the problem of MTPJ stiffness and offer a preventative solution. What results are achieved when performing distraction osteogenesis using two techniques: axial Kirschner wire digital stabilization and spanning the metatarsophalangeal joint?

Methods: We retrospectively reviewed the medical records of patients who underwent gradual metatarsal lengthening between 1990 and 2011. Two techniques, axial Kirschner wire digital stabilization and spanning the MTPJ, were compared. Patients were included in the study only if they had at least 1 year of follow-up after external fixation removal. We obtained measurements from weightbearing anteroposterior and lateral view radiographs obtained preoperatively and ones obtained at least 1 year after external fixation removal.

Results: Eighty-eight patients (152 metatarsals, 124 feet) with brachymetatarsia underwent distraction osteogenesis via a percutaneous osteotomy and application of external fixation. Sixty-seven metatarsals had Kirschner wire fixation to stabilize the digit, and 85 metatarsals had two-pin fixation spanning the MTPJ. Average amount of metatarsal lengthening was 15 mm (range, 425 mm), equating to an average of 30% of the average preoperative metatarsal length. Average time until external fixation removal was 17 weeks (range, 8-28 weeks). Average duration of follow-up afterexternal fixation removal was 2 years (range, 1.0-10.8 years). All patients were satisfied with the final length of the metatarsal. Adverse events included 16 problems, 17 obstacles, and 50 complications. Average declination of the lesser metatarsals was unchanged after treatment. An average of 10 degrees (range, 617 degrees) of medial angulation or bowing of the metatarsal occurred in 18 (12%) of 152 metatarsals undergoing lengthening. Patients with two-pin fixation spanning the MTPJ had fewer problems, obstacles, and complications as well as fewer complaints of stiffness.

Conclusion: Our study is the largest in the literature and shows this percutaneous technique of gradual metatarsal lengthening with external fixation and with distraction across the MTPJ is successful and accurate. Distraction osteogenesis with two-pin fixation spanning the MTPJ had fewer complications and complaints of stiffness than treatment with Kirschner wire fixation. The techniques are associated with a relatively low incidence of adverse events, maintain a rectus toe position during lengthening, and provide a functional joint postoperatively.

#301: Early complications associated with limb lengthening using a magnetically activated intramedullary lengthening device in pediatric patients

Mark L. Miller (USA),
J. Eric Gordon

Question: Limb lengthening of the lower extremities in pediatric patients through distraction osteogenesis has traditionally been accomplished through monolateral or hexapod external fixation and the early complications of distraction osteogenesis has been well described. Recent technology, with the development of a magnetically activated intramedullary lengthening device, has allowed distraction osteogenesis without the use of external fixation. The aim of our study is to describe the early complications, within 3 months, and risk factors associated with lower extremity limb lengthening in pediatric patients using a magnetically driven intramedullary lengthening device.

Methods: All pediatric patients undergoing limb lengthening using a magnetically driven intramedullary device performed by two attending surgeons at two hospitals within one institution between July 2013 and February 2015 were retrospectively reviewed with IRB approval. Demographic data, radiographs, medical records were reviewed for each patient. Problems, obstacles, and complications occurring were determined based on Paley description for the Ilizarov method (CORR 1990). Complications were considered early complication if they occurred within 6 months of initial implantation.

Results : 17 unique pediatric patients (17 limb segments) underwent lower extremity limb lengthening using a magnetically driven intramedullary lengthening device between July 2013 and February 2015. 13 antegrade trochanteric femoral lengthenings, 2 retrograde femoral lengthenings and 2 tibial lengthenings were performed. Patient age range was 10-18 (average 15.2). 9 patients had congenital limb length discrepancy, 8 patients had a developmental cause for their limb length discrepancy. No stature lengthenings were performed. 8 patients had a prior limb lengthenings using circular external fixation (all congenitals). Lengthening goals ranged from 2.5 cm to 7 cm. 14 of 17 patients reached their goal lengthening. 6 of 17 patients sustained complications based on Paley criteria. 2 of 17 patients had obstacles requiring surgical intervention and 3 of 17 had problems delaying treatment, all related to improper home use of the external control device. Complications included two lengthenings aborted due to knee subluxation, one failure to form regenerate, one intraoperative fracture from anterior nail protrusion, one injury to nerve branch of superficial peroneal nerve to the EHL, and one nail which did not lengthen due to patients soft tissue distance between internal magnet and external control device. 5 of 6 complications occurred in patients with a congenital cause for limb length discrepancy.

Conclusion: Lower extremity limb lengthening using a magnetically driven intramedullary lengthening device is developing technology which has been used to treat pediatric patients with limb length discrepancy. Despite relative ease of insertion of the device, early complications can occur, even in the hands of surgeons experienced with lower extremity lengthening using circular external fixation. Surgeons without experience in lower extremity lengthening should exercise caution when using the magnetically driven intramedullary device and be mindful of the early complications which can occur.

#302: Rotational Guided Growth

Gonzalo A. Martel (Argentina),
Dror Paley, Gabriela Sobrado, Francisco Praglia, Lawrence Holmes Jr, Arellano Elena

Question: Do rotational guides growth could be achieved in the growing bone with the use of an internal implant called PPD? Growth plate of long bones has been handled successfully in treating patients with discrepancies or deformities in varus, valgus or flexion of the limbs. Hypothetically rotational deformities could also be corrected by an accurate stimulus at the growth plates (physis).

Methods: For this study 8 calves 2 months old were selected, all of them got the PPD implant on the right metacarpal of their cephalic limbs. Monthly clinical and radiographic checks were conducted on the operated and on the contralateral limb as control, length and rotation were evaluated. The most rotated individual was chosen to harvest their limbs for dissection, the rest were reserved for 2 years follow-up.

Results: All the individuals treated in the sample got rotational growth. Radiological rotation was noted after 1 month in 3 of the 8 operated calves. After 3 months the rotation was evident both radiological and clinical on all individuals. After 2 years follow up only 25% of the sample remains with some rotational correction.

Conclusion: Rotational corrections can be gradually generated and maintained in immature growing long bones by means of minimally invasive surgery. Gradually generated rotational corrections over healthy physis do not generate discrepancies.

#303: Periprosthetic fractures of the femur the treatment paradigm shift?

Alexander Chelnokov (Russia),
Igor Piven, Igor Shlykov, Konstantin Piastopulo, Alexey Semenistyy.

Question: Current treatment of fractures around hip implants has focused on locked plating in well-fixed stems, and if the stem is loose the conventional approach requires revision to a long stem with plates, cerclage and grafting, or even total femoral replacement. These treatment modalities are invasive, expensive, and result with high complication and reoperation rates. Recently a new approach including stem lengthening by a connecting nail was introduced but it is presumed to be appropriate only for stable stems, and exposure of the stem tip required for open connection. Its applicability in loose subsided stems is unknown. Techniques of closed reduction of both fracture and stem position have not yet been developed. Fixator-assisted technique can be helpful but its use in different periprosthetic fracture patterns has not yet been defined. Aim of our study was to design a technique of less invasive intramedullary fixation in periprosthetic fractures and deformities of the femur to provide primary stability of the stem and the femur.

Methods: Motivated by a case of plate failure in periprosthtic femoral fracture we designed and used a modification of an industrial solid titanium femoral locked nail. Its design provides tight fit of the distal part of the femoral stem. Since 2007, fixator-assisted internal fixation was used in the treatment of 71 femoral periprosthetic fractures: Vancouver B1 23 cases (8 cemented), Vancouver B2 24 (2 cemented), B3 17 (3 cemented), Ñ-7 (2 cemented). The nails were individually custom-made to fit the particular stem design and size. Simplified Ilizarov frames were used to gain alignment and length acutely in 63 cases or gradually (5 14 days) in 8 cases. In 29/41 case (5 cemented) of B2/B3 fractures femoral stems were subsided 10 mm and more.

Results: Frame application allowed to restore length and alignment of the segment in all 30/71 cases of stable stems (B1 and C). With fixator-assisted nailing it appeared attainable to reduce subsided stem position relatively to the major trochanter and the acetabulum in all 29/41 cases. In 9 of them also acute lengthening of the femur was performed to 1-3,5 cm. Three frame types were defined depending on two factors: injury type according to Vancouver classification, and position of the stem tip inside or outside medullary canal. Frame type 1 (Vancouver B1 and C type) is secured to the proximal and distal aspects of the femur. Type 2 (Vancouver B2-B3, stem tip outside the distal fragment) the frame secured to the iliac wing and the distal femur. And frame type 3 (B2-B3 with the stem tip inside the medullary cavity) consists of one arc secured to the distal femur, with connection to an insertion handle of the intramedullary nail this frame type allows femoral lengthening by pulling the femur downwards over the stem-nail . 64 patients (90%) were available for follow up in 1 year. 62 healed (4 after secondary procedures). Two have asymptomatic nonunion. In 32 cases of non-cemented loose stems available for follow-up healing occurred along with intact distal locking screws up to 6 years of observation which was recognized as reintegration of the stem. There were no signs of stem loosening revealed in all cases (24) of subsided non-cemented stems that were reduced. In loose cemented stems where reintegration can not be expected elective revision was performed with a primary femoral stem (3/5), and two patients with low functional demands are being observed. Major complication included 1 case of deep infection in 1,5 year after the index surgery (two stage revision was performed) and 2 cases of slim stem breakage treated with revision to a long stem. All these complications occurred in patients with cemented stems.

Conclusion: For elderly patients with severe comorbidities the technique provides less invasive treatment option with rapid recovery. Immediate unrestricted weight-bearing appears safe regardless of stem loosening. In case of loose dislocated stems the presented approach provides not only strong primary fixation but also correction of subsided stem position along with restoration of limb length and alignment. A new option of acute femorallengthening over existing femoral stem was introduced. In patients with uncemented loose stems secondary stem stabilization can be expected so formal revision with stem replacement renders unnecessary. Breakage of 6 mm locking screws is expected after usual time of femoral fracture union so the breakage may be used as an indicator of proper time for elective revision. In loose cemented stems a new two stage approach is introduced including immediate low invasive fracture stabilization with the periprosthetic nail, and elective revision after fracture union in demanding patients. So the current approach with plating in stable stems and revision in loose ones can be replaced by the introduced approach in vast majority of cases.

#304: A clinical research on the treatment of post-traumtic tibia osteomyelitis with Ilizarov technique

Kai Zhang


#305: Radiological criteria for fixator removal

Lukas Zak,
Gerald E. Wozasek


#306: Retrograde femoral length and deformity correction using reverse planning and motorized telescopic nails after physeal trauma arrest

Mark T. Dahl (USA),
John Birch, Jennifer Laine

Question: To describe the technique and results of retrograde femoral length and deformity correction with motorized telescopic nails in patients sustaining premature distal femoral physeal arrest. Between December of 2005 and December of 2014, twelve patients with limb length discrepancy and distal femoral deformity resulting from premature distal femoral physeal arrest were treated by the two senior authors at our respective hospitals. Two devices, the Fitbone nail and the Precice nail, allow accurate rate and rhythm control of distraction for limb lengthening. A novel preoperative planning method, known as the Reverse Planning Method (RPM) was used to achieve neutral mechanical alignment while lengthening along the anatomic axis of the femur. The method of retrograde intraoperative deformity correction and subsequent motorized lengthening was developed by Professor Rainer Baumgart and followed in a similar fashion by the two senior surgeons.

Methods: This is a retrospective, consecutive case series of 12 patients treated by two surgeons with the same protocol. Distal femoral physeal arrest was traumatic in nine, infectious in two, and ischemic in one patient. Five patients were treated with the Fitbone device between 2006 and 2012, and 7 patients were treated with the Precice device since 2012. Preoperative Planning Method: All preoperative plans were performed by Reverse Planning Method as described by Baumgart. The goal was to achieve a neutral mechanical axis at the completion of lengthening using a retrograde femoral technique, by avoiding secondary distal femoral deformity which would otherwise result from medialization of the knee and lateralization of the weight bearing line while lengthening along the anatomic axis of the femur.

Surgical Technique: Several tools described by Baumgart were used for retrograde femoral intramedullary lengthening: 1. Radiographic grid to assess intraoperative alignment, 2. Shanz pins to maintain bone segment rotation and assist in angular correction, 3. Sterile bumps for knee positioning during reaming and nail insertion, 5. Sleeves to protect knee cartilage from reamers and reamings, 6. Rigid, deep fluted reamers to create a stable nail fit and minimize marrow pressure while reaming. The latency period was extended and lengthening rate diminished for greater angular and translation deformity correction.

Results: The average acute angular correction was 9 degrees (range 5-19 degrees). The average acute osteotomy translation was 4 mm (range 2 15 mm). All twelve patients achieved mechanical axis within 2 millimeters of the knee center. All patients were equalized to within 10 mm. The length achieved averaged 4.3 cm (range 2.2 7 cm). No bone grafts were necessary. Complications included one spontaneous knee infection after an ingrown toenail infection spread to the knee joint, six months after the lengthening was completed. The joint sepsis resolved with nail removal, knee lavage and intravenous antibiotic administration for four weeks. The Reverse Planning Method can accurately guide acute deformity correction of the distal femur and result in ideal mechanical axis alignment at the completion of retrograde femoral lengthening for distal femoral physeal arrest.

Conclusion: The surgical method of Baumgart was successful in achieving the planned intraoperative correction goal and lengthening goal. Both the Fitbone nail and Precice nail performed without mechanical failure.

#307: Treatment of open fractures of the tibia with locked intramedullary nail with a core releasing antibiotics. Comparative study with standard nailing.

Nuno Craveiro-Lopes (Portugal),
Carolina Escalda, Manuel Leo

Question: The aim of this study was to compare the clinical and radiographic results of a interlocking nail with a releasing antibiotic core of PMMA with a standard interlocking nail for the treatment of open fractures of the tibia.

Methods: Prospective, controlled trial including 30 patients with open fractures of the tibia. Patients were divided into two groups according to the treatment method: Group I (STD), consisting of 14 patients treated by delayed interlocking standard nailing, after an antibiotic treatment and bed rest. Group II (SAFE) comprising 16 patients treated with a interlocking intramedullary nail with a core of PMMA cement with antibiotics, 5 of which had a temporary stabilization with an external fixator. Antibiotics chosen to impregnate the SAFE nail in cases without prior bacteriology were vancomycin (2gr) and flucloxacillin (2gr).

Results: There were no statistically significant differences between groups with respect to demographic data (age, gender), type of fracture and degree of exposure (p 0, 05). The mean follow-up was 2.4 years (5 months to 4 years) for the STD group and 2.1 years (4 months to 3 years) for the SAFE group. 15 of the 30 patients had positive bacteriology, including 13 cases with aggressive agents predominating Enterobacter, Enterococcus, Pseudomonas and MSSA groups. The infection rate after nailing was 43% (6/14 patients) for the STD group and 6% (1/16 cases) to the SAFE group, a statistically significant difference (p = 0.02) The mean time to union was 7.5 months (3 months to 1.5 years) for the STD group and 4.5 months (2 months to 8.5 months) for the SAFE group, a statistically significant difference (p = 0.02) The complication rate was 64% (9/14) in the STD group and 25% (4/16) for the SAFE, a statistically significant difference (p = 0.03). The 7 cases of nailing that came to infect, were treated with nails with cement impregnated with antibiotics in 6 cases, 5 of which cured and on the other, the infection recurred was treated with the Ilizarov method. A case of infected STD nailing was treated with suppressive antibiotics treatment continuously until fracture consolidation and infection healed after removing the nail, 8 months later.

Conclusion: We observed that the open fractures of the tibia treated with SAFE nails presented a statistically significant lower rate of infection, faster consolidation and fewer complications compared with treatment with deferred standard nails. The SAFE DualCore Universal nail is a biologically active device, releasing antibiotics effective for the treatment of open fractures of the tibia. Compared to similar devices available on the market, it has the advantage of allowing selection of the type and dose of antibiotics, it allows fixation with screws of intermediate bone segments, it shorten the period of hospitalization and treatment time, reducing the costs associated with the treatment of this pathology.

#308: Proximal femur lengthening in post-trauma reconstruction

Miliind M Chaudhary (India),
C. R. Harish

Question: Does regenerate bone form well in complex cases of infected fractures and nonunions of femur? What factors correlate with axial deviation in coronal plane at regenerate?

Methods: 67 consecutive cases of proximal femur lengthening performed for post trauma reconstruction at our institute over 10 years were studied retrospectively. an average of 7.8 cm of length was achieved ( 1 to 18 cm) in 67 patients( 43 with infected nonunions, 12 with aseptic nonunions and 12 with infected fractures with bone gap). Bone formation through a proximal femoral corticotomy was excellent despite having a high level of difficulty score of 21.6. We studied axial deviation of the regenerate in the coronal plane and tried to find out if it correlated with shape of distal nonunion, shape of corticotomy, distance of corticotomy from lesser trochanter, no of pins in proximal fixation, type of fixation of proximal fragment (LRS, Trochanteric or Neck type) , amount of lengthening and age of patient.

Results: 66 out of 67 regenerates did not need any augmentation. There were 16 instances of premature consolidation signifying very good bone formation. There was no statistically significant.

Conclusion: Despite having a high level of difficulty score in complex post trauma reconstruction lengthening regenerate bone formed very reliably in our series. Chief worry was to watch for axial deviation which was seen in almost 50% cases more than 7. Only age correlated rather weakly with deviation which could be explained by reduced elasticity of tissues giving more resistance to lengthening.

#309: External fixation in polytrauma

Carlo Alberto Pareja Caceres (Republic of Panama)

External fixation is a successful treatment in polytrauma?

Methods: Yes, it is a very successful treatment on these cases of polytrauma.

Results: Our results are excellent.

Conclusion: External Fixation is very helpful in polytrauma since it saves life and function on polytrauma patients.

#310: PRECICE HTO nail; preliminary clinical experience

Miliind M Chaudhary (India),
Rupak Chatterjee, Tarun Chhabra

Question: Is gradual correction of varus deformity in Medial compartment osteoarthritis of knee possible using an implantable nail?

