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ABSTRACTS
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 1-159

Abstracts


Date of Web Publication22-Aug-2017

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How to cite this article:
. Abstracts. J Limb Lengthen Reconstr 2017;3, Suppl S1:1-159

How to cite this URL:
. Abstracts. J Limb Lengthen Reconstr [serial online] 2017 [cited 2019 Jan 20];3, Suppl S1:1-159. Available from: http://www.jlimblengthrecon.org/text.asp?2017/3/3/1/213576




  Basic Research Top



  PP 1: The epidemiology of patients in a limb reconstruction service Top


Vivek Garikapati, William Harrison, Kiran Saldanha

St. Helens and Knowsley Hospitals Trust, Merseyside, Liverpool, United Kingdom

Background: Limb reconstruction requires high levels of patient compliance and impacts on social circumstances, however no study has assessed the epidemiology of limb reconstruction patients. We aim to describe patients attending Limb Reconstruction Services (LRS) to highlight and address the social implications of their care. Methods: All LRS cases under one surgeon in a DGH were included from 2010 - 2016. Demographics, ASA grade, smoking status, mental health status and employment status were collated. Postcode was converted into an Index of Multiple Deprivation score. Patient socioeconomic status was then ranked into national deprivation score quintiles and were adjusted by census data and analysed with Student's T-test. The distance from the patient's residence to the hospital was calculated. Patient attendance at clinic, elective or emergency admissions was also assessed. Results: There were 53 patients with a mean age of 45 years, majority male. Most patients were smokers and 83% were ASA 1 or 2. The majority of indications were for acute trauma, chronic complications of trauma, congenital deformity and salvage fusion. Mental health issues affected 23% of cases and 57% of working-aged patients were unemployed. Mental health patients had a higher rate of trauma as an indication than the rest of the cohort. Deprivation quintiles identified that LRS patients were more deprived but this failed to reach statistical significance (p=0.9359). The mean distance from residence to hospital was 12 miles. The patients derived from a large region made up of 12 local authorities. There was a mean of 17 individual LRS clinic attendances per patient (range. 3-42). Cumulative distance travelled for each patient during LRS treatment was a mean of 495 miles. The total distance travelled for all patients was over 26,000 miles. Conclusions: The results mirror the findings of trauma demographic and socioeconomic epidemiology. The high rates of unemployment and mental health problems may be a risk factor for requiring LRS management, or may be a product of treatment. Clinicians may consider a social care strategy and fully utilise broader MDT to address the social inequalities. This should include mental health assessment, smoking cessation, support for employment circumstances and plans for travel to the hospital. Further work should prospectively assess changes in housing circumstances, community healthcare needs and whether there was a return to employment and independent ambulation at the end of treatment. Acknowledgements: There are no known conflicts of interest.


  PP 2: Post-Operative care on external fixation - Current trends after 36 years of experience in Lecco – Italy Top


Maurizio Angelo Catagni1, Francesco Guerreschi2, Luigi Lovisetti1

1. G.B. Mangioni Hospital, Lecco, Italy

2. Ospedale Alessandro Manzoni, Lecco, Italy

Background: Abstract Text. 1) Suggestion for the patient. Check all the connections between rods, rings, bolts, etc. as often as possible because they can get loose. 2) Lengthening, correction and bone transport. Follow the rate of lengthening and compression as recommended. Check if all the rods are parallel. If there is a mistake, the rods bend. Stop everything and contact your surgeon. It's recommended for the patient to keep a daily record of all the adjusts. 3) Dressing. The pin tract should be dressed twice a week. Cleaning of the skin with antiseptics and remotion of scab. Apply antiseptic gauze. If inflammation occur around the wire, the cleaning should be more often. If persists it's recommended. local antibiotics or if the inflammation persist or pus is present, it is recommended to contact your surgeon. 4) Bath. Upon suture removal, it's possible to take a bath or shower:. - in a swimming pool, in the sea, at home in a bath tub. After the bath, peroxide hydrogen spray and new dressing. To prevent the frame corrosion it's good to apply commercial silicone spray. 5) Complications:. Swelling. Keep the limb elevated during immobility. Partial weight-bearing in the lower limb when walking. If edema persist, see your doctor. Pain. If it's localized around wires and increases when moving the joints, it's probably an initial infection around the wire. Antibiotics may be required. If the pain is localized at the level of muscle and usually independent of the movement, is continuous and present during the night, it has to be treated with muscle relaxant drugs. If the pain is acute, strong and with simultaneous noise; this is a consequence of bone fracture at the site of precocious consolidation. In this case it is necessary to do shortening. If the pain disappears, restart lengthening. An X-ray and surgeon visit is recommended. An unexpected pain can arise from the breakage of a pin or wire. Generally, is easy to identify and the surgeon must be contacted. Contractures. During lengthening, foot equinus position and knee into flexion or extension may occur. Therefore, it's necessary to perform persistent physiotherapy and use a dynamic splint. Deviation. During lengthening, axial deviation may occur and the doctor must be informed. 6) Frame Removal. The fixator is removed under general anesthesia or with sedation. It is prudent to apply braces, use crutches for 3 weeks and take e new x-ray before complete loading. Methods: n/a. Results: n/a. Conclusions: n/a. Acknowledgements: n/a.


  PP 3: Mimicking the structure of fracture hematomas using snake venom enzymes for the creation of ex vivo natural designer scaffolds to enhance bone repair Top


Vaida Glatt1, Anna Woloszyk1, Kevin Tetsworth2

1. University of Texas Health Science Center, San Antonio, United States

2. The Royal Brisbane Hospital, Brisbane, Australia

Background: The treatment of large bone defects and fractures with delayed healing or nonunion remains a major clinical problem. When fractures occur the blood coagulation cascade is activated, leading to the formation of a structurally mature clot. This hematoma is crucial to the initiation of bone healing serving as a reservoir for growth factors, a space for cell infiltration, and a guiding structure for ingrowing blood vessels. Our previous studies found structural differences in blood clots formed healing 1mm cortical rat defects having a more porous structure, thicker fibrin fibers repairing bone more rapidly compared to 3mm clots. Thus, the aim of this study was to explore the ability of the procoagulant ecarin (saw-scaled viper venom) to alter the structural properties of a blood clot in an attempt to mimic formed hematoma to improve bone healing. Methods: Whole blood (WB) was collected from mice and human. Purified ecarin was added at various concentrations from 0.05 to 2.5U/mL to citrated blood, which was allowed to fully coagulate before the clots were fixed. Cell and fibrin fiber morphology was analyzed by scanning electron microscopy. Results: The results showed distinct clot morphologies dependent on the concentration of ecarin and the species used. Uncitrated mouse WB showed normal disc-shaped erythrocytes, which were entangled in a loose fibrin mesh. Erythrocytes of human WB also had normal morphology, but the fibrin mesh was packed more densely. At 0.05U/mL, half of the erythrocytes showed signs of crenation in the mouse blood clot. In contrast, only a few crenated cells were seen when ecarin was added to the human blood. At 0.6U/mL, all mouse blood cells appeared crenated compared to only less than half of the human blood cells. At 2.5U/mL, the erythrocytes appeared distended in mouse blood, while in human blood the cells appeared more crenated. Fibrin fibers were thinnest (50nm) at 0.05U/mL, thicker (80-120nm) at 0.6U/mL and thickest (150-200nm) at 2.5U/mL. Conclusions: This study showed that the morphology of blood clots can be effectively manipulated using ecarin. In addition, fibrin fiber thickness is concentration dependent and resembles normally coagulated blood clots at the lowest concentration. This study also showed that the morphology of blood clots was species dependent. These results suggest that snake venom coagulating factors could act as natural biological additives to produce ex vivo blood clots that could be used as a novel therapy to enhance bone repair. Acknowledgements: We would like to express our gratitude to Thor Friis, PhD for the help with the study.