Methods: 5 patients with medial compartment osteoarthritis of the knee were treated with a medial open wedge high tibial osteotomy which was opened gradually to achieve slow correction of the varus deformity. The medial open wedge HTO was performed as usual with the difference that the biplanar tibial tuberosity osteotomy was distal in direction and hence remained as a part of the proximal fragment. A self-lengthening nail of 10.7 mm dia and 155 mm length was inserted as a standard IM nail. The nail was locked distally with 3 bolts, 2 medio-lateral and 1 AP bolt. Proximally they were locked with one AP bolt and one Mediolateral bolt which swivelled to allow correction of varus in the coronal plane. This distraction occured with help of an external Remotge controller which turned the magnets inside which actuated the drive mechanism.

Results: 5 patients had surgery to relieve their pain from medial compartment osteoarthritis of the knee. Their average age was 54 years ( 42 to 64) and average preoperative HSS score was 40 and PostOp score at 6 months was 77. Mean Preoperative Mechanical axis deviation was. Mean preop PPTA was 79.4 degrees. Mean PostOp PPTA was 77.2 degrees. Mean duration of distraction needed was 13 days ( 8 days to 20 days) Mean time to full weight bearing ambulation without walking aids was 3 months. Maximum correction of varus deformity achieved was 11.8 degrees. Minimum correction was 8 degrees. Correction fell short of necessary by 4 to 7 degrees in 3 patients. THe MAD was corrected to a mean of 41% In 3 patients who needed more than 12 degrees of correction, the nail distracted the osteotomy apart to fracture the lateral cortex and hence lengthen the limb. This was accompanied by sudden pain. These 3 patients had reversal of their distraction to restore limb length.

Conclusion: The era of self-lengthening nails to perform internal lengthening started about two decades ago. We report the first 5 cases performed to gradually correct a varus deformity with an internal device controlled by an external remote controller. The PRECICE HTO nail in its first version allows gradual correction of upto 12 degrees of varus allowing regenerate formation, doing away with the need for bone graft substitutes.

#311: Specifics of work organization of an orthopaedic center specialized in limb lengthening and reconstruction surgery

Alexander Gubin (Russia),
Elena Voronovich, Dmitry Borzunov, Andrey Kobyzev, Yuri Gorokhov, Eduard Goncharuk

Question : Ilizarov Center is the biggest orthopaedic hospital of Russia, which widely uses limb lengthening and reconstruction surgery. Despite many-year experience and active development of limb lengthening and reconstruction surgery in Russia and in the world there are objective organizational problems in the work of these hospitals and departments. So, it becomes a significant reason for many orthopaedic institutions not to develop this field. Development of organizational strategies for hospitals involved in limb lengthening and reconstruction is an important aspect of work of ILLRS and ASAMI-BR. The aim of this study is to determine the main problems and find options for solutions in organization of limb lengthening and reconstruction surgery in orthopaedic hospitals.

Method : According to reports of healthcare system of Russia we determined approximate numbers of how widely external transosseous osteosynthesis is used. Trends of development of limb lengthening and reconstruction surgery in the Ilizarov Center were analyzed. Demographic features of patients admitted to the Ilizarov Center were studied. Dynamics of in-patient treatment over the last 5 years and the largest organizational changes over the same period were analyzed.

Results : Despite active development of other fields of orthopaedics the absolute number of limb lengthening and reconstruction surgeries in the Ilizarov Center has not decreased. In Russia in general, the focus of interest are such economically more attractive fields as joint replacement and spinal surgery. Application of the Ilizarov method and Ilizarov fixator is becoming more and more relevant for some conditions, especially septic. A number of services of the hospital such as admission department and intensive care were reorganized and upgraded. Personnel involved in limb lengthening and reconstruction surgery, as a rule, has high organizational inertia.

Conclusion : 1. Limb lengthening and reconstruction surgery can be most effectively organized in large orthopaedic hospitals with various areas of expertise or in multi-specialty hospitals. 2. Medical personnel, involved in limb lengthening and reconstruction surgery, have psychological specifics determining their success in this field. 3. Age and technological and professional succession is the principal basis for development of limb lengthening and reconstruction surgery in a hospital.

#312: Treatment of infected bone defects with Ilizarov external fixator

H. Daniel Sagarnaga Alcoreza (Bolivia)

I report the experience from the last fourteen years done in my practice at the Hospital de Clinicas of La Paz and private practice, the treatment of massive tibial and femoral bone defects by the use of bone transport and also acute compression and distraction using the Ilizarov external fixator.

Method: Thirty-eight patients were treated since October/2003 until February/2014, using these techniques. The patients were 16 females and 22 males. The defect size ranged between 2, 5 and 15 cm (average: 6.05 cm). The age ranged between 14 and 70 years (average 38). Etiology obviously was infected nonunion in all of them. The affected place was the tibial diaphysis in 26 patients, the femoral diaphysis in 8 and 4 in humerus. The external fixation time ranged from 5 months to 24 months (average: 9.5 months). All active cases (n = 32) were treated by debridement with resection of necrotic bone including removal of implants in infected osteosynthesis. We had some complications as rigidity of joints like ankle and knee, which improve with the work of the physical therapy (eight patients). Eight patients had superficial infection of one of the wire or pins or both and this was successfully treated by antibiotic by oral therapy and a every 24 or 48 hours cure at the emergency of the wire or pine. The method of treatment was defined between bone transport and acute compression at the place of bone defect and lengthening at the proximal or distal methaphysis. With this work we think that the treatment that we used it is so grateful for the patients, who just had one or two alternatives before reach the amputation. This method is for us the best to fill massive bone defects. The management of massive segmental bone defects it is a challenge for the surgeon and a good training in Ilizarov techniques is important to have good results.

Results: The cases were followed up for one to three years and the results were evaluated by Paley criteria of bony results ( union, infection, deformity and leg-length discrepancy ) and Functional Results (significant limp , equinus rigidity of the ankle, soft-tissue dystrophy, pain and inactivity) .

Ilizarov methodology produced good results in infected bone defects of long bones. The results were comparable being more satisfactory the treatment with acute compression-distraction, needing fewer interventions than the bone transport. Even the long time that is necessary to have a satisfactory result, it is not a loss time. I can prove a humbling experience for any orthopedic surgeon. Knowledge and skill are prerequisites for facing the challenge. Massive skeletal defects usually follow severe open fractures or excision of tumors. Autologous cancellous bone grafting has long been the hallmark of skeletal defect management, but when these defects are massive, the bone graft will not be enough to fill the defect; the process of graft incorporation and corticalization to support body weight will take a long time and may never be complete. Vidal (1967) popularized the use of cancellous bone graft in conjunction with external fixators to manage skeletal defects, but it was necessary to have bone graft from more than one donor site, which adds to the morbidity of the patient and in smaller women with thin iliac crests, the amount of graft was not enough to fill the defect. Microvascular techniques to transfer the fibula with its blood supply and sometimes with skin and muscles proved to be useful in overcoming large skeletal defects, but are highly demanding and have some drawbacks. With the use of modular-ring external fixators and transosseous wires attached to the rings under tension to stabilize the bone fragments, Ilizarov introduced the concept of induction of local bone formation with a minimally invasive procedure. Ilizarov coined the term distraction osteogenesis to describe the induction of new bone formation between osseous surfaces that are gradually pulled apart. His clinical successes of salvaged limbs that would otherwise have been amputated and returned disabled patients to productive levels of activity eventually spread by word of mouth throughout the Communist bloc of countries. By 1981, a group of Italian orthopedic surgeons had learned of his technique. More recently, the method was introduced in North America, where it has been adopted primarily for limb lengthening and the correction of limb deformities as well as the treatment of nonunions and bone loss secondary to trauma, infection, or tumor. Since 1999, we have used bone transport to overcome skeletal defects after trauma, osteomyelitis, or tumor excision, with satisfactory results.

#313: The induced membrane technique for healing of bone defects. A review of 9 cases.

Ulrik Kähler Olesen (Denmark),
Anders Wallin Paulsen, Per Bosemark, Henrik Eckardt

Question: Segmental defects of long bones are notoriously demanding to treat. We evaluate nine cases where the Masquelet induced membrane technique to substitute bone loss has been used. We discuss the method compared to other types of bone reconstruction and share our tips and tricks to reduce treatment time and improve patient comfort.

Method: Eight patients (nine injuries) operated between 2011 and 2014 were included . Four were infected. Outcome was time-to weight-bearing, consolidation, complications, bone grafting.

Results : All patients were weight bearing fully after 270 days. Mean time to weight bearing was 225 days. Time to full weight bearing was shorter in patients where nails were used to stabilize the construct: median 115 (range 0-268) compared to plates: median 244 (range 219-271). Two cases are not fully consolidation at present. Three cases needed grafting, one was misaligned. There were no amputations, no persistent infections, and no implant failures.

Discussion : The induced membrane technique is a relevant alternative to traditional bone substitution in select cases, yet somewhat unpredictable in its course and prolonged immobilisation is often required.

Conclusion : Nailing seems to improve the outcome by reducing treatment time and volume of bone graft needed and should be considered when feasible.

#314: Management of Neglected Clubfoot by Ilizarov using Ponseti principles

Ram Avtar Agrawal (India)
, Rajat Agrawal

Question: In all developing countries, few neonates with clubfoot are brought for management; rather neglected clubfoot is encountered more frequently. Repeated surgeries on the soft tissue in neglected clubfoot causes increased stiffness of the foot while bony procedures make a foot, which is usually already small, even smaller. In neonates, Ponseti corrective cast treatment is accepted worldwide now. Can Ilizarov be applied in older children by using Ponseti principles?

Methods: We applied Ilizarov fixator in older children with neglected clubfoot from 5 to 22 years in 33 patients. Mead duration was 38 weeks. Ponseti principles were used while correcting with Ilizarov frame. An olive wire was passed through the talus, no wire were passed in calcaneus. First the plantar fasciotomy was performed followed by correction of forefoot pronation by gradual distraction between forefoot and mid foot rings followed by supination of forefoot ring. After this adduction was corrected gradually; finally tendo Achilles tenotomy is done and frame configuration is changed, wire is passed in calcaneus to correct the equines gradually.

Results: Results were analyzed by Dimeglio/Bensahel scoring system based on degree of correction achieved. Out of 33 patients, 22 had excellent results, 7 had good results, 4 had fair results. There were minorcomplications of skin breakdown, pin tract infection. Relapse was seen in 4 cases.

Conclusion: The aim of treatment of neglected clubfoot is to obtain a fully corrected and mobile foot at maturity rather an absolute anatomical but stiff foot. Ilizarov technique achieves correction by distraction of foot allowing realignment. Ilizarov technique based on Ponseti principles is an effective method of treatment of neglected clubfoot, it radically decreases the need for extensive open surgery.

#315: Comparison of PACS and Mobile Application for Assessment of Lower Extremity Length and Alignment

Amanda T Whitaker (USA),
Julio J. Jauregui, Martin G. Gesheff, John E. Herzenberg

Question: Over 500 medically related mobile applications are available for tablets that use various platforms. Some offer treatment suggestions, and others aid in obtaining measurements, either for the physician or the patient. Although commonly utilized, very few of these applications have undergone testing and peer-review for their accuracy. Previous studies have compared measurements for limb deformity evaluation that were obtained using the gold standard of hard copy radiographs and the picture archiving and communication system (PACS). These studies found that hard copy radiographs and PACS are equal in terms of intra-and inter-observer reliability. What is the accuracy of radiographic measurements obtained with a mobile application (referred to hereafter as App) when compared to the PACS, and is there any intra - And inter-observer variability observed with these measurements among different orthopedic practitioners?

Methods: Four participants (attending physician, senior resident, junior resident, and physician assistant) measured the limb length (LL), the lateral distal femoral angle (LDFA), and the medial proximal tibial angle (MPTA) of 48 limbs (24 patients), twice with the App and twice with the PACS. We calculated limb length discrepancy (LLD) using subject reported limb lengths. We determined whether there was any statistical difference between the measurements obtained with the App or the PACS. We also determined the consistency for the intra-observer correlation coefficient (ICC) for both systems and the consistency for the inter-observer (4 participants) correlation coefficient for both systems.

Results: There were no statistical differences when assessing the LLD, the MPTA, or the LDFA angle measurements between the App and the PACS (p = 0.68, 0.87, and 0.97, respectively). The intra-observer ICC when measuring the LL, LDFA, and MPTA was similar between the App and the PACS (0.96, 0.89, and 0.96 vs. 0.96, 0.93, and 0.95) [Figures 1-2]. Additionally, the inter-observer ICC was also similar between the App and the PACS (0.98, 0.96, and 0.99 vs. 0.99, 0.98, and 0.98) [Figures 3-4].

Conclusion: This study shows that the App is an accurate application for measuring LLD, LDFA, and MPTA. When comparing the App to PACS, the length measurements and the angular measurements are equally consistent with both systems. Both systems appear to be valid instruments for the clinical setting of evaluating lengths and angles on standing radiographs. Training level did not affect the accuracy of measurements. This is the first study to evaluate the pre-operative validity and consistency of the planning mobile application when compared to the gold standard of PACS.

#316: Bone remodeling after limb lengthening according to the data of the radiological methods of the study

Diachkov Konstantin A (Russia),
Diachkova Galina V.

Question: To study the dynamics of the bone remodeling after its lengthening to solve the problem on the quality of the newly formed bone, mechanisms of organotypical bone formation in the late follow-up and to define the criteria for study of the distraction regenerate bone with qualitative evaluation of the basic parameters.

Methods: Tibial bone remodeling was studied in dynamics in 128 cases of achondroplasia, low height and congenital and acquired shortening of the lower limbs at the different stages of lengthening using current radiological diagnostics (multi-slice CT (MSCT) and MRI). Current techniques of post-processing MSCT data were used in the work.

Results: Bone remodeling after lengthening is complicated and rather long process similar to the process of bone reconstruction during growth as literature and our data indicate. Distraction regenerate during fixation is presented as trabecular bone with longitudinally oriented bone trabecula. With the growth this area acquires trabecular structure typical for metaphyseal position of the bone forming trabecular lines along the weight-bearing axis (longitudinally oriented trabecula in the distraction regenerate are forming under the tension forces oriented along the bone axis). The next stage in the process of the natural growth is formation of marked cortical plate and medullary canal as the diaphysis structures from the trabecular bone by trabecular resorption from endosteal surface and densifying and thickening of the cortex. The remodeling of trabecular bone of the distraction regenerate is produced by the similar way. After completion of the bone growth in the regenerate the loading on the newly formed bone is increasing and trabecular adaptation of the bone tissue takes place; the inter-trabecular space is filled in with the bone forming cortex with simultaneous trabecular resorption in the area of future medullary canal starting from the side of the proximal and distal fragments of the host bone. After fixator disassembly the process continues, small amount of the bone trabecula is preserved for some time in the central part of distraction regenerate and 1-1,5 year later the medullary canal is completely formed.

Conclusion: Performed study allowed us to follow the dynamics of bone remodeling in the area of lengthening that passes several stages similar to the natural growth, offer the criteria for and define the stages of remodeling evaluation of the newly formed bone quality, therefore, the current methods of radiological diagnostics should be included in the algorithm of the intra-vital study of radio-morphological details of complicated and long process of the bone formation during its lengthening. Algorithm of the newly formed bone study should include modified techniques of MSCT data processing and the study of cortical quality should be accompanied by measurements of its common and local density.

#317: The Ilizarov lateral tibia bone removal technology treats the diabetic foot ulcers

Qikai Hua (China),
Chen Xian, Liangjun Zhao

: Is the patient with diabetic foot ulcers wanger 3~4 treated in the Ilizarov lateral tibia bone removal technology can achieve high rate of limb salvage?

Methods : Follow up visit the fifteen diabetic foot ulcers patients (wagner 3~4) who go under the Ilizarov lateral tibia bone removal surgery from August 2013 to December 2014. To estimate the rehabilitation of the ulcer and the rate of the limb salvage.

Results : Fifteen ulcers in fifteen patients can be cured. All limbs are salvaged.

Conclusion : To manage the diabetic foot ulcers in the Ilizarov lateral tibia bone removal technology can reach a high rate of limb salvage.

#318: The outcomes of distraction arthroplasty for ankle osteoarthritis can be improved by arthroscopic debridement

Jianchao Gui (China),
Yiqiu Jiang, Xiaofei Yang, Yang Li

Question : Osteoarthritis (OA) is a degenerative disabling joint disease affecting more than 10% of the adult population. Joint distraction is a relatively new approach to the treatment of severe ankle OA. But the results were reported to be about 75% improvements. How to improve the result of distraction arthroplasty is urgently needed. The purpose of this study was to compare the outcomes of distraction arthroplasty for ankle osteoarthritis with or without arthroscopic debridement performed simultaneously.

Methods : A retrospective randomized clinical study was conducted in 30 patients of ankle osteoarthritis. Among them, 20 patients were treated by distraction arthroplasty alone while the other 10 patients were treated by distraction arthroplasty in combination with arthroscopic debridement. Pre-treatment data were obtained by retrospective analysis using questionnaires and patients charts. Post-treatment assessments were undertaken using the same questionnaires and by physical examination. All patients were evaluated with an average follow-up of 26 months.

Results : ALL reported improved pain and movement with those co treated by distraction arthroplasty and arthroscopic debridement experiencing the best results. The average preoperative AOFAS score was 55 (range, 29 to 82), and the average postoperative score was 74(range, 47 to 96) in the distraction arthroplasty alone group, while the average preoperative AOFAS score was 50 (range, 25 to 74), and the average postoperative score was 89(range, 61 to 96) in the co treatment group. The improvement difference of AOFAS scores between the two groups was significant.

Conclusion : The outcomes of distraction arthroplasty for ankle osteoarthritis can be improved by arthroscopic debridement, especially for those with severe capsular contracture and bony impingement.

#319: Possibility of correction of neglected clubfoot using the Ilizarov external fixator

Roberto Guarniero (Brazil),
Guilherme Bottino Martins, Joe Roberto Bevilacqua, Luis Fernando Seixas Rossi

Question: The possibility of correction of neglected clubfeet with Ilizarov's methodology - in children and adolescent patients.

Methods: Doing a prospective study of 16 patients with severe clubfeet defomities using the circular external fixator following ilizarov's concepts.

Results: The methodology worked very well in 15 out of 16 patients with severe foot deformities.

Conclusion: The severe deformities of the foot and ankle have been correctedby the usage of the Ilizarov's conscepts.

#320: Flatfoot secondary to tibia varum Ilizarov - Correction in adults: Incidence and dynamics after Ilizarov correction

Evgeny Grebenyuk (USA),
Faye-Rose Grebenyuk, Sergey Muradisinov

Question: Did the tibia varum correction cause the flat foot deformity or it unmasked an already present condition?

Methods: Flatfoot is more often preoperative finding in patients with tibia varum. The flatfoot deformity is either fully or partially compensated as well as asymptomatic.

Results: Significant percentage of patients presented flatfoot deformity post-tibial correction. Among 18 limbs with varus deformity with mean MAD 17 3 mm, flatfoot was present in 12. Postoperative calcaneal valgus was present in 14 limbs.

Conclusion: Foot condition should be an important deciding factor when performing tibia varum correction. Additionally, flatfoot correction should be included in the treatment plan.

#321: Trans-fibular ankle fusion with centralized retrograde fibula and Ilizarov external fixator in unstable Charcot ankle

Tamer Abdel Mawla Abdel Gawad (Egypt),
Nabil Ahmed Elmoghazi

Question: Does trans-fibular ankle fusion with centralized retrograde fibula and Ilizarov external fixator in unstable Charcot ankle leads to a sound ankle fusion with good ankle alignment?

Methods: Fifteen patients with unstable Charcot ankle with average age of 42 years (range 35-62 years). Lateral transfibular ankle approach with harvest of 15 cm of nonvascularized distal fibula, debridement of the articular cartilage of the ankle and obtaining good alignment of the ankle then the fibula was inserted retrograde through the calcaneus after reaming of the medulla with a press fit mechanism. Ilizarov external fixator was applied to the Tibia and calcaneus to compress the ankle fusion site.

Results: The mean follow up was 2.5 years (range 1-5 years), we achieved sound ankle fusion in all cases with oteointegration of the fibula with stable ankle. 3 cases of superficial wound infection and 4 cases of pin tract infection and both treated by parenteral antibiotics. One case had stress fracture of the middle third of the tibia at the site of half pin and treated by long leg cast. No cases of deep infection or amputation.

Conclusion: Unstable Charcot ankle can be treated successfully by ankle fusion using combined retrograde fibula and ilizarov external fixator which lead to stable ankle joint.

#322: TrueLock Hexapod system used to correct a fixed equniovarus deformity of an ankle

Stephen J. Frania (USA),
Carl B Lindberg

Question: Can the TrueLock Hexapod System be used to correct an equinovarus deformity?

Methods: We applied the TrueLock Hexapod System by Orthofix with tibia and fibula osteotomies and gradually corrected the deformity over six weeks.

Results: The external fixation system was removed after 8 weeks. A bridge plate was then applied to the medial aspect of the tibia to hold correction obtained. The ankle was noted to be in rectus position with the deformity corrected.

Conclusion: The True Lock External Fixation system is a viable option to gradually correct complex foot and ankle deformities. In addition a bridge plate may be used upon external fixation removal to reduce nonunion.

#323: Dynamic Tension Technique for Medial Slide Calcaneal Osteotomy

Pasquale Cancelliere (USA),
Tyler Kelly

Question: Is there a better way to perform the MCSO without being constrained by predetermined amounts of internal fixation?

Methods: Through a modified tensioning technique the calcaneal tuber can be translated medially to any desired amount to obtain more accurate correction. The surgical technique is as follows: a standard 18g, 1 and 1/2inch needle is placed under the skin in the sagittal plane on the lateral aspect of the calcaneus. It should be directed as to be parallel to the posterior facet of the subtalar joint. C-arm fluoroscopy should confirm this as well as the position of the needle, which will correspond to the osteotomy is sufficiently anterior. Once the needle is placed in appropriate position (Fig1), an incision is made overlying the needle. Layered dissection should protect the peroneal tendon and sural nerve as the incision should extend beyond the height of the calcaneus. Once the calcaneus is exposed, the periosteum should be incised and carefully avulsed off the bone with a key elevator to preserve the blood supply. At this point, the calcaneus should be marked an osteotomy completed. The author prefers to score the bone with an oscillating saw, check the scoring on the fluoroscopy image and complete the osteotomy with an osteotomy. Once the osteotomy is completed and confirmed that no hinges remain, the skin incision is closed in layers. Then, a 2.0 mm olive wire should be drilled the freely mobile calcaneal tuber. The wire should be perpendicular to the lateral wall of the calcaneus and parallel to the weight bearing surface. After all the remaining arthrodesis and/or other osteotomies are completed, the remainder of the trans osseous wire should be drilled. At the authors institute, external frames are not pre-assembled so that the wires are laced to reflect the deformity and anatomy so that the external frame is more precisely placed and correction is optimized. Now, the distal wires in the foot and tibia should be connected to the respective rings and tensioned. We prefer the Russian Method versus barrel tensioners. At this point the fixation bolts should be placed on the foot plate or hindfoot ring for the calcaneal tuber wire. The lateral bolt should only be partially (50%) tightened to still allow for the olive wire to glide through. The next step involves placing the C-arm fluoroscopy in the Calcaneal Axial view position. Tensioning from the medial side will allow the tube to slide and translate medially, under direct visualization. Tensioning is completed when hindfoot valgus is corrected visually or sufficient translation is reached. At this point, the lateral bolt will be tightened to 100% and the wire tensioned again medially to 90N. Then, a second calcaneal wire is drilled from medial to lateral, proximal to distal, parallel to the weight bearing surface so that is crosses the osteotomy and securely fixates it. Then it is also tensioned to 90N. Finally, Lateral and Calcaneal Axial views should be repeated. The only potential complication with this technique has been a slight dorsal translation of the tuber. This is due to inappropriate wire placement or attachment to the ring or foot plate. Post operative radiographs, were taken prior to discharge and at 2 weeks post operative intervals until 2 weeks after removal of the Ilizarov frame. All frames were assembled using DNE SEAL (Slattington, PA). In the 14 cases, complete correction of STJ was obtained, no non unions were obtained, and no revisions were required to the STJ.

Results: 25MCSO's were performed through this technique, all with excellent results. Average translation obtained was 7 mm, with a range from 5 mm to 10 mm. No cases of tarsal tunnel injury or loss of reduction were encountered. 2 cases of slight dorsal subluxation (3-4 mm), were encountered in the early cases. At time of removal of external fixator, all patients had complete correction of STJ VALGUS and pain.

Conclusion: When performing an osteotomy, we must always keep in mind the 3 rules of osteotomy. If the osteotomy itself or the placements are incorrect, it will result in either ineffective correction or worse in a translation deformity (osteotomy rule 3). The MSCO is effective because it is in full respect of rule 2 which is dictates the need for translation when the CORA and osteotomy are at 2 different levels. This is often the case with deformity at the ankle or sub talar joint. The MSCO is a powerful and effective osteotomy in the foot, regardless of fixation used. However, often it is underutilized. We have developed this technique over our experience with the Ilizarov methodology and perform the MSCO this way every time with excellent and predictable results. This technique does not preclude any other osteotomies or arthrodesis procedures performed on the foot and ankle at the same time. In conclusion, we invite the reader of this article to consider our technique when performing the MSCO. It is minimally invasive, safe and effective in correcting STJ valgus and realigning the STJ whether for the purpose of joint salvage or arthrodesis.

#324: Hexapod Frame configurations in the management of foot and ankle deformities

Roberto Bevoni (Italy),
Giorgio Montanari, Mikhail Samchukov, Franz Birkholtz, Mauro Girolami

Question: Is it possible to standardize hexapod frames mounting configuration for the foot and ankle pathologies and deformities

Methods: After the development of the first hexapod system (Taylor Spatial Frame TSF Smith & Nephew), several studies included the treatment of foot and ankle disorders, bringing to light the pros and cons of this new instrument. In recent years, new devices in this family have started emerging; each with its own perceived advantages and limitations. The aim of this study is to simplify the current approach to the foot and ankle external fixation systems, describing the principal frame configurations used in foot and ankle surgeries. We analyzed the literature regarding hexapod frames applications for foot and ankle pathologies and we found the description of various types of mounting, but there is not a unique and standardized method to choose a frame mounting, even for the treatment of similar deformities. We described the segmental stabilization modules for each anatomic district. We then analyzed all the configurations described in literature and we choose the most used, dividing them according to the site of the pathology. After this reviewing process we simplified the approach to the foot and ankle external fixation using hexapod frames choosing and describing 7 configurations that permit to solve all the foot and ankle deformities and pathologies.

Results: Depending on number of correction levels, all hexapod configurations are combined into three groups including single-level, double-level, or triple-level frames. For each level of correction, the hexapod module is further defined as vertical (parallel to the tibial axis) or horizontal (parallel to the hindfoot/forefoot axis) and categorized as 6V or 6H frames, respectively. Finally, double-level hexapods are characterized respectively to the type of frame stacking as vertically inline (6VX6V), horizontally inline (6HX6H), orthogonally inline (6VX6H), or vertical parallel (6V + 6V) frames. Therefore, there are seven standard hexapod frame configurations utilized for correction of foot and ankle deformities: 1) Single-level vertical (6V) hexapod frame, 2) Single-level horizontal (6H) hexapod frame, 3) Double level vertically inline (6VX6V) hexapod frame, 4) Double-level horizontally inline (6HX6H) hexapod frame, 5) Double-level orthogonally inline (6VX6H) hexapod frame 6) Double-level parallel vertical (6V + 6V) hexapod frame, 7) Triple-level 6VX (6HX6H) hexapod frame.

Conclusion: The simplification of the application of hexapod frames to the foot and ankle purposed in the study, standardize the approach to deformities of the foot and ankle. As any other circular fixation system, hexapod-type frames for foot and ankle deformity correction contain, adapted to the limb anatomy, various external supports attached to the bone segments with wires and/or half pins, but interconnected by six variable-length struts instead of hinges and angular distractors. Seven main configuration permits to treat any kind of deformities or pathology of the foot and ankle.

#325: Title: Minimal invasive surgery for talar neck fracture using external fixation

Hani Badahdah (USA),
Mario Cala, Gabriel Santamarina

Question: Does Minimal invasive surgery for talar neck fracture using external fixation reduce the incidence of postoperative complications?

Methods: By using external fixation for talar neck fracture.

Results: These are the results after 9 months of postoperative follow up:

1) No infection or wound complications developed.

2) No osteonecrosis of the talus developed.

3) No non-union or malunion developed.

4) Early weight bearing with faster recovery.

5) Patient's satisfaction was high

Conclusion: Using external fixation over internal fixation for talar neck fracture reduces the risk of non-union, malunion or osteonecrosis of the talus because of less hardware involvement with external fixation. Also, the chance of blood supply compromise is very low compared to the internal fixation which increases the chance of the bone healing. Early weight bearing was allowed for the all patients which reduces incidence of deep vein thrombosis and pulmonary embolism. Minimal invasive surgery for talar neck fracture reduces the risk of infection and wound complications postoperative.

#326: Clinical results of distal tibial oblique osteotomy (DTOO) and distal tibial intra articular osteotomy (DTIO) treated for the traumatic ankle osteoarthritis

Tomohiko Asahara (Japan)
, Tsukasa Teramoto, Shota Harada, Motoyuki Takaki, Nobuyuki Takenaka, Takashi Matsushita

Question: Since 1994 Distal Tibial Oblique Osteotomy (DTOO) was performed on the varus type ankle osteoarthritis. The characteristics of DTOO were preserving the ankle joint and its motion and most of the patients could run again after surgery. The purpose of this study is to report the clinical results and concepts of DTOO. Since 1996 , severe ankle osteoarthritis with the deformity of the tibia plafonda was treated by Distal Tibial Intra-articular Osteotomy (DTIO). The purpose of this study is to report the operative methods and the clinical results of DTOO and DTIO treated for the traumatic ankle osteosrthritis.

Methods: The study population comprised 7 patients with the ankle osteoarthritis and by DTIO. Their age was in the range of 19-73 years. The causes of the ankle osteoarthritis were the primary osteoarthritis (1 cases), th e cavus foot (1 case) and the post truma (5 cases). The follow-up period was in the range of 6 months-10 years and the average was 4.5 years. All cases was performed DTOO or DTIO and the some cases was added the fibular osteotomy . Then the the osteotomy site was spread at by using a spreader and Ilizarov External Fixator was used for the fixation of the fragment except one case. This case was fixed by the plate.

The iliac bone was grafted into the spreading space. The patients were loaded with 2 crutches at 6 or 8 weeks after the surgery. The Ilizarov external fixator was removed 3 months after the surgery. We used a rating scale to determine the ankle function both before and after surgery. On a 100-point system, 40 points were allocated for pain and 20 points each were allocated for walking, performing activities of daily living and range of motion.

Results: The total mean score improved from 38.6 to 65.3 points after surgery. Except one case , th e pain of the ankle joint with the ankle osteoarthritis were improved. The cause of the failure was the correction of eqinus foot after trauma. DTIO corrected the deformity of the ankle surface. The correction of the ankle joint surface and the alignment and the stability of the ankle joint. foot was improved because the joint shape of the ankle joint was changed and the total contact of the ankle joint was regained by the spread of distal tibia until the lateral articular surface of the talus is in contact with the medial articular surface of the lateral malleolus.

Conclusion: DTOO and DTIO were useful for the surgical treatments of the traumatic ankle osteoarthritis. Some cases who had the deformity of the fibula needed the fibular osteotomy.

#327: Z lengthening osteotomy, plate fixation and allograft in short 4 th metatarsal acute lengthening

Mohammed Jalal Al Sayyad (Saudi Arabia)

Brachymetatarsia is not an uncommon congenital foot disorder that is due to a premature closure of the ephiphyseal plate. The literature has numerous surgical procedures for the correction of this problem. In recent years, the callus distraction technique described by ilizarov has been utilized for this problem. Other techniques in gaining length for the short metatarsal was developed to avoid some short comings of the external fixation techniques

Methods: This is a retrospective study of the use of the acute lengthening technique for the correction of congenitally short metatarsal. This series included six feet in four female patients and one male patient, all with a short fourth metatarsal. Preoperative complaints were metatarsalgia and/or cosmesis. A Z - shapped lengthening osteotomy was performed followed by acute lengthening and plate fixation and allografting.

Results: The metatarsal was lengthened acutelly. The preoperative metatarsal length ranged from 3.5 to 4.2 cm. The end stage metatarsal length ranged from 4.7 to 6.3 cm, with an average increase in length of 1.2 cm.

Conclusion: As compared to other techniques described in the medical literature, the Z acute lengthening osteotomy, plate fixation and allografting technique has its own unique set of advantages and disadvantages.

#328: Medial Column Fusion in Charcot Foot with External RingFixator

Gregory A. Jaryga (USA),
Alan Garrett, Michael Downey

Question: Fifty Four active male employed as truck driver with unstable medialcolumn right foot secondary to Charcot Arthropathy. Bracing modalities unsuccessful in relieving pain and further breakdown of boney segments.

Methods: Strict edema control prior to surgical intervention. Combination acute surgical correction with removal of nonviable sclerotic arthropic boney fragments with osteotomy of affected joint surfaces and repositioning to normal anatomical contour of mid-foot with application of external ring fixator for compression and stability.

Results: Excellant anatomical reduction with maintained anatomical alignment and fusion of mid-foot boney segments secondary to rigid control with external fixator. Patient able to return to family, return to chosen profession as truck driver and return to his life activities.

Conclusion: External ring fixation for the difficult to manage Charcot arthropic fracture of mid-foot and medial column provided a excellent modality as well as expected outcome of resolved unstable and poorly braceable foot to a braced extremity with plantar grade foot to leg relationship.

#329: Corrective Osteotomies For Distal Radius Malunions

Minoo Patel (Australia)

Extra articular distal radius malunions can cause pain, deformity, restricted movement and carpal instability, and predispose to arthritis. The deformities are 3 dimensional and complex. We present a simple graphic method for analysing these deformities. We present our technique for simple multiplanar correction of distal radius deformities with stable 2 pillar (lateral and volar) fixation, with or without an ulnar shortening osteotomy.

Methods: The Graphic Method of distal radius deformity analysis involves plotting the sagittal, coronal and axial plane deformities based on CT analysis, and obtaining the Oblique (true) Plane of the deformity. This can be plotted on ot the axial image of the distal radius, which translates into a simple opening wedge corrective osteotmy. We use an anatomically contoured locking volar buttress plate and lateral pin plate device to obtain stable 2 pillar fixation, augmented by bone grafting of the opening wedge using a calcium phosphate putty.

Results: 26 cases were treated over a 7 year period with a minimum 3 year follow-up. The average deformity was 19 deg loss of palmar tilt, 11 deg loss of radial tilt and 5 mm ulna plus. Post correction the average palmar tilt was 5 deg, radial tilt 18 deg and neutral variance. There was no loss of fixation. There were three tendon complications, EPL rupture, EDC adhesions and EPL adhesion. At 12 months the average DASH score was 15 and PRWE 21.

Conclusion: Our technique is a simple reproducible technique for correcting distal radius malunions.

#330: Ilizarov external fixation for the distal clavicle fracture

Yuichiro Nishino (Japan),
Tomohiko Asahara

Question: We experienced one case that was failed osteosynthesis of the distal clavicle fracture. This case was a Parkinsons disease patient of the 50 years old level. First, osteosynthesis using the exclusive plate was performed, but one week after, The plate; screw was back out. 2 nd , Another exclusive plate was chosen, But Osteosynthesis ended in failure.

Methods: The ope wound was red and swollen. We felt the risk of the infection by the third operation. And We judged that We could not cope by the internal fixation. We chosen the Ilizarov external fixation. 4 half pin were applied for the proxymal bone, and 3 Ilizarov wire were applied for the distal bone. To raise the fixation power, 2 Ilizarov wire were applied for the acromion . Each pin and wires were connected using Rancho cube and Carbon Ring.