  PP 4: Reverse dynamization efficiently heals large segmental bone defects using a reduced dose of BMP-2: Top


Vaida Glatt1, Nicole Bartinkowski2, Christopher Evans3

1. University of Texas Health Science Center, San Antonio, United States

2. Institute of Health and Biomedical Innovation, Brisbane, Australia

3. Mayo Clinic, Rochester, United States

Background: Several treatments exist for healing of large bone defects, including recombinant human bone morphogenetic protein-2 (BMP-2). Our previous studies showed the local mechanical environment influenced the healing of defects using 11μg dose of BMP-2. Improved results were obtained with Reverse Dynamization (RD), where defects are initially stabilized with low axial stiffness followed with high. The study's goal was to determine whether RD can reduce the dose of BMP-2 needed for bone union. Methods: Rat, femoral, 5 mm defects were stabilized with 4 different stiffnesses, and under RD were treated with 5.5μg BMP-2. The defects were stabilized with low stiffness for 2 wks followed by 6 wks high stiffness. Groups were healed under constant conditions of ultra-low (10%), low (40%), medium (70%) and high (100%) axial stiffness (100%; 254 N/mm2), and two groups under RD. Healing was assessed by X-rays, and at the end of 8 wks by μCT and histology. Results: Radiologic and histology showed the callus size was smaller at the end of 8 wks treatment with the two highest fixation stiffnesses. The data confirms previous findings that lower stiffness fixators produce bigger callus formation than do more rigid fixators, showing an accelerated healing process with RD 40%. Defects appeared to be smaller in diameter compared to constant 40% stiffness group, having a more organized architecture with thicker distribution of new cortical and less trabecular bone, indicating advanced remodeling. In contrast, defect healing initially stabilized with the RD 10% fixator appeared to be compromised, having disorganized architecture, absence of defined cortical circumference, large diameter, and cartilaginous tissues when compared to the RD 40% and under the constant conditions 10% groups. Conclusions: The data confirms the influence of modulating the mechanical environment on the healing of defects using reduced dose of 5.5 μg BMP-2. This dose was able to heal the defects but the speed and quality was sensitive to stiffness and modulation. Best results obtained using RD with initial stiffness of 40% and the worst using RD with initial stiffness of 10%. Possibly, modulation of mechanical conditions in the latter group occurred too early. Healing of defects in the RD 40% group was superior to all groups, showing improved and accelerated healing. The data confirms that fixator axial stiffness can be modulated to maximise the regenerative capacity of bone healing with a reduced dose of BMP-2. Acknowledgements: U.S. DoD (W81XWH-10-1-0888), Vice-Chancellor's Research Fellowship, QUT, AU.


  PP 5: Octahedral Antiprisms: The geometry of the hexapod and the aetiology of paradoxical accelerated lengthening Top


Kevin Tetsworth

Royal Brisbane Hospital, Herston, Australia

Background: Hexapod fixators have become increasingly popular, but few surgeons fully understand their geometry. These fixators appear to increase in height faster than the individual struts are lengthened. This study was undertaken to investigate the deformation of a hexapod, to determine if ordinary Euclidean geometry explains this paradoxical behaviour. Methods: Standard geometrical principles were used to define the change in frame height expected for a given change in strut length. Struts were visualised as the hypotenuse of a triangle formed with one ring as the base, with the third side of the triangle formed by the perpendicular from that ring to the intersection of the strut and its point of connection to the other ring. Trials were conducted for combinations of ring sizes and strut lengths, covering a range exceeding those possible using any currently available device. Results were compared to simulated changes in frame height using software provided by the manufacturer of one device. Results were compared to simulated manipulations of hexapods using independent software. Shapeworks (Dassault Systemes; Waltham, MA, USA) and Great Stella (Software3D; Melbourne, VIC, Australia). Results: Using standard geometrical principles, calculated changes in strut length and corresponding changes in frame height were identical to those modelled by independent software. These also corresponded closely with the changes in frame height provided by the software native to one device. The observed accelerated lengthening appears to be a fundamental property of hexapods, and is fully explained by Euclidean geometry. This phenomenon was most evident with the largest rings and the shortest struts. Conclusions: Although they contain rings, the geometry of a hexapod fixator is best visualised as an octahedral antiprism. Euclidean geometry fully explains the behaviour of a hexapod with great fidelity. There is no need to consider alternative geometrical constructs, as suggested in a recent publication. When the length of the hypotenuse (struts) increases, the height paradoxically increases disproportionately. This effect is an inherent property of right triangles when you constrain the system by having one side fixed, with a constant length. This is not an issue if surgeons use the software provided by the manufacturer, but potential problems arise for surgeons who manipulate the frame independent of the available software. Therefore, intuitive frame manipulation should only be undertaken with caution. Acknowledgements: Acknowledgement. The author has no conflicts of interest to declare relevant to the current study.