Results: 7 weeks after, we could get the bone union. The bone shortening was not occur, and bone stability was well controlled.

Conclusion: Ilizarov external fixator was very useful for the distal clavicle fracutre. It saved the internal osteosynthesis that failed.

#331: Reduction of chronic Monteggia lesions by hexapod frame - 4 year follow up

Micha Langendoerfer (Germany),
Francisco Fernandez, Thomas Wirth

Question: Chronic neglected Monteggia lesions are challenging to be treated, there is a high risk for complications such as scarring, joint stiffness, nerve damage and re-dislocation of the radial head as reported with open reduction and annular ligament reconstruction. In addition an ulnar deformity may persist as well as a radial overgrowth can be noted, requiring an ulnar lengthening and flexion osteotomy. Acute lengthening is limited and may lead to delayed union. Using monolateral fixateurs can address this problem, loss of correction and insufficient traction of the radius may lead to re-dislocations as well. We wanted to examine the intermediate results of the reduction technique by the use of a hexapod frame, especially regarding the risk of re-dislocation.

Methods: The closed reduction of the radial head was achieved by lengthening and angulating the ulna in flexion after proximal, percutaneous corticotomy. The reduction was obtained by a hexapod frame , which was mounted in 180 rotation with proximal referencing. The radius was distally fixed until two weeks after reduction. Series: 8 missed and neglected Monteggia lesions and 1 chronic traumatic subluxation of the radial head, 5 male, 4 female. The average age at trauma was 79 months (46-127), the average delay of treatment was 25 months (4.5-56).

Results: The closed reduction was achieved in all cases without secondary surgical interventions except angulation and distraction adjustments using the TSF software. In average an ulnar lengthening of 15.5 mm (4-26) and a flexion of 25.0 (15-26) was needed to reduce the radial head and to keep it in place. One case needed additional open reduction due to interposition of a capsular soft tissue formation. The time in frame until consolidation and stable reduction was 96,2 days in average (69-144). In the follow-up , which was in average 54 months (43-68), we found one case with sudden re-dislocation, which was treated by open reduction and annular ligament plasty. In all other cases we found a persistently stable reduction. The elbow ROM was in all cases equal or better than before surgery, the DASH and the Mayo EPS showed excellent or good functional results.

Conclusion: The hexapod frame allows precise reduction of the radial head by continuously lengthening and angulating the ulna. Secondary surgical interventions can be avoided in most cases. Nonetheless secondary re-dislocations may occur during growth in pediatric patients, therefore follow-up until completed skelettal maturation will be necessary to evaluate the hexapod technique.

#332: Elbow reconstruction after massive bone loss

Richard Luzzi (Brazil),
Fabio Martynetz

Question: Massive bone loss around elbow is an uncommon situation, and its associated with post traumatic infection. There are not many options to treat it, and arthrodesis is usually indicated if this joint is painful, and unstable to sustain/elevate this limb. Can we have a different option that can avoid an elbow arthrodesis, maintaining a functional joint after a massive bone loss?

Method: This is a case series of three patients (2 females and 1 male) from one hospital who underwent elective non anatomic elbow reconstruction due post traumatic sequelae and infection, with a massive bone loss. Non of them had a funcional upper limb before surgery due completely inability to sustain the hand in front of their body, and pain. Surgery consisted of a posterior elbow access, and resection of fibrosis and irregular bone ends to create a round surface in distal humerus, in contact with redesigned concave proximal ulna. A hinged circular external fixator was used in all cases, and a new center of elbow rotation was created with this frame in alignment with distal humerus. Forearm was maintained in pronation position (around 45), and carrying angle was respected using normal side as a reference. Elbow bone defect was minimized applying compression until both bone ends (humerus, and ulna) could be close, and maintain movement with no bone ends ! impact, aiming to develop a hyper mobile functional non union. During surgery, radial diaphysis line should be aligned with distal humerus in all positions in AP and lateral views on image intensifier, in flexion and extension, maintaining the same distance from distal humerus. Collateral ligaments were not reconstructed. Physical therapy was initiated next day after surgery, and were orientated to follow an exercise program that included 4 hours per day movements in this new elbow. Two of them did the exercises.

Results: Patients stay in frame for 6 months in one case, and 4 months in two. They were stimulated to use upper limb as much as they could. Elbow range of motion average in frame was 18.3 of extension, and 76.6 (ranging from 0-30 of extension, and 60-90 of flexion). After frame removal all of them had an unstable elbow under medial and lateral stress tests. Clinically they were able to use their hand in front of their bodies in two cases, and reach head and mouth. One case needed a second procedure to ulnar nerve transfer due pain while flex the elbow. Follow-up average is 20 months (13-25 months), and range of motion is 25 of extension to 86.6 of flexion (ranging, respectively from 0-45, and 80-90) and after this period two patients are still able to use their upper limbs as described. One patient recovery partially her supination (75).

Conclusion: Hinged circular external fixation can be considered as a treatment option to avoid an elbow arthrodesis after massive bone loss.

#333: Combined correction and lengthening of forearm deformities with external fixator

Joachim Lauen (Germany),
Volker Bhren, Charlotte Kraft, Matthias Rueger

Question: Congenital forearm deformities are rare, the growth disorders relatively complex, surgical reconstructions difficult. Most surgical solutions are late and refer to acute reconstructions using closed or open wedge osteotomies with limited length gain.

Methods: 39 patients were included in this study, ages 2 to 25. Indications were Madelungs deformity (7), complex deformities by congenital multiple exostosis (16), radial or ulnar hypoplasia and other congenital malformations (8) and post-traumatic physeal growth disorders with axial deformity and length discrepancy (8). The surgical technique included a strictly radial and ulnar pin application from an open approach, acute deformity correction, lengthening by callus distraction. Defined sites of pin application allow a functional control of the lengthening extent. The systems used were monolateral external fixators, for special lengthening demands a long rail module was constructed with a higher axial stability.

Results: Malformations and length deficiencies, stability and function were improved in all treated cases. No contractions or vascular complications were seen, temporary paraesthesia for a few days remitted ad integrum (4). The infection rate was restricted to pin tract infections grade 1 (5), no higher grades occurred. System related the double ball joint proofed instable for lengthening demands.

Conclusion: The surgical technique with mono- or bilateral application of fixators without compromising muscles or tendons allows a deformity and length reconstruction under functional control and reduces complications as contractures.

#334: Thumb metacarpal distraction induced CMC joint subluxation: The effect of unopposed bidirectional distraction

Kyros Ipaktchi (USA),
Grady Maddox, Ramin Ipaktchi

Question : Does thumb metacarpal distraction exert a retropulsive force across the carpo metacarpal (CMC) joint?

Methods : Patients with traumatic thumb deficiencies were treated using two different metacarpal distraction fixator assemblies: A standard first metacarpal based construct which did not control possible retrograde transport of the metacarpal bone into the CMC joint (group A) versus an extended fixator design which included the trapezium in the fixator assembly and neutralized possible retrograde distraction forces across the CMC joint (group B). A supporting cadaveric study was designed with 2 cadaveric wrists in each group mimicking the clinical 2 groups. In addition to the fixator application, a pressure probe was inserted into the CMC joint of all cadavers. Pressure within the CMC joint was measured during experimental transport.

Results : Standard metacarpal distraction fixator placement for thumb lengthening resulted in both antegrade as well as retrograde transport during osteoneogenesis in the patient. This resulted in CMC joint subluxation during the distraction period in group A. Inclusion of the trapezium into the distraction fixator assembly transfixed the thumb CMC joint and protected the CMC joint from retropulsive subluxation during transport in group B. Intra articular pressure measurements during experimental metacarpal lengthening in cadaveric specimens demonstrated a significant increase in compression induced pressure in the CMC joint in experimental group A. Intra articular pressure in the CMC transfixing fixator design of experimental group B did not increase.

Conclusion : The thumb carpometacarpal joint does not offer sufficient restraint during metacarpal distraction. As a result both antegrade as well as retrograde transport can be seen if distraction forces across the CMC joint are not neutralized. This type of bidirectional transport appears to be unique to the thumb and is not seen in long bone distraction. Resulting CMC joint subluxation can expose patients to CMC arthritis and limit functional outcome. We propose a modified extended metacarpal fixator assembly, which includes the trapezial bone to neutralized CMC subluxating retropulsive forces during distraction osteoneogeneisis of the thumb.

#335: Thumb CMC joint subluxation during metacarpal lengthening: An unwanted effect of bidirectional transportation

Kyros Ipaktchi (USA),
Grady Maddox, Ramin Ipaktchi

Question : Does thumb metacarpal distraction exert a retropulsive force across the carpometacarpal (CMC) joint?

Methods : Patients with traumatic thumb deficiencies were treated using two different metacarpal distraction fixator assemblies: A standard first metacarpal based construct which did not control possible retrograde transport of the metacarpal into the CMC joint (group A) versus an extended fixator design which included the trapezium in the fixator and neutralized possible retrograde distraction forces across the CMC joint (group B). A supporting cadaveric study was designed with 2 cadaveric wrists in each group mimicking the clinical 2 groups. In addition to the fixator application, a pressure probe was inserted into the CMC joint of all cadavers. Pressure within the CMC joint was measured during experimental transport.

Results : Standard metacarpal distraction fixator placement for thumb lengthening resulted in both antegrade as well as retrograde transport during osteoneogenesis in patients. This resulted in CMC joint subluxation during the distraction period in group A. The inclusion of the trapezium into the distraction fixator assembly transfixed the thumb CMC joint and appear to protect it from retropulsive subluxation during transport in group B. Intra articular pressure measurements during experimental metacarpal lengthening in cadaveric specimens demonstrated a significant increase in compression induced pressure in the CMC joint in experimental group A. Intraarticular pressure in the CMC transfixing fixator design of experimental group B did not increase.

Conclusion : The thumb carpometacarpal joint does not offer sufficient restraint to with hold distraction forces during metacarpal lengthening. As a result both antegrade as well as retrograde transport can be seen if distraction forces across the CMC joint are not neutralized. This phenomenon of a bidirectional transport is not seen during long bone distraction. Resulting CMC joint subluxation can expose patients to CMC arthritis and limit functional outcome. We propose a modified extended metacarpal fixator assembly which includes the trapezial bone to neutralized CMC subluxating retropulsive forces during distraction osteoneogenesis of the thumb.

#336: Forearm lengthening in patients with congenital upper extremity

Evgeny Grebenyuk (Russia),
Dmitry Popkov, Lyudmila Grebenyuk

Question: Congenitally deformed and shortened upper limb result in significant functional and cosmetic impairment in such patients. PURPOSE of the study was to evaluate the results of Ilizarov lengthening and deformity correction in patients with congenital forearm anomalies and evaluate the limiting factors in forearm Ilizarov lengthening.

Methods: Ilizarov bone lengthening and deformity correction allows restoring bone length and axis in congenital upper extremity deficiencies, although functional result depends on proper strategy of treatment.

Results: Our study included 74 cases of congenital forearm deficiency in children. Patients were divided into 3 groups: congenital radial club hand (35 cases), ulnar club hand (22 limbs) and forearm stump at the proximal level (17 cases). We performed forearm Ilizarov lengthening and deformity correction to restore bone axis and length. Additional assessment included acoustic velosimetry to control soft-tissue tension in patients with forearm stumps. Mean amount of lengthening was 5.4 1.4 cm. Mean healing index in the group of intramedullary nailing was 27.0 days per cm. There were no cases of nonunion or bone fractures after frame removal, although 4 cases of negative functional result due to severe finger contractures observed.

Conclusion: Lengthening and deformity correction in cases of congenital club hand and forearm stump is still a difficult problem because of lack of soft tissues and complex external fixation technique due to small two-bone segment corrected. Ilizarov bone lengthening and deformity correction allows restoring bone length and axis in congenital upper extremity deficiencies, although functional result depends on proper strategy of treatment.

#337: Triplanar correction of posttraumatic Cubitus Varus with monolateral external fixation: A new technique.

Nuno Craveiro-Lopes (Portugal),
Carolina Escalda, Manuel Leo

Question: Cubitus varus is the most common complication of the supracondylar fracture of the humerus in children. Incidence is between 4 and 58% of cases and the increased difficulty in correction refers to the need to make a triplanar correction and maintain it up to the consolidation, so that a perfect aesthetic correction is achieved. The rotation index was described by us in 1995 after a review of 28 patients six of wich (21.4%) had developed cubitus varus. It is measured on a lateral radiograph as the ratio of the anterior spike of proximal segment and the diameter of the distal fragment, with an acceptable value less than 0 point 3. We found that the instability was caused by the swinging effect when the rotation is greater to 30%. In this previous study there was no correlation between age or the type of injury and the onset of complications such as cubitus varus. Moreover, it was observed that the correlation between the rotation index and the occurrence of cubitus varus was much stronger than with the Baumann angle. In the present study we reevaluate the aesthetic and functional results after the introduction of the rotation index as a predictor of cubitus varus and described a new technique for correction of cubitus varus.

Methods: From 1995 to 2012, we have treated 139 supracondylar fractures of the humerus and reviewed 89 of Garland type II and III. Most of the cases, 92% were treated with closed reduction technique and was used and for fixation, divergent Kirshner wires was used in 56% of the cases, crossed wires in 18% and 3 wires in another 18%. In seven cases, it was necessary to perform an open reduction with use of wires or external fixation for stabilization. With regard to the correction of this deformity, we have treated in our department a total of 10 cases over a period of 17 years. Indication for surgical correction includes a unaesthetic deformity that parents or the patient requires to be corrected, the existence of ulnar neuropathy or loss of strength in the arm due to an abnormal carrying angle. Multiple procedures are described for the correction of cubitus varus, although all have problems in obtaining accurate correction or stability of fixation. In 1995 the author described a new surgical technique including a linear osteotomy with triplanar correction, using a monolateral external fixator that provides immediate stable fixation, early mobilization in flexion-extension and if needed, correction of the final position in an ambulatory way.

Results: What concerns the use of the Rotation Index as indicator of probability of cubitus varus, based on Flinn criteria, the results of this study showed its use, gave excellent and good results in 94% of the cases with regard to aesthetic criteria and 97% relative to functional criteria. Seven patients (8%) had a total of 8 complications, including two mixed vascular and nerve injuries, one of which resulted in septic arthritis and 5 require surgical nerve release, with full recovery. In 9 patients (10%) it was detected that rotation index was above 30%, which led to a repetition of the reduction in the same procedure in 5 cases and a imediate reoperation in 4 cases. The comparison between the two studies, the first between 91 and 94, before the introduction of the rotation index and the second between 95 and 2012 after introduction of this index as a criteria of good reduction, showed a dramatic reduction in the occurrence of cubitus varus from of 21% to 2%, a statistically very significant difference. What conserns the surgical correction of cubitus valgus we this new technique, correction of the carrying angle was from mean -19 to 3. 4 patients out of 10 needed postoperative fine tuning of the correction in an ambulatory way. The total time of use of external fixation was on average 5 weeks, between 3-8 weeks. There were no cases of infection or parental dissatisfaction by bad correction.

Conclusion: What concerns the treatment of supracondylar fractures, It is therefore recommended to proceed to a new reduction maneuver and wire fixation whenever the Rotation Index is greater than 0.3. In this study, no cubitus varus appeared when this index was corrected with a new reduction maneuver or reoperation in patients without other complications. What concerns the surgical correction of cubitus varus, we can say that this technique allows to correct all components of the deformity, with symmetric alignment with the contra lateral arm in all treated cases. It allows immediate visual and radiographic control with the elbow in extension and flexion, permitting fine tuning of the correction in an outpatient way. In this group of patients we had no complications or bad corrections.

#338: Lateral external fixation for displaced unreducible supracondylar humeral fractures in children

Noam Bor (Israel),
Eitan Dujovny

Question: In most cases, the standard technique for displaced type-III supracondylar humeral fractures in children includes, closed reduction with manipulation followed by stabilization with either cross-pins or multiple lateral pins. The problems with this technique are that perfect reduction cannot be achieved by means of manipulation alone, and there is a risk of persistent instability followed by wires fixation. The alternative open reduction of these fractures may lead to complications like as elbow stiffness and infection. We were looking for a better treatment method which will overcome the downsides of the upper mentioned.

Methods: A small lateral external fixator (Synthes) had been used to solve some of the problems associated with the irreducible Gartland type-III fractures with the usual techniques. Two 4 or 5 mm Schanz screws are inserted perpendicular to the long axis of the distal and proximal fracture segments, closed reduction and stabilization is achieved by manipulating the fracture using the pins as joysticks. 7 children, 5 males and two females, were treated with this technique during the last 3 years. The ages ranged from 5.5 to 13 years (mean 10 years).

Results: All external fixators were removed after a mean of 6 weeks. Sedation was provided during the removal procedure. 5 patients were found to have bilateral symmetrical elbow axes within the physiological cubitus valgus range of 5 to 10 degrees. In one patient an excessive valgus of 7 degrees in comparison to the uninjured limb was resulted, and in another patient, 5 mm posterior translation of the distal fragment relative to the proximal fragment was noticed. Three months after removal of the fixator all patients had achieved full range of motion of the elbow.

Conclusion : Our method which was originally described by Theddy Slongo (Berne, Switzerland), provides an alternate method with which closed reduction and good stabilization can be achieved in unstable or markedly displaced supracondylar humeral fractures Gartland type-III. The technique avoids open reduction when a satisfactory reduction cannot be achieved with the usual closed manipulation techniques.

#339: Bilateral humerus lengthening with unilateral external fixators in achondroplasia: Is it safe and does it improve daily life?

Halil Ibrahim Balci (Turkey)

Not only the short lower extremity but also short upper extremity of the achondroplasic patients restricts daily life. Unilateral external fixators can provide easier lengthening opportunity for these patients. Does lengthening of the bilateral humerus in achondroplasic patients increase the upper extremity function with improving the Disabilities of the Arm, Shoulder and Hand ( DASH) scores? Is it safe ? and What should be the goal of the lengthening?