  PP 6: The Use Of Cocultured Mesenchymal Stem Cells With Tendon-Derived Stem Cells As A Better Cell Source For Tendon Repair Top


Tianyi Wu1, Jia Xu1, Yimin Chai1, Gang Li2

1. Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China

Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China

Background: The injury of tendon tissues presents a significant clinical challenge to orthopaedic surgeons. Cell-based tendon grafts have become an alternative for tendon rupture reparation. But the ideal cell source for tendon repair remains controversial. In this study, we hypothesized that bone marrow divided mesenchymal stem cells (BMSCs) would exhibit enhanced tenogenic phenotype after co-cultured with tendon-derived stem cells (TDSCs); an optimal co-culture condition could provide promising cell resource for tendon healing. Methods: BMSCs and TDSCs were harvested from rats and cultured alone or co-cultured in 1:20, 1:10, 1:5 and 1:1 ratio. Their proliferative capacity didn't show significant difference between co-cultured cells and pure BMSCs control group by MTT assays. The tendon specific marker was compared by quantitative real-time polymerase chain reaction (qRT-PCR). The tendon specific mRNA expression (tenomodulin, scleraxis, decorin, fibromodulin, collagen type I and III) in all radio of co-culture group, were significantly higher than BMSCs control group after cultured for 7days and 14days especially with 1:1 and 1:5 ratio. The collagenous proteins production results showed that the red color in 1:10, 1:5, 1:1 co-culture group was darker than that of BMSCs control group, and we also confirmed this further by colorimetric assay. The immunofluorescent staining results for collagen type I and mRNA levels of tendon specific markers in GFP-labeled BMSCs were enhanced during co-culture. Results: Our results suggest that BMSCs can exhibit enhanced tenogenic phenotype after co-cultured with TDSCs. The ration of 1:20 to 1:10 promotes co-cultured cells tenogenic phenotype towards that of TDSCs. When the ration reaching 1:5 to 1:1, co-cultured cells could perform even higher tenogenic ability. Conclusions: In conclusion, cells mixture containing TDSCs possess much more similar character of tendon with that of pure TDSCs which is more suitable for tendon tissue engineering. BMSCs co-cultured with TDSCs might be a better cell source than BMSCs for tendon tissue engineering. Acknowledgements: This work was supported by a grant from the National Natural Science Foundation of China (NSFC No.81371946, 31400834) to Gang Li and Liangliang Xu; and from the Hong Kong Government Research Grants Council, General Research Fund (CUHK471110 and CUHK470813) to Gang Li. The work was also supported in part by SMART program seed funding to Gang Li, and the Lui Che Woo Institute of Innovation Medicine of the Chinese University of Hong Kong.


  PP 7: Enhancement Of Bone Regeneration With The Accordion Technique Via HIF-1a/VEGF Activation In A Rat Distraction Osteogenesis Model Top


Jia Xu1, Gang Li2, Yimin Chai1

1. Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China

2. The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR

Background: Axial micromotion of bone fragments promotes callus formation and bone healing during the process of distraction osteogenesis (DO). The present study investigated the effects of the combined axial compression and distraction (accordion) technique on bone regeneration in rat DO model. Methods: Male Sprague-Dawley rats (n = 62) underwent right tibial transverse corticotomy, and were randomly divided into four groups after lengthening. control (no manipulation) and three experimental groups assigned based on the period of accordion maneuvers in the consolidation phase (Groups 1, 2, and 3 with accordion technique applied at weeks 1, 3, and 5, respectively). Animals were terminated at 1 week after each accordion phase (i.e., weeks 2, 4, and 6). Callus formation was monitored by X-ray radiography; new bone quality was evaluated by micro-computed tomography (μCT), histological analysis, and mechanical testing. Serum levels of hypoxia inducible factor (HIF)-1α and vascular endothelial growth factor (VEGF) were measured. Results: Callus formation after accordion maneuver at week 3 (Group 2) increased significantly over time of consolidation. The μCT and mechanical analysis revealed Group 2 had more newly formed bone and superior mechanical properties in contrast to the other groups at termination. Histomorphological and immunohistochemical analyses confirmed a greater degree of osteogenesis and angiogenesis corresponding to increased serum levels of HIF-1α and VEGF in Group 2. Conclusions: The accordion technique was effective in promoting bone consolidation via activation of HIF-1α/VEGF during DO. The accordion technique may be used in the middle phase of bone consolidation to promote bone formation in patients undergoing DO treatment. Acknowledgements: The work was partially supported by grants from National Natural Science Foundation of China (NSFC No.81371946 to Gang Li and No.81572122 to Yimin Chai). Hong Kong Government Research Grant Council, General Research Fund (CUHK470813 and 14119115) and a project grant from China Shenzhen City Science and Technology Bureau (GJHZ20140419120051680) to Gang Li. This study was supported in part by SMART program, Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong.