Methods: In our retrospective study 36 humerus of 18 patients with a mean age of 11 (range 7-30) are lengthened between 2001 and 2013 in bilateral fasion with monorail external fixators with a mean 40 (12-104) months follow up. we analysed the external fixator index, change in DASH score, complications, bone and functional scores

Results: The mean DASH score was 32,3 (range 20-40) pre-operatively and 9,4 (range 6-14) post operatively (p = 0,037). There were no sequela. In our study we needed a lengthening with a mean of 60% (range 94-40) according to the preoperative humerus to reach the goal, independant perineal and perianal hygien.

Conclusion: Humerus lengthening of the achondroplasic patients is not just a cosmetic operation but also it is a functional necessity that decreases the dependance of achondroplasic patients to others.

#340: Correction of poliomyelitis foot deformity by Ilizarov

Ibrahim Abu O Mira (Egypt),
Yasser Elbatrawy, Alexander Kirienko, Mahmoud Zayed.

Question: What is the treatment of poliomyelitis foot deformity?

Methods: C orrection of poliomyelitis foot deformity by Ilizarov.

Results: A painless and plantigrade foot was obtained in all patients.

Conclusion: Ilizarov technique has proved efficiency in the management of poliomyelitis complex foot deformities, when conventional techniques have failed, considered technically demanding and fraught with serious complications. The Ilizarov apparatus is rigid yet versatile, and the minimal nature of the surgical intervention creates the optimal biologic and mechanical environment for rapid bone healing and early functional rehabilitation. A painless and plantigrade foot was obtained in all patients.

#341: Evaluation of the results ulnar lengthening for correction of forearm deformity in multiple hereditary exostosis, preliminary results

Amin Abdel Razek Youssef Ahmed, (Egypt)

What was the evaluation of the management for type IIb Masada classification of forearm deformities by Ilizarov ulnar lengthening?

Methods: A series eight patients with type IIb Masada deformity were treated by Ilizarov lengthening at El-Hadra University Hospital, Alexandria, Egypt during the period of January 2008 to June 2011. There were 6 males and 2 females; right forearm was affected in 5 patients. The mean age is 8.6 months; all cases showed ulnar shortening with dital ulnar exostosis and radial head dislocation type IIb. A detailed functional assessment was conducted before and after correction. The motion ranges recorded included elbow flexion/extension, forearm pronation/supination, wrist plantar-flexion and dorsi-flexion, as well as radial and ulna deviation. Radiological assessment consisted of bilateral upper extremity anteroposterior radiographs with the hand sand elbows in an anatomic position. A lateral radiograph of the forearm that included the hand, wrist, and elbow was obtained.

Operative Technique: All patients were operated under general anaesthesia, with application of Ilizarov frame to the forearm. The frame used was assembled of 2 complete rings, the proximal one was fixed to the proximal ulna using a wire and two 4 mm shanz. The distal ring was fixed to both radius and ulna using a transverse wire, and the stability was reinforced by two 4 mm shanz fixed the ulna. Ulnar osteotomy was done between the rings. Lengthening was started after 10 days by a rate of 1 mm per day to length the ulna and pulls the radius down. Follow-up was done weekly both clinically and radiologically. All cases showed spontaneous reduction of the head radius and correction of the forearm deformity. At that time distraction was stopped, and the patients were followed up every 2 weeks till full consolidation of the callus was achieved. The frame was removed after full consolidation of the callus and immediate exercise to the wrist and forearm was started.

Results: At a period of follow up of 21 months (12- 36 months) all patients showed spontaneous reduction of the radial head and correction of the forearm deformity The range of motion improved: flexion increased from 105 to 130, extension reached to 10 while it was 25preoperatively and the supination increased from 30 preoperatively to 55 postoperative, all these were statistically significant. All patients and their parents were fully satisfied at the end of follow up. No recurrence of the deformity was noted during the latest follow-up. All the gains in the motion of the forearm were retained during the last follow-up. The mean duration of the period of external fixation in this group of patient was 8.8 weeks.

Conclusion: Ilizarov lengthening of the ulna is an excellent method for correction of forearm deformity and to improve elbow range of motion in patients with hereditary multiple exostosis.

#342: Organization of research at the Ilizarov Center

Alexander Gubin (Russia)
, Dmitry Borzunov, Olga Borzunova

Question : Ilizarov Center is the largest orthopaedic hospital in Russia, which performs research studies. Special characteristic of the hospital is its location far from cities concentrating scientific resources, which is unusual for an institute of such level. This fact is uncommon for the USSR and Russia. This phenomenon has, certainly, appeared as a result of ingenious ideas of the founder of the Center G. Ilizarov. Development of science in modern Russia also has a large number of specific features. It determines both unique character and complexity in organization of research studies. The purpose of the study is to determine the main features of development of science at the Ilizarov Center in historical perspective and now, to create a roadmap for organization of research studies at the Center.

Method : Scientific publications of the Ilizarov Center over the past 40 years have been analyzed. Data of human resource department regarding the number and structure of researchers has been used. Principles for formation of stimulation of research studies in various historical periods have been studied.

Results : Vast geographical distance from the Center to the capital played an important role in positive development of the Ilizarov method in the USSR and in the world. At the same time it created a large number of systemic problems, demanding decisions non-standard for the country. Economic motivation in stimulation of research studies has been and remains important. Researchers are characterized by surprisingly low organizational inertia.

Conclusion : First, Centers, which appeared on the basis of scientific discoveries, are unique. 2. Modern technologies remove limitations associated with geographic location. 3. Setting priorities of research work, aimed at defining the institution is the key to efficiency under conditions of budget cuts. 4. Deficit of human resources can be compensated by collaboration on various levels and involving personnel from non-scientific departments.

#343: Treatment of infected pseudoarthrosis of patella with external fixator

Ivonir Fagundes Alves Junior (Brazil),
Osvaldo Clinco Junior, Hilario Boatto, Felipe Martinez Neto, Thiago Amorim Bastos, Glauber Kazuo Linhares

Question: The patella fractures have an incidence of approximately 1% of all fractures of the axial skeleton and can be caused by direct, indirect or combined trauma. Classically, fractures of the patella are currently treated with direct reduction and internal fixation, requiring widely exposure of the patella. As frequent complications, it can be related the symptoms synthesis materials in 15% of cases, infection and complications of the surgical wound in 10.7% of cases and loss in reduction of up to 20% of cases. With the increase in energy of trauma injuries caused by the increasing use of motor vehicle, it was led to change the pattern of fractures and soft tissue envelope injury, causing greater rates of patella fractures complications. We will present a case report, in which a female patient, 26, with transverse patella fracture caused by direct trauma, was treated with tension band technique. She presented postoperative wound infection and skin dehiscence.

Question: This patient underwent the synthesis material removal, surgical cleansing and debridement of the wound, resulting in the loss of fracture reduction and lack of coverage for soft tissue on the patella. She received intravenous antibiotics therapy for 21 days, resulting in the infection resolution. The targeted solution was to assemble the circular external fixator, consisting of 1 ring, set with 2 oiled k wires and 2 smooth k-wires, pre-tensioned to the fracture compression. For coverage of soft parts, a tensioning suture was performed where the edges were approximated gradually, thus avoiding the dermal micro-vascular stress and other more invasive procedures, such as muscle snip or skin transplantation.

Results: The patient in the immediate postoperative period was undergone to physical therapy to gain the knee range of motion, reaching 90 degrees bending in the second week postoperative. The total load was permitted in the affected leg, with satisfactory strength and muscle tone. With the tensioning suture, she obtained the soft tissue coverage with the progressive approximation of the edges in 20 days, ensuring a good skin healing. The external fixator was removed at 12 weeks, with satisfactory fracture healing. The skin tissue showed no change, with good skin coverage of the patella.

Conclusion: Patellar fractures complications are more frequent, because of the increase in surgical indications of these fractures and the trauma standard change of this segment. The external fixator is an option for fractures that present complications such as wound areas infection and dehiscence of the skin tissue. The rehabilitation of the patient was favorable, managing to achieve a good range of motion postoperatively, besides being able to walk with full capacity without support or help in the immediate postoperative period.

#344: Posttraumatic severe equinus deformity correction with Ilizarov application

Chayanin Angthong (Thailand)

How about the efficacy and techniques of Ilizarov application to correct the posttraumatic severe equinus deformity?

Methods: This study is to report the effectiveness and techniques of Ilizarov application for the correction of posttraumatic equinus deformity in 2 patients. First patient had severe equinocavovarus after tibial fracture and compartment syndrome 40 years ago.

Second patient had severe equinus for 3 months after longterm treatment of open fracture of tibial shaft and Lisfranc injury included tibial arterial injury.

Results: First patient underwent the posterior anklesubtalar joint capsular releases and Achilles lengthening. The Ilizarov fixation was applied and gradually corrected after soft tissue releases. Sural flap was done to cover the residual posterior defect. Preoperative and postoperative equinus were 120 and 30 degrees, respectively. He can walk using high heel Shoes and with or without gait aid at 1 year after the correction. Second patient underwent the same regimen as a first patient. Preoperative and postoperative equinus were 60 and 0 degrees, respectively. He is still in the recovery time in three weeks after rotational flap coverage. There were no another complications in both patients.

Conclusion: Ilizarov application is recommended to use for the correction of posttraumatic severe equinus deformity. Posterior residual soft tissue defect is difficult to avoid but flap coverage can be used to correct this complication.

#345: Comparison of two different distraction osteogenesis techniques over intramedullary nail for the reconstruction of infected nonunion of femur

Halil Ibrahim Balci (Turkey)

We compared the results of two different distraction osteogenesis technique known as, bone transport and acute compression and lengthening over intramedullary nail, in the treatment of infected femoral nonunion.

Methods: 22 patients (9 in segmental bone transport over intramedullary nail and 13 in over intramedullary nail) with infected femoral nonunion were operated with combination of unilateral external fixator and intramedullary nail. Femur bone defects less than 4 cm and more than 9 cm were excluded from the study. Other excluding criterias were; host C patients, the age more than 60 , Body Mass index more than 40 and heavy smokers. Age, gender, range of motion (ROM) of the affected knee and hip, external fixation time, follow-up period were recorded from patient records retrospectively. Bone and functional results were evaluated with the use of the criteria of Paley et al. Complications were also classified according to Paley et al.

Results: The mean age was 43,5 years, the mean follow-up period was 48 months (range: 14 to 128 months). The follow-up time was similar in two groups (45+/-37,6 months in segmental bone transport, 49,4+/-36,4 months in compression distraction)(p = 0,79)). The defect size in segmental bone transport group (7,33+/-1,6 cm) was more than the Acute compression and distraction group (4,92+/-1,04 cm) (p = 0.0001). The external fixator time was 207+/-87 days in segmental bone transport group and 120+/- 16,5 days in Acute compression and distraction group (p = 0,002) . The external fiksator index was different between segmental bone transport group (24,8+/-12,3 cm) and Acute compression and distraction group (25,2+/-4,9 cm)(p = 0,925). Docking site nonunion was observed in 3 patients treated with bone transport. Two of them were treated with exchange intramedullary nailing and autografting. There were no non union in compression distraction group.

Conclusion: The two different techniques, in this study, have similar results except docking site problems which are higher in segmental bone transports group. However, the rate of complication at docking side and the period of external fixator time were in favor of Acute compression and distraction over intramedullary nail. Therefore, we advice to use the Acute compression and distraction over intramedullary nail technique for the selected cases with infected femoral nonunion less than 7 cm which is the limit for acute shortening that does not negatively affect muscle function and vascular supply.

#346: Distraction lengthening of the fingers following replantation

Wang Bin (China),
Jia Song, Jiang Wenping, Wang Hui, Chen Chao

Question: The functional and cosmetic reconstruction of replanted fingers or thumbs

Methods: From October 2010 until February 2014, we treated 9 replanted fingers in 9 patients (9 males) using Ilizarov distraction osteogenesis technique in 3-5 months after replantation

Results: In all the 9 patients bone consolidation was completed. The length of the replanted fingers was regained (17 mm in average). 2 patients had arthrodesis because the original articular surface were debrided in the process of replantation. The patients were satisfied with the cosmetic and functional improvement of their fingers

Conclusion: Adequate length is a fundamental requirement for opposition. Some patients would choose lengthening of the replanted finger for functional or aesthetic reason. The basic principle of lengthening of the replanted fingers or thumbs are to resume the opposition , sensation, length, strength, mobility, aesthetics while consider the limitation of neurovascular. distraction osteogenesis technology provides a good choose for reconstruction of replanted fingers or thumbs

#347: Ilizarov appartus application for osteomyelitis in Charcot foot deformity and with post-traumatic osteomyelitis

Jacob Odessky (Israel),
Alexader Odessky

Question: Results comparison of treating cases of feet osteomyelitis between patients suffering from Charcot foot deformity with osteomyelitis and patients with post-traumatic osteomyelitis of foot, using the Ilizarov appartus.

Methods: 20 patients after debridement procedures due to infectious process of feet underwent compression or distraction arhtrodesis using the Ilizarov apparatus. All of the patients had severe, multiplanar deformity of feet. Patients were divided into 2 groups, first group included patients with Charcot deformity of foot accompanied with infection (N = 6), second group included patient suffering from post-traumatic osteomyelitis of feet (N = 14). The duration of external fixation treatment were compared between the 2 groups prospectively.

Results: Between 2006-2014, 20 patients, aged 2072 years (average 50), with osteomyelitis of the feet were treated by Ilizarov apparatus in our institution and divided to 2 groups. First group included 6 patients (4 men, 2 women), average age 58.6 (range 52-70), all of the patients suffer from Charcot foot and infection. 5 patients underwent previous operations that failed. All of the patients underwent compressive tibio-calcaneal arthrodesis. The duration of external fixation treatment in this group averaged 6.5 month (range 5.5-7). All 6 patients were fused and able to weight bare. Second group included 14 patients (9 men, 5 women), average age 41.5 (range 20-72). The infectious process in this group was a result of an open fracture dislocation of talus (N = 4), open fracture dislocation of ankle (N = 4), bimalleolar fracture (N = 4) and a calcaneal fracture (N = 2). 6 patients in this group had additional AVN of talus. All patients in this group underwent a number of surgeries, including ORIF and attempts of surgical treatment of osteomyelitis with unsatisfying results. 2 patients in this group were treated by a distraction subtalar arthrodesis, 6 patients were treated by compression ankle fusion, 4 patients were treated by distraction tibio-calcaneal arthrodesis, and 2 patients were treated by compression tibio-calcaneal arthrodesis and length restoration proximal tibial osteotomy. The duration of external fixation treatment in this group averaged 5.7 month (range 2.5-10). Union was reached in 12 patients. 2 patients with ankle arthrodesis developed non-union due to early removal of apparatus as result of poor compliance.

Conclusion: We concluded that the use of Ilizarov apparatus in cases of foot osteomyelitis give good results. We noticed that patients suffering Charcot foot deformities require a longer external fixation period in the course of their treatment.

#348: Versatility of the Soleus muscle flap for soft tissue defects and osseous reconstruction of the lower limb

Edgardo Rodriguez-Collazo (USA),
Lee Stein, Steve Frania

Question: Soft tissue reconstruction of the distal on third of the tibia continues to be a challenge for reconstructive surgeons. A variety of surgical options such as segmental bone shortening and free soft tissue transfers. The soleus muscle is part of the superficial posterior compartment of the lower limb. All muscle of this compartment are classified as Type II. Their vascularity proximal is supplied by larger vascular pedicles and distally by smaller minor pedicles. The soleus muscle could be transposed medially and laterally depending of the extent and length of the defect. Proximal rotation and distal rotation is possible if at least two pedicles are maintained.

Case Report: 42 y/o man with history of diabetes sustained left calcaneal fracture. Initial surgical approach was ORIF resulting in osteomyelitis with draining fistula not responding to antibiotics for a period of 14 weeks. After all the hardware was removed the residual chronic wound was treated by a rotational reverse soleus flap to provide soft tissue coverage. Skeletal external fixation was applied to prevent microvascular damage to the flap. Immediate application of the Integra collagen matrix applied with vac therapy. A delayed approach was implemented 15 days after the initial flap rotation to finalized with split thickness skin graft.

#349: Circular fixation for tibio-talar arthrodesis vascularized fibular transposition and peroneus brevis muscle flap

Edgardo Rodriguez-Collazo (USA),
Steve Frania, Jeff Weiland, Byron Hutchinson

Question: Solid osseous fusions continues to be a difficult problem for surgeons. Multiple scenarios place patients at risk such as diabetes, rheumatoid arthritis and other metabolic conditions. In cases of revisional surgery damage to the vascular supply of the affected areas is inevitable.

Case Report: 58 y/o female with three failed ankle and subtalar fusion. History of smoking and osteoporosis. Surgical approach consisted in resection of the remaining articular surface at the level of the tibio-talar articulation. Followed by vascular medialization of the fibula at the level of the non-union. Temporary fixation was used to maintained proper position. The entire anterior portion of the resected osseeus segment was covered with a vascularized rotational peroneus brevis flap. Skeletal external fixator was utilized to achieved compression of the site. Satisfactory fusion was obtained at 11 weeks.

#350: Peroneus brevis muscle flap for distal tibia full soft tissue defects-circular external stabilization

Edgardo Rodriguez-Collazo (USA)
, Byron Hutchinson, Steve Frania, Jeff Weiland

Question: Distal third lower limb soft tissue defects are considered some of the most challenging conditions to treat. If the underlying osseous structures could be also compromise with excessive scar formation or a bacterial nidus. Muscle flaps could provide excellent soft tissue coverage and provide vascularity to the affected area to eradicate deep osseous infection.

Case report: 52 y/o old female history of osteomyelitis of the distal tibia. Her distal blood flow was adequate to supply distal pedicles rotational flap. The peroneus brevis muscle provides sufficient coverage for distal tibia, posterior ankle and lateral hindfoot. After removal of the internal hardware the rotational flap was performed. The soft tissue coverage was performed as a delayed stage utilizing soft tissue skin graft after the flap stabilization for 2 weeks. The circular fixator was maintained for a period of 4 weeks until for incorporation of the graft.