  PP 8: Human Fetal Mesenchymal Stem Cells Secretome Enhances Bone Consolidation In Distraction Osteogenesis Top


Jia Xu1, Gang Li2, Yimin Chai1

1. Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China

2. The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR

Background: Distraction osteogenesis (DO) is one of the most dramatic reconstructive technique for inducing bone regeneration, but it involves an undesirably long period for bone consolidation. Developing innovative approaches to enhance bone consolidation is in burning need. Human fetal mesenchymal stem cells (hFMSCs) have been shown to express more primitive developmental genes than those of human adult mesenchymal stem cells (hAMSCs), which is a preferable source for cell therapy and tissue regeneration. In present study, we investigated the immunogenicity of using human mesenchymal stem cells (MSCs) secretome on rat cells, the effects of secretome on osteogenic differentiation of rat MSCs (rBMSCs), and the potential application of hFMSCs secretome in promoting bone consolidation in a rat DO model. Methods: Secretome was collected from MSCs culture and was used to treat rBMSCs. Following secretome treatment, cell proliferation, alkaline phosphatase staining, Alizarin Red S staining, and mRNA expression of osteogenic differentiation related genes including ALP, Runx2, OCN, OPN, and Osx in the rBMSCs were checked, as well as mixed rat peripheral blood lymphocyte reaction. hFMSCs secretome was injected locally into the regenerates at the end of lengthening every 3 days in the rat DO model, till termination. The regenerates were subject to weekly X-rays, micro-computed tomography (μCT) and mechanical testing examination. The bone quality was assessed by histology and immunohistochemistry examinations. Results: Compared to the secretome from rBMSCs and hAMSCs, hFMSCs secretome had the best osteogenic induction ability and low immunogenicity. hFMSCs secretome with different doses showed no effect on cell viability. hFMSCs secretome at the dose of 100 μg/μl could significantly increase the expression of alkaline phosphatase and all the osteogenic marker genes, as well as the amount of calcium deposits in the rBMSCs. Finally, the local application of hFMSCs secretome in distraction regenerates in a rat DO model significantly improved bone consolidation according to the results of μCT, mechanical test, histological and immunohistochemistry analysis. Conclusions: The current study demonstrated that hFMSCs secretome promotes osteogenesis of rBMSCs and bone consolidation during DO. hFMSCs secretome may be a new therapeutic strategy to enhance bone consolidation in patients undergoing DO treatment. Acknowledgements: The work was partially supported by grants from National Natural Science Foundation of China (NSFC No.81371946 to Gang Li and No.81572122 to Yimin Chai). Hong Kong Government Research Grant Council, General Research Fund (CUHK470813 and 14119115) and a project grant from China Shenzhen City Science and Technology Bureau (GJHZ20140419120051680) to Gang Li, a project grant from the Shanghai committee of science and technology research projects (11JC1409400) to Yimin Chai are gratefully acknowledged.


  PP 9: Placing Your Wires In The Leg. How High Can You Be To Be Safe And Avoid Complications Such As Knee Joint Infections? Top


Daniele D. Pili, Maurizio A. Catagni

Ilizarov Centre Lecco, Lecco, Italy

Background: Placing wires and pins in the leg has been often a matter of discussion. Anecdotic ideas that placing a wire or a pin above the fibula head will carry an high risk of knee joint infection have mislead surgeons on placing wires and pins. Methods: A prospective study of patients having had external circular frames placed with wires or pins placed above the fib head has been carried out. Results: No knee joint infection has been experienced in our series. No difference with patients having pins placed in conventional way has been noted. Conclusions: Placing wires or pins above the fibula head is safe and doe not carry an higher risk of knee joint infection. Acknowledgements: Wires or pins placed above the fibula head when carrying out external fixation is safe and doe not carry an higher risk of knee joint infection.