#351: Application of external fixator in fractures of distal radius

Sergio Iriarte (Bolivia)

Is the Monolateral External Fixator an effective method in treatment of high energy and unstable fractures of the distal radius?

Methods: Analyzing the treatment and results of 182 patients, 12 of them presented bilateral fracture, in total 194 wrist fractures, from April 1993 to April 2014 (21 years follow up)

Results: Consolidation in 100% of the cases; deformity absent or discreet 89%; functional result: excellent or good 75%; time of treatment from 6 to 8 weeks; time of consolidation 6 weeks.

Conclusion: The method determines good stability; good control of the forces of lateral angulation and torsional deformity, the elasticity of the assembly favors the formation of bone callus, possibility of controlled traction, early mobilization, and short time of treatment.

#352: Correction of Cubitus-Varus Deformities in Children Using the Taylor Spatial Frame

Mark Eidelman (Israel)

Cubitus-varus is well known complication of malunited fracture of the distal humerus in children and adolescents. Standard treatment of this deformity needs significant exposure and is associated with high complications rates. We present our experience with percutaneous distal humeral osteotomy and 3D correction using Taylor Spatial Frame (TSF).

Methods: Between the years 2011-2015 we operated on 5 patients (four females and one male) with mean age 9.5 years (range 8-12). All patients had malunion of distal humeral supracondylar fractures and severe cubitus varus deformities. All patients had at least two planes of deformity to correct. Mean carrying angle was 21 degrees varus (range 19-23 degrees varus). We evaluated all patients' files and x-rays and examined patients recently. All patients or parents filled Quick Dash assessment scores.

Results: All patients achieved correction goal. The carrying angle of the elbow was corrected to within the range of the normal population. All had full range of motion on the last follow-up. One patient underwent re-operation a week after the initial surgery due to mispositioning of the distal half pins. No other complications were recorded. All patients and parents were satisfied with achieved correction results.

Conclusion: Based on our initial experience we believe that TSF is an accurate and predictable method for correction of this complex condition. However, there are many pitfalls of operative technique and therefore meticulous adherence to external fixation rules and principles is highly advisable.

#353: Correction of severe Equinus deformities in older children using Taylor Spatial frame.

Mark Eidelman (Israel)

Treatment of rigid equinus deformities might be challenging task. Most patients already underwent at least one soft tissue release and recurrence of equinus is common. The purpose of this study was evaluation results of treatment of severe equinus using Taylor Spatial Frame (TSF) .

Methods: 15 patients ,4 females and 11 males with mean age 14.1 years that were treated in our institution from 2005-2012 were conducted to this study. Five patients had clubfoot, five arthrogryposis, three developmental equinovarus, and two patients had deformities secondary to growth arrest of the distal tibia and extensive deep burns. Mean preoperative dorsiflexion was -15.8° (range 5-60°). Soft tissue distraction with standard TSF was done in 12 patients and three patients underwent supramalleolar osteotomy in order to achieve correction goal (10 degrees dorsiflexion).

Results: Correction goal was achieved in 13 patients, equinus recurred in two patients and subsequent ankle fusion was done. Mean time with frame was 91 days (range 62-162), mean postoperative dorsiflexion was + 10.4 °(range -5°-+20 °). At the latest follow-up functional outcome was excellent in two patients, good in ten, fair in two and poor in one patient.

Conclusion: Despite severe and rigid equinus majority of our patients achieved correction goal and good functional results.

Significance: Based on our experience TSF is reliable and powerful tool for correction of rigid equinus in older children.

#354: The Trigonometric Planning Method for Femoral Lengthening Along The Anatomical Axis with or Without Frontal Plane Deformity Correction (A New Method)

Sherif Galal (Egypt)

We identified another method to determine the trajectory of the nail in the lower femoral fragment (the post lengthening anatomical axis) based on laws of trigonometry by calculating the angel enclosed between this new anatomical axis & the mechanical axis (Femoral Mechanical Anatomical angle, FMA). At the end of lengthening, the correct position for center of the femoral head is to lie along the upward extension of the normal mechanical axis of the lower femoral segment, & because the length of the femoral neck is constant during lengthening, we can conclude that in the correct post lengthening position the piriformis fossa (the upper limit of the anatomical axis) should assume a position that's more medial to the upward extension of the anatomical axis of the lower fragment (because the length of the femoral neck will not be enough to bridge the gap between the upward extensions of both the mechanical & the anatomical axis of the lower femoral segment. This is opposite to what happens to the center of the femoral head, which moves to a position that's more lateral to the mechanical axis when lengthening is done along the anatomical axis. Thus we can conclude that the FMA in the post lengthening position will be less than that in the pre-lengthening condition. In this final (post lengthening) position, the trajectory of the intramedullary nail will be the (post lengthening) anatomical axis of the lengthened femur; this line extends between the intramedullary nails entry points at the knee (center of the knee) & at the hip (piriformis fossa).

Methods: In the pre-lengthening condition we can draw a triangle ABC where point A represent the nail entry point at the center of the knee, point B represent the center of the femoral head, point C represent the piriformis fossa, AC line represents the anatomical axis, AB line represents the femoral mechanical axis & we'll refer to its length as "c", BC line is the femoral neck & we'll refer to it's length as "a". We'll refer to the FMA angel as "Alpha", & we'll refer to the angle between the mid-diaphyseal line of the proximal femoral fragment & the line joining the center of the femoral head to the piriformis fossa as "Gamma". In this triangle we only need to measure the distance "c" & angle Alpha (normally 7° on average) In the post-lengthening condition we'll use A, B, C to refer to the same points as before, we'll refer to the (new) length of the femoral mechanical axis as "c`", the femoral neck length will remain (unchanged) as "a", we'll refer to the (new) FMA angle as "Alpha` " & angle "Gamma" will remain (unchanged). In this triangle we only need to measure the distance "c`" (c`= c + amount of lengthening).

Results: By applying the trigonometric rule of "Law of sines" we get the following results: For pre-lengthening triangle: sin Alpha/a = sin Gamma/c. Thus a X sin Gamma = c X sin Alpha. For post-lengthening triangle: sin Alpha`/a = sin Gamma/c`. Thus a X sin Gamma = c` X sin Alpha`. Thus c X sin Alpha = c` X sin Alpha`. Thus c/c` = sin Alpha`/sin Alpha. In this equation c, c` & Alpha are known, so we can calculate sin Alpha` & by using the inverse trigonometric function of "arcsin" we can estimate the (new) FMA angle.

Conclusion: Once we have this angle we can draw the (new) anatomical axis of the lower femoral fragment & by applying the usual rules for deformity analysis & planning we can consider the point where this line intersect the anatomical axis of the proximal fragment as the apex of the deformity, accurately measure the magnitude of deformity, chose osteotomy level.

#355: Tri-planar Tibial Deformity Correction by Mono-lateral Fixator Assisted Nailing

Sherif Galal (Egypt)

In Blount's disease, there is a complex three-dimensional deformity, which typically includes varus, internal rotation, and procurvatum (3). The purpose of this study was to evaluate the results of using a monolateral fixator assisted nailing for triplanar correction of tibial deformity resulting from Adolescent Tibial Vara. All the patients gave the informed consent prior to being included into this study; the study was authorized by the local ethical committee and was performed in accordance with the Ethical standards of the 1964 Declaration of Helsinki as revised in 2000.

Methods: We identified 26 patients (34 limbs) who underwent corrective osteotomies under image intensifier. We observed accuracy of correction (based on correction of the MAD), duration of surgery, postoperative knee ROM, and complications. Minimum follow-up was 11 months (6-18 months).

Results: We achieved the desired MAD within 10 mm of the goal in 28 of 34 limbs. The Operative time was 86 ± 34 minutes per bone. Preoperative and postoperative knee ROMs were similar and there were no major complications.

Conclusion: Fixator-assisted internal fixation combines the accuracy, minimal invasiveness of fixators, with patient compliance and the comfort of internal fixation. Temporary external fixation allows precise correction of the deformity and will be removed at the end of the operation.

#356: Assessment for Activities of Daily Living and Sports for Patients undergoing Cosmetic Stature Lengthening

Dong Hoon Lee (Korea)
, Keun Jeung Ryu, Jin Ho Hwang, Hyun Woo Kim, Hoon Park

Question : Cosmetic stature lengthening using distraction osteogenesis recently applied for individuals with dis-satisfied short stature who wish to be taller. Since the surgery deals with no definite physical pathologic conditions, it is always under controversy from an ethical standpoint. Comprehensive analysis for the ability to perform activities of daily living and sports after cosmetic stature lengthening has not been fully documented. We aimed to investigate level of activities of daily living and sports after cosmetic stature lengthening.

Method : This study is based on prospectively collected data. October 2009 to March 2013, we evaluated 104 patients who underwent stature lengthening who met the pre-specified inclusion criteria. All patients underwent bilateral lower limb lengthening at femur (10 patients with ISKD) or tibia (4 patients with ISKD, 63 patients with LATN, and 27 patients with LON). The preoperative height and the final length gain were 163.57.2 cm and 6.32.4 cm respectively. The mean age at the time of surgery was 22.54.4 years. Evaluation for the level of activities of daily living and sports were via the following three methods; (a) the IKDC subjective score (0 point (worst) -100 points (best)), (b) the Sports Activity Rating Scale (SARS) which consists of a level of physical exercise and its frequency (0 point (worst) - 100 points (best)), and (c) four patient-reported questionnaire which consisted of an activity level of daily living, light exercise, strenuous exercise, and overall physical capability as a percentage compared to preoperative state (0 percent (worst) - 100 percent (best)). Evaluations for the IKDC and SARS and were performed at 1 year and 2 years postoperatively. Evaluations for four patient-reported questionnaires were done at 2 years postoperatively.

Results : The IKDC subjective score was 67.418.9 points at 1 year and 83.320.0 points at 2 year at postoperatively. The SARS score was 65.229.1 points at 1 year and 66.025.1 points at 2 year at postoperatively. The IKDC subjective score and SARS score showed no significant differences between the bones lengthened (femur vs tibia). The IKDC subjective score and SARS score showed no significant correlation with the percentage lengthened (final length gain/Preoperative length of the index bone which would be lengthened, 18.82.7%). Patient-reported scores for activity level at 2 years postoperatively for daily living, light exercise, strenuous exercise, and overall physical capability were 90.49.0, 88.210.6, 64.424.6, and 74.516.0 points respectively.

Conclusion : Patients who underwent cosmetic stature lengthening showed gradual improvements in activities of daily living and sports after the surgery. They showed almost full recovery of the preoperative level of activities of daily living and light sports, but showed limited recovery of the preoperative level of strenuous exercise.

#357: Acute Angular Deformity Correction Following Tibia and Fibular Fracture Malunion: A Case Report

Craig Clifford (USA),
Christyn Rossiter

Question: The purpose of this paper is to illustrate the use of Ilizarov circular external fixation for the acute correction of a lower leg malunion. The aim is to answer whether the utilized technique offers successful results for this indication.

Methods: A residual angular valgus deformity presents difficulty in ambulating without pain and poses a challenge for bracing. In this case a 39-year-old male has been ambulating with the use of a crutch for 3 years status post a tib/fib fracture. The subject has been in significant pain at the site of malunion and unable to ambulate without the use of a walking aid. Use of Ilizarov circular external fixation to correct the deformity provided the subject with an anatomically aligned lower leg.

Results: The procedure chosen for the acute correction was an oblique osteotomy of the tibia and fibula to allow for angular realignment and lengthening. Ilizarov circular external fixation in the form of a static frame was used to maintain the corrected position. The subject was maintained in the external fixator for the total course of 6 months. The subject was non-weight bearing and at 4 months a CT was taken and there was found to be adequate regenerate. Also at 4 months the leg was stressed and found to be stable. At this time the foot ring was removed and the subject was allowed weight bearing as tolerated with the tibial rings still in place. After another 2 months the external fixation was removed and the subject was transitioned to full weight bearing in an Arizona brace.

Conclusion: Use of the Ilizarov circular external fixation adequately and appropriately restored proper anatomic alignment in acute angular correction and lengthening of a tib/fib fracture malunion with residual valgus deformity. The report provides a successful outcome of the described technique for this indication, and may be useful in other similar instances.

#358: The treatment of complicated genu deformity using Ilizarov technique by external fixator combined with orthosis

Zhenjun Wang (China),
Jiancheng Zang, Sihe Qin

Question: To explore the advantage and valuation of external fixator combined with orthosis followed by Ilizarov technique for the treatment of complicated knee joint deformity.

Methods: In May 2005-December 2012, 36 cases36 kneeshad been done using Ilizarov technique by external fixator combined with orthosis, including 23 males and 13 females, aged 6-56 years, mean 28 years. Genu recurvation deformity of polio sequelae in 17 knees, the hamstring tendon had been tighted and the lower limb had been fixed by Hybrid external fixator at 20 degrees position temporary, the orthosis with threaded rods instead of the femoral part of external fixation two weeks later; Genuflexion deformity accompany by limb lengthening in 10 knees, Lower limb had been fixed with cross-knee orthosis and then gradually distracted with a threaded brace rod; There were 8 knees that genu varus deformity combined lateral collateral ligament relaxation, had been fixed by Hybrid external fixator after tibial osteotomy and lateral collateral ligament reconstruction, two weeks later, the femoral part been removed, a thigh brace and a threaded rod stretched across the knee; Genu flexion deformity caused by hemangioma in 1 case, its correction by the combination of femoral external fixation and leg brace.

All the cases were followed up for 8-60 months, mean followed 19 months, all of them were satisfied with the deformity correction and limb weight-bearing line. Healing time on osteotomy was 60-150 days, average 120 days; external fixator pin tract infection in 5 knees, improved after dressing; according to HSS scoring system, excellent in 18 knees, good in 10 knees, the fine rate was 87.5%.

Conclusion: The combination of external fixator and orthosis abide by Ilizarov technique have lots of advantadges, such as simple, less invasive, fixed flexible. The satisfactory limb shape and perfect knee motion can be achieved in the correction of complicated genu deformity with soft tissue problem.

#359: Simultaneous distraction osteogenesis for treatment of bilateral multiple brachymetatarsia

Qinglin Kang (China),
Yachao Jia, Honghao Chen

Question: To analyze and explore the outcomes and complications of the treatment on bilateral multiple brachymetatarsia by simultaneous distraction osteosgenesis.

Methods: Between July 2008 and December 2013, 20 cases with bilateral multiple brachymetatarsia were treated in our institution. Totally 78 metatasals were gradually lengthened respectively using a mini-external fixator after a dorsal percutaneous osteotomy with osteotome through pre-drilled holes. 14 patients showed 4 short metatarsals (first and fourth, bilaterally), 2 patients had 5 (first and fourth in right; first, third, and fourth in left) and 2 patients presented 6 (first, third, and fourth, bilaterally). The average age of patients was 21.6 years of age (range, 16 to 32 years). To prevent complications and morbidities of lengthened metatarsals, the tarsometatarsal joint or proximal affected metatarsal with adjacent ones was fixed temporarily, which was aimed to provide a stable environment for distraction osteogenesis. Additionally, a 1.5 mm transarticular K-wire was fixed through metatarsophalangeal joint to prevent subluxation. All these K-wires would be removed when the lengthened metatarsals reached the parabola line.

Results: The mean follow-up was 39.6 months (range, 19 to 56 months). All patients achieved cosmetic appearance. The average amount of lengthening was 16.3 ± 3.1 mm in the fourth metatarsal, 23.5 ± 4.2 mm in the first, and 15.3 ± 3.4 mm in the third. The average postoperative AOFAS score was 83.2 ± 7.6. Stiffness of the fourth metatarsophalangeal joint was the most common reason of functional deficiency. Additional operations of autogenous bone graft were performed in the first metatarsal lengthening zones of two patients.

Conclusion: The gradual lengthening by distraction osteogenesis has a reliable outcome of the treatment on bilateral multiple brachymetatarsia, which is better than combination of lengthening and shortening adjacent metatarsals by bone excision and autogeneous bone graft.

#360: The use of Gradual Correction with the TL-Hex external fixator in Blount's disease

Pieter Maré (South Africa)
, David Thompson

Question: What is result of gradual correction with the TL-Hex external fixator in Blount's disease in terms of accuracy of correction, union and complications?

Methods: A retrospective chart and X-ray review of 7 patients (9 legs) treated by gradual correction with the TL-Hex external fixator was completed. Degree of correction of varus and procurvatum was assessed on pre-operative and post-correction X-rays. Internal rotation deformity correction was assessed clinically. Complications such as neurovascular compromise, minor and major pin tract infection and hardware complications were documented. The pre-operative planning, surgical technique and post-operative treatment protocol was reviewed.

Results: Mean varus was corrected from 21° (17° to 45°) to 1°(-2° to 4°). Mean procurvatum was corrected from 8° (0° to 25°) to 0° (0° to 8°). Internal rotation was corrected to between 5° to 10° of external rotation in all patients. Three patients needed one additional program to correct residual deformity (one over-corrected coronal aligment, one under-corrected saggital alignment and one rotational over-correction). The mean time in frame was 112 days. Three patients required oral antibiotics for minor pin tract infection. One patient required intravenous antibiotics and wire removal for major pin tract infection. One patient required frame adjustment after correction for soft tissue impingement. One strut loosened after consolidation prior to frame removal.

Conclusion: Gradual correction of Blount's disease with the TL-Hex external fixator is a safe and effective treatment method.

#361: An Anatomical Study of the Greater Trochanter Starting Point for Intramedullary Nailing in the Skeletally Immature

Paul J. Park (USA),
Douglas Weinberg, Kathleen Farhang, Raymond W. Liu

Question: Trochanteric entry femoral nails have been increasing in popularity in the pediatric population for stabilization in fractures and osteotomies. The proper position for entry point in the coronal plane has been well studied; however, the sagittal plane in the pediatric population has not yet been well characterized.

Method: Eighty-eight cadaveric femora ages 8-20 years were studied in an apparent neck-shaft angle (ANSA) position, with distal condyles flat on the surface, and a true neck-shaft angle (TNSA) position, with internal rotation to neutralize femoral anteversion. Anterior and lateral offset were measured on lateral and anteroposterior photographs, respectively, as the perpendicular distance from the greater trochanter apex to the center of the intramedullary canal. The effect of rotational position (ANSA versus TNSA) of the proximal femur was compared using the intraclass correlation coefficient (ICC) for anterior and lateral offset. Correlations between age, demographics, anteversion, and greater trochanter morphology with anterior and lateral offset were evaluated with multiple regression analysis.

Results: Mean age was 15.8 3.8 years. Mean anterior displacement of the trochanteric apex was 4.8 3.0 mm and 4.6 3.2 mm in the ANSA and TNSA positions, respectively. Mean lateral displacement was 10.6 4.2 mm and 9.7 4.0 mm in the ANSA and TNSA positions, respectively. The intraclass coefficient (ICC) for anterior offset in the ANSA versus TNSA position was 0.704, and 0.900 for lateral offset. Change was minimal for anterior offset in the ANSA and TNSA positions versus age (standardized beta values 0.240, 0.241, respectively). There was a significant correlation with increasing lateral offset in the ANSA and TNSA positions with increasing age (standardized beta values 0.500, 0.385 respectively).

Conclusion: In the pediatric population, the tip of the greater trochanter is consistently anterior by approximately 5 mm. Mean lateral displacement was approximately 10 mm and increased with increasing age. Nail entry at the pediatric greater trochanter apex would likely result in anterior placement. We recommend inserting the guidewire 5 mm posterior to the apex of the trochanter and confirming coronal and sagittal position with fluoroscopy.

#362: An anatomic study to evaluate the rotational profile between the radial styloid-bicipital tuberosity and ulnar styloid-coronoid process

Douglas S. Weinberg (USA),
Paul J. Park, Kaeleen A. Boden, Kevin J. Malone, Daniel R. Cooperman, Raymond W. Liu

Question: Evaluating rotation during open reduction internal fixation (ORIF) of forearm fractures is of paramount importance. Traditionally many surgeons have assessed this relationship using the distance between the radial styloid and bicipital tuberosity, and the ulnar styloid and the coronoid process on AP and lateral radiographs, respectively. However, to our knowledge, there is minimal original research available to confirm either of these relationships. We therefore designed a cadaveric study to quantify the rotation between these bony landmarks.

Methods: 600 cadaveric radii and ulnae were obtained from the Hamann-Todd osteological collection. All specimens were screened for evidence of fracture, infection, or metabolic disease. In order to simulate the position of the forearm during fluoroscopic imaging, the radius and ulna were rotated until the maximal distance between the respective bony prominences in the AP or lateral planes was observed. Using a microscribe 3D-digitizer, virtual representations of these landmarks were created in the x, y, and z-planes. The rotational profiles between the radial styloid and bicipital tuberosity was calculated in the radius, and the ulnar styloid and coronoid process in the ulna.

Results: The radial styloid was 160 15 degrees supinated from the bicipital tuberosity. The ulnar styloid was 183 14 degrees supinated from the coronoid process. There were no differences in the rotation of the radius or ulna between ages (p 0.05 for both bones), genders (p 0.05 for both bones), or races (p 0.05 for both bones).

Conclusion: These findings suggest that conventional methods to assess intraoperative rotation of the radius on AP radiography may be inadequate. Similarly, while the population average rotational profile of the ulna on lateral radiograph may be consistent with previously held beliefs, these results suggest there is a wide range of variability among normal anatomy. In order to provide the most clinically useful information, future analyses should focus on establishing the rotational window over which these landmarks remain constant.

#363: Preoperative planning of osteotomy for legs shape correction

Leonid N. Solomin (Russia),
Pavel N. Kulesh, Elena A. Shchepkina

Question: At the present day, many methods of preoperative planning of osteotomy for genu varum treatment are used. It is usually performed by using long-films. Result of the planning is the range of correction angle (range of valgisation). Preoperative planning provides compliance of reference lines and angles (MAD, mTFA, aTFA, MPTA, LDT) to normal values. However, there are no methods to estimate the legs shape after correctional osteotomy before operation perform. It is extremely important for patients who are not satisfied with legs shape. That is why it was necessary to develop the preoperative planning method allowing estimating in advance a shape of legs that will be reached after various variants of correction.

Method: According to the Professor A. A. Artiemevs classification there are ideal legs shape, bow legs, curved shanks, knock-knees. In the analysis of references we studied types of manipulations with bone fragments used for legs shape correction (angulation (valgization), translation (medialization), distraction), effects of the manipulations on changes of legs shape and indications for performance of each type of manipulations. We developed the method of preoperative planning of osteotomy for bow-legs correction allowing to predict a legs shape which will be reached after correction. The method is based on application of the long-films executed in a standing position. We perform planning using the graphic editor by moving of skiagrams of the distal fragment of the tibia and skiagrams of the fibulas. Movement of the skiagrams of the bones perform with movement of the corresponding fragments of the legs shape. We perform planning step by step. First step - planning of valgization of the distal bone fragments. If after that the legs shape accorded to curved shanks, we perform the next step planning of medialization of the distal fragments. Moreover, if the patient estimate the width of shanks as excessive we plan distraction (bringing fibula down). After preoperative planning receive the pictures of a legs shape after correction and corresponding to the pictures skiagrams of bone fragments positions, measure the amount of valgization, medialization and distraction necessary for reaching a desirable legs shape, define compliance of reference lines and angles to normal values.

Results: We performed preoperative planning for 25 patients operated for legs shape correction in 2011-2013 before procedure. According to the planning, achievement of an ideal legs shape by valgization was possible at seven patients (28%). These patients reached an ideal legs shape by valgization. Other 18 patients (72%) needed the medialization of the distal fragments of tibial bones. From them four patients refused the medialization and curved shanks were reached by one patient who plans secondary surgery. The others 14 (56%) chose correction with a medialization (from them - 5 patients with bringing down of a fibula). 11 patients reached the ideal legs shape. Two patients refused achievement of an ideal legs shape. They preferred to eliminate the bowlegs partially. In one case, bowlegs were not eliminated completely because of early consolidation.

Conclusion: The analysis of application of the original method of preoperative planning for 22 patients shows that in 19 cases (86%) the legs shape after correction completely corresponded to preoperative planning. When reached legs shape did not correspond to preoperative planning, it corresponded to the ideal legs shape.

#364: Knee joint arthrodesis by Ilizarov and using BIOS

Leonid N. Solomin (Russia),
Konstantin L. Korchagin

Question: To estimate the efficiency of various methods of knee joint arthrodesis in treatment of patients with huge defects of bones forming the knee joint who have contraindications for arthroplasty.

Method: Group 1 included 24 patients who underwent arthrodesis made using a long intramedullary nail (BIOS). In group 2 (25 patients) was performed compression arthrodesis by hybrid external fixation frame ( by Ilizarov). We compared the main clinical, radiographic parameters and quality of life based on the SF-36 questionnaire.

Results: The total duration of staying in hospital for patients with arthrodesis by Ilizarov was higher (60 + 6 days) than while using BIOS (34 + 3 days). Time of onset of fusion in patients treated by Ilizarov was less than the same in BIOS: 192 + 20 and 310 + 14 days respectively. Total number of complications in patients treated by Ilizarov method was lower (9.5%) than in BIOS group (11.1%). According to the scale SF-36 earlier rehabilitation was observed in BIOS group; in 12 months after operation parameters in both groups do not differ. More than half of the patients in the future will require additional treatment to eliminate limb length discrepancy.

Conclusion: Both analyzed methods of knee joint arthrodesis sufficiently effective to treat this group of patients. Using of intramedullary locking nails is more comfortable for patients, provides an earlier restoration of the function of the limb. However, the Ilizarov apparatus provides earlier fusion. In addition, the use of Ilizarov apparatus is substantially " single-option" in cases when there are contraindications for internal fixation.

#365: How to help the patients with severe hip and knee flexion deformity stand up and walk

Qin Sihe (China),
Jiao Shaofeng, Pan Qi, Wang Zhenjun

Question: Many reasons can cause severe hip and knee flexion deformities. Patients suffer these kind of deformities lose the function of stand and walk. We had treated 20 cases with severe hip and knee flexiondeformities, help them reconstruct the function of stand and walk.

Methods: We operated on these patients follow the principles below: correct the deformities gradually, stabilize the joints, reconstruct the force line and balance the muscle strength.

Results: With an average 41 months follow-up, all the patients obtain the function of upright walking without any severe complications.

Conclusion: limited surgeries combine with ilizarov method can help patient with severe hip and knee flexion deformities reconstruct the function of stand and walk.

#366: Early results of single stage chronic osteomyelitis treatment with antibiotic impregnated calcium sulphate beads

Abhishek Chaturvedi (UK),
Gavin Barlow, Hemant Sharma

Question: The management of chronic osteomyelitis is fraught with difficulties; a multi-disciplinary team approach is recommended for optimum outcome. Thorough debridement, dead space management and organism targeted antibiotic therapy gives the best clinical results. Calcium sulphate beads impregnated with antibiotic is an absorbable option for prolonged local antibiotic elution and dead space management. This study aims to analyse the early results of single stage management of osteomyelitis with antibiotic impregnated calcium sulphate beads. Following surgical debridement, calcium sulphate impregnated typically with tobramycin and/or vancomycin is inserted to obliterate the dead space. Intravenous antibiotics typically teicoplanin and piperacillin-tazobactam are administered until culture results permit rationalization to narrow spectrum agents. Patients are followed up in Infectious Diseases and Orthopaedic clinics for a period of 12 months and discharged if quiescence is achieved.

Methods: We conducted a retrospective analysis of our prospective database to identify patients treated with our single stage protocol for chronic osteomyelitis. We excluded patients that had (1) less than 8 months of follow up, (2) incomplete metal-ware removal, (3) patients lost to follow up. Each patient was staged using the Cierney-Mader classification. Clinical, radiographic, and laboratory (microbiological, biochemical and haematological) methods were used to monitor response to treatment.

Results: Fourteen patients (9 men, 5 women) with mean age of 41 (16-73) years and mean follow up over 10 (8-12) months were included in study. Eleven patients had previous surgeries involving internal fixation; the rest were primary osteomyelitis. Seven patients had washouts and removal of metal-ware procedures for osteomyelitis prior to referral to the bone infection service. Cierney-Mader classification determined that 8 patients were classed as type A (normal hosts); 4 as BS (systemically compromised); 2 as BLS (locally and systemically compromised). Anatomic analysis suggested 7 were Type 1 (medullary osteomyelitis); the remaining 7 were type 3 (localized disease). Five patients were staged IA; three each staged IIIA and IIIBS; and one each staged IBS, IBLS, IIIBLS. Staphylococcus Aureus was the commonest causative organism. Follow up radiograph monitoring indicated absorption of the beads by 3 months. Currently half our cohort has completed the follow up period. There has been no evidence of recurrence based on clinical, radiographic and blood based parameters in all patients

Conclusion Short-term results of single stage osteomyelitis treatment with calcium sulphate beads impregnated with antibiotics are promising.

#367: Open tibial fracture Gustilo III-C: Reconstruction with vascularized flap of latismus dorsi and serratus and modular external fixator

David Cancer Castillo (Spain),
Sergi Oliv Vias , Anna Isart Torruella , Ignacio Ginebreda Mart

Question: Man of 44 years suffered a motorcycle accident with open diaphyseal fracture of the left tibia and fibula of Gustilo grade III -C.

Methods: Transferred from another center, open fracture diagnosed grade III-C tibia and fibula injury with vascular-nervous package anterior tibial and peroneal artery, extensive soft tissue injury of bone exposed middle third of the left tibia and muscle compartments above and back. Friedrich is done for necrotic tissue, suturing of the anterior tibial artery, pendant rotation to cover the defect before and osteosynthesis with external fixator. Once at our center, we see the flap necrosis and an unstable fracture focus. Surgical debridement is performed for the necrotic tissue, stabilizing the fracture using a spare fixer hybrid external fixation system and application of VAC therapy to recover soft tissue deficits. Later performed surgical resection with a latismus dorsi and serratus flap with microsurgery and skin cover. Finally, bone resection of the anterior distal tibia bone to get bloody and stabilization modular external fixator. Two months after, the external fixation was removed and the fracture was synthesized with an endomedular nail in two times.

Results: The patient now performs functional rehabilitation for muscle strengthening and walks on his own with the help of crossings. The tibia fracture is in consolidation process.

Conclusion: The open fractures Gustilo III-C are serious injuries that require urgent multidisciplinary action for solve the neurovascular and soft tissue injury as well as a proper fracture stabilization with a modular external fixator. It is important to respect the basic principles of external fixation: anatomically system adaptable to different situations and phases of treatment, enabling access to soft tissue injury, mechanically functional (stability, alignment ) and comfortable (as comfortable as possible).

#368: Treatment of long bone noninfected nonunions by parafocal osteotomy according to Paltrinieri

Redento Mora (Italy)

Osteotomies performed in the management of nonunions can be classified into three types, according to Pilnacek (1998); intrafocal osteotomy: it is performed at the nonunion site and consists of resection of the entire area around the nonunion; transfocal osteotomy, performed through the nonunion siteto reshape the bone ends; parafocal osteotomy, performed some centimeters from the nonunion site. Parafocal osteotomy is an operative technique described by Paltrinieri, that stimulates the osteogenic potential in cases of long bone noninfected nonunions by means of a single or double osteotomy performed some centimeters away from the nonunion level, proximal or distal to the lesion (Paltrinieri, 1961). The roles of the parafocal osteotomy are to remove all mechanical stimulations from the nonunion site and to reestablish the axis to normal by correcting simple or complex deformities. In the first case operated by Paltrinieri, after the tibial osteotomy the lower limb was immobilized in a cast, and the nonunion healed in 3 months. Umiarov (1986) suggested the use of a parafocal osteotomy associated with immobilization by means of a circular external fixator, to combine the advantages of these techniques.

Methods: Between 1996 and 2012 26 patients affected by tibial nonunions (12 hypertrophic and 14 normotrophic) were treated with Paltrinieri's parafocal osteotomy, with a follow-up of 2-18 years. A careful preoperative clinical and instrumental evaluation was performed in order to detect and exclude infected nonunions. There were 18 men and 8 women with a mean age of 31 years (range: 25-52 years). All patients were treated 8-18 months after trauma. 20 patients were previously treated with internal osteosynthesis, 6 patients with a cast. Each case was associated with a simple or complex bone deformity. At the operation, a corticotomy was performed 3-6 cm away from the nonunion site; one case with a double complex tibial deformity was treated with a double (proximal and distal) parafocal osteotomy. In all cases both corticotomy and nonunion wer stabilized with an Ilizarov device. Immediate rehabilitation program and early weight bearing were started. From the second post operative day, gradual correction was performed at the corticotomy site until the deformity was corrected and a good axis restored.

Results: During treatment wires broke in 7 cases, and 10 patients developed superficial infection at some wire tracts. Nonunion healing, corticotomy consolidation and deformity correction were obtained in all patients in an average of 125 days (range. 90-140 days).

Conclusion: The technique of parafocal osteotomy was successfully employed later by other authors (Ranieri, 1968; Matasovic, 1978). In particular, stabilization with circular external fixators (Iacobellis, 2000; Mora, 2006) showsthe advantages of stability, assembly modularity, multiplanar control, possibility of gradually correcting the deformities, and represents today a natural complement to the simple and effective Paltrinieri's parafocal osteotomy.

#369: Congenital Femoral Deficiency in the adult

Bertil Romanus (Sweden)

What are the treatment options in cases with very short femur and a Congenital Femoral Deficiency in the adult.

Methods: Will present two cases, one with a follow up of 21 years and one recent, operated in February 2015.

Results: The method is a total hip arthroplasty with the femoral implant through a knee arthrodesis and a same amputation.

Conclusion: This procedure improves the function for the patient and improved prosthetic fitting and performance. Previous prosthesis has been tuber supported prostesis with a bulky thigh and knee region and the foot in equinus.

#370: To treat the lower limb deformity in osteogenesis imperfect patients with intramedullary pin fixation and external fixator

Xiuzhi Ren (China)
, Mei Chen, Junlong Liu, Fengling Fang

Question: To evaluate the safety, therapeutic effect and complications of the operation of multiple osteotomy and intramedullary fixation combined with external fixation for children with osteogenesis imperfecta.

Methods: 423 children (male, 285; female, 138) with osteogenesis imperfecta were treated from August, 2005 to August, 2013. Of all the patient, the number of type is 245, type is 174 and type is 4 according to the modified Sillence classification. The age that the patient received surgery differs from 2 years and 1 month to 15 years and 7 months, with average age of 8 years and 3 months. the intramedullary pin with suitable size were inserted into femur from greater trochanter, and tibia from pelma. In 405 cases with LLD 2 cm 10 cases were fixed with intramedullary pins as well as external fixator and bone lengthening were performed 7-10 days after the surgery. The external fixator was applied first to lengthen the contracted soft tissues and correct the deformiy and finally fixed with intramedullary pins in another 8 patients.

Results: 378 children were followed up with an average of 38 months (13-64 months). All the parents of children are satisfied with the result of surgical operation, and the childrens self-care and motion ability improved greatly. The new bone consolidated well. 14 children need second operation due to the translocation of Rush pin, and 25 children need to change internal fixation because of the shorter Rush pin due to bone growth 2 years after surgical operation.

Conclusion: The operation of multipl osteotomy and intramedullary fixation is an effective therapeutic method for children with osteogenesis imperfecta. The extensible nail is preferred for children with potential growth ability. Bone lengthening can be accomplished with external fixtor in these patients.

#371: Treatment of foot and ankle deformities secondary to lower limb hemangioma with Ilizarov technique

Jiao Shaofeng (China)
, Qin Sihe, Wang Zhenjun, Guo Baofeng

Question : Foot and ankle deformity is most common in osteoathropathy secondary to lower limb hemangioma. Traditional method to correct this kind of deformities is mainly depending on releasing the contracture soft tissue, which would not only easy to injure the hemangioma and lead blooding but also hard to totally correct the severe deformities because of the soft tissue limit.