  PP 10: Total Hip Arthroplasty And Total Knee Arthroplasty Infection Top


Pedro Teixeira Mota1, António Lemos Lopes2, Marta Maio2, Rita Sapage2, Carlos Pintado1

1. Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal

2. Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal

Background: Joint replacement is the only treatment capable of completely relieve pain and restore function in patients with severe osteoarthritis. Several complications are associated with joint replacement and the most dramatic is infection. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are the most commonly performed adult reconstructive procedures. When infection is present, several options of treatment are available. antibiotic therapy, polyethylene exchange with component retention, one-stage replacement arthroplasty, two-stage replacement arthroplasty, resection arthroplasty, arthrodesis and amputation. Methods: A retrospective study was conducted and every patient submitted to THA or TKA revision surgery, between 2010 and 2014 were included. The cause of revision was either infection or other. When infection was present, the treatment instituted and the outcomes were analyzed. Results: Between 2010 and 2014, an average 92 primary THA and 115 primary TKA were performed per year. In the same period, 74 THA and 45 TKA revision surgeries were made. Ten (13.5%) hip revisions and six (13.3%) knee revisions were due to infection. One case was lost to follow-up. Of the fifteen remaining, three (20%) cured with preservation of the prosthesis (the three were acute infections), ten (66.7%) resolved with a two-stage arthroplasty exchange, one (6,7%) cured with resection arthroplasty and joint fusion and one (6,7%) keeps infection tolerated with suppressive antibiotic therapy. Conclusions: Arthroplasty infection is painful, disabling and costly and is associated with a mortality of 2.5%. The estimated arthroplasty infection rate is 1-2% for the hip and 2-3% for the knee, similar to the rates we found in our study (1.59%). Usually, debridement and irrigation with polyethylene exchange is reserved for acute infections and two-stage replacement is considered gold-standard for late infections, with a reported success rate of 70-90%. We concluded that infection represents 13.4% of prosthetic revision surgeries in our institution. We have a success rate, with cure of the infection in 14 of 15 cases 93.3%. Nevertheless, we consider a global success rate of 86.7% because one case was cured with knee arthrodesis, representing a considerable loss of functionality. We consider debridement with polyethylene exchange and component retention for acute infections and two-stage replacement arthroplasty for chronic infections are effective treatments for arthroplasty infections. Acknowledgements: The authors have nothing to disclose


  PP 11: Morphofunctional substantiation of a systemic approach to reparative osteogenesis optimization with the use of transosseous osteosynthesis Top


Tamara Alekseevna Silantevai, Elena Nikolaevna Gorbach, Vitaly Viktorovich Krasnov, Mikhail Alexandrovich Stepanov, Natalia Andreevna Kononovich

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: Delayed union or nonunion are observed in five to 10% of clinical cases, especially in high energy and comminuted fractures. The methodology of systemic analysis was used to develop a program to control and optimize the reparative osteogenesis. Methods: Methodology of systemic analysis was developed based on the fundamental research of bone tissue reparation. A descriptive bone tissue model was presented by us as a system of three interrelated structural elements. biomechanical, regulatory trophic and cambial plastic ones. Pelvic and comminuted tibial fractures were modeled in 126 adult dogs. Control animals (n=26) received conservative treatment. External fixation provided good fragment stability and reduction in 100 dogs at the first stage. The second phase was correction of regulatory and trophic supply by angiogenesis stimulation with biological agents or infusion of compounds on the base of autologous blood plasma. The third stage included local injections of osteoinductive preparations produced from homologous bone matrix. The groups of specific stimulation measures and the ones that did not receive them were compared. Tissue samples from the fracture site were harvested at all three stages for histological preparations to study with light optic and electron miscroscopy, histomorphometry, histochemical and electron probe microanalysis. The experiment continued 10 years. Results: In control animals, osteogenesis was of endochondral type. In the external fixation group that was not stimulated, fracture healing was also of endochondral type but stable fixation reduced the period of fracture union. Angiogenesis stimulation provided the healing by osseofibrochondral type and a greater reduction of treatment period. The combination of fixation stability, stimulation of angiogenesis and osteoinduction changed the type of fracture healing to primary osseous and yielded the minimum union time. Conclusions: The principle of a complex fracture repair optimization that includes sequential stimulation of biomechanical, regulatory trophic and cambial plastic bone tissue elements could be a control program of reparative osteogenesis and should be further developed for clinical use. Acknowledgements: there is no conflict of interests