Method : Retrospectively analyzed the data of 24 patients suffered foot and ankle deformities secondary to lower limb hemangioma. All the patients were treated during May 2005 and December 2013. 14 males and 10 females were in this group, with and mean age of 22 years old, range from 6 years old to 26 years old. There are 14 equinus 6 equinovarus and 4 equinocavus in this group. All the patients underwent limited surgery firstly and then using Ilizarov technique to correct the residual deformities. Use a special apparatus to correct knee contracture at the same time if it existed. 5 to 7 days post operation, started to correct the residual deformities with Ilizarov fixator. During the treatment period, patients can partly bear weight with the help of crutches.

Results : Mean follow-up of the 24 patients was 18 month, range from 6 months to 40 months. All the deformities were totally corrected; all the patients got plantigrade feet. Mean treatment time was 23 days, range from 7 days to 35 days. Value the clinical effect with ICFSG score, excellent 14 feet, good 6 feet, fair 4 feet; the rate of excellent and good was 83.3%.

Conclusion : Lower limb hemangioma can lead to foot and ankle deformities, in which equinus, equinovarus and equinocavus are common. Minimally invasive soft tissue releasing procedure combined with Iilizarov technique, which can also reduce the risk of bleeding during the surgery procedure, has an excellent therapeutic effect on treatment of these kind deformities.

#372: External Fixation with Minimally Invasive Reduction of Displaced Intra-Articular Calcaneal Fractures: A New Technique Involving a Traction Device Modification

Raymond Rowan (USA),
Gregorio Caban, Luis Marin

Question: The complications to open reduction and internalfixation of displaced intra-articular calcaneal fractures have been well established in the literature, with wound dehiscence and infection being the most common. Some studies have found wound complication rates as high as 25-33% (Folk et al., Abidi et al). Many techniques have been previously described utilizing percutaneous, and minimally invasive methods of reduction in order to avoid these complications. However, the criticism then aimes at the decreased ability to obtain adequate reduction with restoration of the posterior facet. With this in mind, we sought to improve upon the general technique of using external fixation with minimally invasive open/percutaneous reduction of displaced intra-articular calcaneal fractures, specifically Sanders types II, III, IV.

Methods: Here we present a simple traction device modification to a traditional Ilizarov ring fixator for use in applying traction during the initial reduction step of displaced intra-articular calcaneal fractures.

Results: The construct allows for gradual controlled multi-planar distraction of the tuberosity fragment. Olive wires and offset tensioning enable enhanced correction in the frontal plane, and the arch wire technique combined with graded post positions enables for controlled sagittal plane correction. When classic Ilizarov principles are applied to the construct an improvement over traditional distraction techniques is possible, setting the stage for a better outcome, and shorter OR time.

Conclusion: The general technique of employing percutaneous and minimally invasive methods has been previously described, with various combinations of traditional ring fixators, and mini-rail apparatuses. We believe that the modification presented here allows for improvement over previous constructs as it allows for increased control in the frontal and axial planes, as well as maintenance of the obtained correction for the remainder of the procedure.

#373: New Anatomical and Matching Foot Plate External Fixation Specific for the Foot and Ankle

Adam Ringler (USA),
Luis E. Marin, Bamidele Olupona

Question: Do you have a foot plate that is accompanied with a matching plate which is structured to mimic the anatomical and biomechanical function of foot arches in the lower extremity?

Methods: In order to compare the new design to present technology, one procedure (triple arthrodesis) was chosen. Although this is an isolated procedure, the versatility of the new external fixator design with a foot plate ensures multiple applications to the lower extremity.

Results: The external fixation device with the anatomical arch design was able to withstand 250,000 weight bearing cycles while the other construct failed just after 1 weight bearing cycle. The weight bearing cycles simulated a 200kg person on a Minibionix testing system. The in-plane compressive yield strength of the fixation with the foot arch is statistically significantly greater than other systems. The anatomical design of the frame allows for vector forces to act on theindividual joints (Sub Talar Joint, Talo-Navicular Joint, and the Calcaneo-Cuboid Joint). It allows for constant compression across the joints during weight bearing and non weight bearing. The non weight bearing and non compliant patient should still achieve early fusion since Compression is always achieved.

Conclusion: The Anatomical Foot and Ankle Frame system notjust indicated for a triple arthrodes but is also indicated for use in the lower extremity for other procedures such as: open and closed long bone fracture fixation, to include tensioned wire fixation of periarticular fractures, arthrodesis, osteotomy, reconstruction, non-unions, pseudoarthrosis, correction of bone or soft tissue defects and deformities, dilocations, arthrodiastasis, Charcot Foot Reconsruction, LisFranc dislocations and Calcaneal fractures.

#374: Treatment of severe foot and ankle deformities secondary to lower limb ischemic contracture with Ilizarov technique

Qin Sihe (China),
Shaofeng Jiao, Jiancheng Zang, Qi Pan

Question: to investigate curative effect of ischemic contracture of the lower limb after severe ankle foot deformity by the Ilizarov mini invasive distraction technique.

Methods: 18 cases of severe foot and ankle deformities, using minimally invasive distraction technique during 2002.04 C 2014.03, which is complicated with foot and ankle deformity after ischemic contracture. Male 14 cases, female 4. Age 13-41 years old, 23 on average. 11 cases of left lower extremity, 7 right. Preoperative deformity type: 14 cases of talipesequinovarus, 4 cases of clubfoot, with wide leg cicatricle contracture, 5 failure cases of them had soft tissue release surgery to correct the deformity of the foot previously. Assemble ankle & foot orthosis according to preoperative condition, in accordance with Ilizarov internal fixation principle, install orthopedic ankle traction device which has three-dimensional adjusted function, begin to rotate the traction rod thread 7 days after the operation, gradually correct varus and talipes equines deformity, walk with proper weight load in the process of traction and correction. 13 cases in the group with foot bone deformity are operated limited triple joint osteotomy before installing the external fixator. Postoperative traction time is 15-36 days.

Results: 18 cases were followed up, follow-up time was 10~29 months, 13 months on average. Foot and ankle deformities were corrected satisfactorily, with good function, no pin tract infection, skin flap necrosis, vascular and nerve injury.

Conclusion: Ilizarov technique for treatment of ankle and foot deformity secondary to ischemic contracture, which has the advantages of safe, minimally invasive, satisfactory effect, provide an effective way for surgical treatment of stiff ankle & foot deformity after ischemic contracture.

#375: Statistical analysis of 19221 foot and ankle deformities

Qin Sihe (China),
Jiaoshao Feng, Jiancheng Zang, Zhenjun Wang, Qi Pan

Question: Based on the Statisticanalysis of 19221 foot and ankle deformities treated by Prof. QIN sihe among 36 years, to discusses the concept and principle of deformity correction & functional reconstruction on foot and ankle diseases.

Methods: From May 25, 1978 to December 31, 2014, 32414 cases of limb deformity were operated, in which there were 19221 cases of foot and ankle diseases including 28 kinds of diseases such as poliomyelitis, cerebral palsy, congenital clubfoot, spina bifida sequelae, multiple contracture, traumatic ankle malformationet al. The operation methods include tendon lengthening, soft tissue release, tendon transposition, ankle muscle balance, osteotomy and arthrodesis; fixation methods include gypsum, brace, steel needle, internal fixation (plate, screw, cannulated screw) and external fixator (Ilizarov device and hybrid frame). Curative effect is comprehensively evaluated by the score of deformity correction, functional recovery and patient satisfaction; thelongest follow-up is up to 33 years.

Results: The fixation postoperative foot and ankle operation goes through the initial plaster fixation, external fixation combined with plaster, and current combination of external fixation and brace, ankle correction technology is gradually mature, forming natural philosophy of lower extremity reconstruction, going through operation into the natural philosophy, setting up Qin`s principle of foot & ankle function reconstruction. These principles include choosing external fixation, connecting external fixation rod between needles, fixing combined external fixator pin, connecting tibial fixation and ankle fixation and Ilizarov external fixation technique applied in foot and ankle.

Conclusion: Qin›s system of deformities correction and functional reconstruction for foot & ankle, it is applicable to all kinds of foot and ankle deformity correction, and obtain satisfactory clinical effect.

#376: Ilizarov tibio-talo-calcaneal (TTC) fusion with simultaneous deformity correction in flail and spastic feet neurologic conditions

Minoo Patel (Australia)

Since 2001 we have used TTC fusion with deformity correction using an Ilizarov or Taylor frame in cases of flail feet in spina bifida, and spastic feet in ABI, stroke, CMT and Friedreich ataxia. We compared the techniques and results between the groups.

Methods: 16 feet in 8 cases of spina bifida had equino-valgus or calcaneo-valgus deformity with a pistol-grip calcaneum. All 16 spastic feet had equino-cavo-varus deformity. Technique involved acute correction with osteotomies and soft tissue release, with frame application to hold the correction and fine tune it, and obtain compression across the ankle and sub-talar joints. Retrograde TTC fusion nails were inserted to obtain long term internal spintage.

Results: Successful TTC fusion was obtained in all cases. The average time in frame was 11 weeks in the flail feet group and 12 weeks in the spastic feet group. All had maintained TTC fusion at 3 year follow-up. Of the flail feet, 4 had minor residual crouch, however all ambulated indoors without aids and outdoors with a single or no crutch. None required revision surgery. In the spasticity group 2/2 CMT (4 feet), 1/3 (2/6 feet) ABI and 3/3 (3 feet) stroke patients could ambulate with or without aids. None of the Friedreich ataxia cases (3 feet) were able to ambulate despite having a plantigrade foot. None required revision surgery. Pain was a major issues with cases of Friedreich ataxia.

Conclusion: TTC fusion with deformity correction using fixator assisted nailing gives reliable and reproducible results in neurologic cases.

#377: Fixator assisted nailing for revision of failed ankle fusion with bone loss and deformity

Minoo Patel (Australia)

Failed ankle fusions with bone loss and deformity are a reconstruction challenge. We present a new technique of revision fusion using an Ilizarov or Taylor Spatial Frame for deformity correction and fixator assisted retrograde nailing (FAN) for revision ankle fusion.

Methods: Between 2001 and 2014, 26 cases of failed ankle fusion with bone loss and deformity were treated using the FAN technique. All had bone loss and or deformity. 18 were neuropathic Charcot joints. There were 17 with diabetes and three with severe sero-negative arthropathy, two of whom were immune-compromised. 5 cases had primary osteoarthritis, 2 had secondary post-traumatic arthritis and two had rheumatoid disease. 7 cases had a destroyed talus. The joint surfaces were revised from a lateral or antero-lateral approach. The fibula and medial malleolus were osteotomised. Early in our study we routinely reamed the lateral malleolus with an acetabular reamer for local bone graft, but no longer consider this essential. If the deformity was correctable acutely a retrograde nail was inserted primarily. The Biomet revision ankle fusion nail was ideal for this application with its adjustable locking jig. The frame was used for stability and compression. The nail was initially locked distally only. Once union was achieved the nail was locked proximally and frame removed. If the deformity was not amenable to acute correction, the fixator was used to obtain gradual correction and compression. Once union was achieved a locked retrograde nail was used to augment the stability of fusion.

Results: 24/26 cases achieved union. One immune suppressed patient with Charcot neuropathy had a painless persistent non-union and foot infection, and eventually required a below-knee amputation after three years. One patient walks on a painless ankylosis supported by a cam walker. Three cases required secondary anterior bone grafting. Two required the insertion of an implantable bone stimulator. Two cases required revision surgery with an Ilizarov frame to achieve union. Even though there were instances of minor pin site infection there was no primary de novo infection. There was reactivation of osteomyelitis in one cases, resulting in loosening of the nail and non-union. Union was finally obtained with re-application of frame, intramedullary reaming and insertion of antibiotic cement rod. The final foot position was within 5 degrees of plantigrade in all cases. The mean AOFAS A/H score was 74. The average time in frame was 11 weeks.

Conclusion: Fixator assisted retrograde nailing (FAN) is a reliable technique for revision ankle fusions with bone loss and deformity, especially in neuropathic feet.

#378: Complex 3-dimensional Reconstruction of Congenital Shortened Metatarsal Deformities

Joachim Lauen (Germany)
, Volker Buehren, Charlotte Kraft, Matthias Rueger

Question: Congenital shortened deformities of metatarsal bones are rare. The surgical reconstruction should respect the integrity of the foot.

Methods: We performed 38 metatarsal lengthening-reconstructions with monolateral fixators. Indications were incomplete shortened hexadactyly (7) and hypoplasia (31). Length deficiencies were between 0,8 and 4,2 centimetres. In cases of joint reconstruction a bridge transfixation to the proximal phalangeal bone was performed (6). Follow up time between 1/2 and 10 years.

Results: Malformation and length deficiencies could be reconstructed in 34 cases accurately, in 4 cases with 2-4 mm rest deficit. The fixator time was between 38 163 days, the mean healing index for 1 cm 50 days, for 2 cm 70 days, and for 3 and 4 cm about 100 days. Poor callus regenerate and delayed consolidation were observed in 6 cases, healing with interposition of fibula or pelvic bone block properly. There were no contractions or neurovascular impairment, superficial infections in 12 cases, no deep ones. Regular toe movement was regained after 4 to 20 weeks, no luxation or contractures. The main complications relied on compliance and technical problems, which could be solved.

Conclusion: The results are convincing, so that we can recommend the lengthening reconstruction of congenital metatarsal deformities with external fixator.

#379: Multiplanar correction of aquired talipes equinovarus utilizing dynamic ilizarov external fixation: A case report

David Larson, (USA),
Kenneth Hegewald, Byron Hutchinson, Adolfo Rocha Geded

Question: The purpose of the presented case report is to demonstrate that rigid acquired talipes equinovarus (TEV) can be corrected dynamically with a minimally invasive technique with the use of Ilizarov external fixation. Many corrections for rigid TEV are invasive in nature. With the use of external fixation, a minimally invasive approach can be utilized which allows for closed gradual correction and minimizes damage to soft tissues.

Methods: Deformity correction was performed on a 10-amp; #8208; & #8209; year old male with rigid acquired TEV of the right foot due to myelomeningocele as an infant. He was severely debilitated and developed a pressure ulcer from his deformity. The child underwent surgical correction with the use of external fixation via the Ilizarov method. The frame was used to correct 3 points of the deformity in 4 phases over a 4-month time period.

Results: Upon removal of the external fixator, the patient was able to ambulate on a now plantigrade foot. At one year follow up the patient had a mild residual forefoot equinus, which required an anterior tibial tendon transfer to restore a plantigrade orientation.

Conclusion: This case study demonstrates that with the use of external fixation, TEV can effectively be treated with a minimally invasive approach. When used dynamically, the forefoot adductus, calcaneal varus and ankle equinus can all be corrected with a single application of the external fixator.

#380: Ankle Arthrodesis with Cement Coated Intramedullary Nail and Ring External Fixation for Limb Salvage

Douglas Beaman (USA),
Cassandra Tomczak

Question: What are the outcomes for infection control, limb salvage and function after single-stage realignment ankle arthrodesis with antibiotic containing cement coated intramedullary nail and ring external fixation in patients with severe ankle deformity and infection?

Methods: Eight patients treated with limb salvage single-stage realignment ankle/hindfoot arthrodesis utilizing an intramedullary nail coated with methyl methacrylate containing antibiotics, and ring external fixation were retrospectively reviewed. A chart review was performed collecting patient demographics, including age, sex, BMI, comorbidities, presence of diabetes, neuropathy, history of limb wound and infection, and ambulatory status. Radiographic analysis was completed, analyzing preoperative and postoperative deformity correction, healing, infection management and associated pedal pathology (ie. contralateral or ipsilateral adjacent joint Charcot neuroarthropathy, amputation or trauma). Subjective outcomes from FAAM and Lickert questionnaire were collected.

Results: There were five male and three female patients, with an average age of 56 years (range 42-66 years) and average BMI of 39 kg/m2 (range, 29- 50 kg/m2). Comorbidities included neuropathy (7), IDDM2 (5), and chronic systemic steroids for rheumatoid arthritis (1). All subjects had current ulcers or a history of open wounds. Three patients had acute osteomyelitis and two had latent osteomyelitis. Three had chronic ulcerations near the surgical site. Seven had unbraceable deformity and were nonambulatory. All were candidates for below knee amputation. Six had Brodsky stage 3a Charcot neuroarthropathy, with three also exhibiting stage 1 and 2, and one with concurrent stage 1. Two patients did not have a Charcot process. Of these, one had diabetes with neuropathy and acute osteomyelitis status-post ankle fracture ORIF. The other had rheumatoid arthritis with an ankle fusion nonunion and a chronic lateral ankle wound. At an average 21.2 months (range 8-52 months) follow-up limb salvage and infection control was achieved in 100%. All patients had a functional, plantigrade lower extremity, scoring excellent (1), good (3), fair (4) using the Reinkert/Carpenter scale. Seven of the eight patients required postoperative bracing. Seven had radiographic confirmed bony union at time of follow-up; one had a stable fibrous union. The tibiotalar joint was fused in two patients, tibiocalcaneal fused in three, and tibiotalocalcaneal in three. Bony stability was achieved using an ankle/hindfoot fusion nail coated with methyl methacrylate containing vancomycin and tobramycin. Ring external fixation (averaging 125 days) was utilized in seven patients to augment internal fixation and allow weightbearing. Preoperative coronal plane deformity averaged 34 degrees (range 24-58 degrees). At follow-up, the all feet were well aligned relative to the tibia. Complications included; wound dehiscence (1), traumatic proximal tibia fracture (1), contralateral intertrochanteric hip fracture (1), external fixation modification (5), IMN migration (1), and osteomyelitis from Ilizarov wire (1). All patients developed superficial pin site infections that were successfully treated.

Conclusion: This study demonstrated in a severely deformed and medically compromised patient group, single-stage realignment ankle arthrodesis with antibiotic impregnated cement coated intramedullary nailing and ring external fixation can achieve infection control, bony union, and limb salvage.


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