  PP 12: Use Of Autologous Culture Expanded Bone Marrow Stem Cells With Fibrin Gel In Distraction Osteogenesis And Deformity Correction Top


Hae-Ryong Song, Kwang-Won Park, Hyun-Gon Kim, Ruel Dela Cruz, Pratik Haresh Lakhani

Institute for Rare Diseases and Department of Orthopaedic Surgery, Korea University Medical Center, Guro Hospital, Seoul, South Korea

Background: Ever since the discovery of tension stress effect by ilizarov, its application as distraction osteogenesis for bone regeneration and limb lengthening is used routinely [1]. Various physical, biological and systemic factors [2-8] have been extensively researched and sought for early consolidation and producing better quality regenerate. Use of tissue engineering for osteogenesis and bone regeneration is also expanding since the last decade. Methods: For transplantation of RMS OSSRON™, fibrin glue (Greenplast, Green Cross, Yongin, Korea) were used along with atelocollagen implant (SurgiFill™, Sewon Cellontech, Seoul, Korea). Approximately 0.8 mL of thrombin was discarded from thrombin syringe of fibrin glue, and rest is mixed with autologous cultured osteoblasts. Then, the whole mixture (1 ml) is collected into a thrombin syringe. Fibrinogen was mixed with atelocollagen in ratio 1:1, and 1 ml mixture was collected into another syringe. Both syringes are connected to a Y piece and spinal needle. The mixture is injected at the site of lengthening under C-arm guidance. After injection, RMS OSSRON™ becomes gel form within 3 – 5 minutes. Results: Case 1. A 9-year-old achondroplastic boy underwent simultaneous bilateral femoral lengthening. The autogenic bone marrow was harvested in that same sitting. Distraction at the rate of 1mm per day with a rhythm of 0.25 mm every 6 hourly, was started 7 days after the surgery. 2 weeks after distraction, grade 2 pin tract infection was detected and managed accordingly. ACO were injected 28 days after the surgery. 2.5 months after surgery the proximal clamp was found loose with varus angulation of regenerate on left side, which was corrected acutely. 3 months after surgery, with 6 cm length gained, there was severe lumbar lordosis secondary to hip flexion contracture. Distraction rate was reduced to 0.5 mm per day for 1 week with aggressive physiotherapy. The femora were lengthened up to 9 cm over a period of 133 days. Conclusions: Use of autologous bone marrow derived culture expanded osteoblasts do help in reducing the external fixator duration, however large randomized multicentric trials should be carried out for, better consolidated results. Management of nonunions, early callus consolidation in limb lengthening and management of bone gaps still continues to be a challenge, and tissue engineering with stem cells for bone regeneration is still a vast blue ocean, worth exploring. Acknowledgements: Thanks for Institute for Rare Diseases and Department of Orthopaedic Surgery, Korea University Medical Center, Guro Hospital


  PP 13: Staphylococcal Enterotoxin C2 Expedites Bone Consolidation In Distraction Osteogenesis In Rats - A Proof Of Concept Study Top


Gang Li1, Jia Xu2, Yimin Chai2

1. The Chinese University of Hong Kong, Shatin, Hong Kong SAR

2. Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China

Background: Distraction osteogenesis (DO) technique could be used to manage large-size bone defect successfully, but DO process usually requires long duration of bone consolidation. Innovative approaches for augmenting bone consolidation are of great need. Staphylococcal enterotoxin C2 (SEC2) has been found to suppress osteoclastogenesis of mesenchymal stem cells in vitro. Methods: In this study, we investigated the effect of SEC2 on proliferation and osteogenic differentiation of rat bone marrow derived mesenchymal stem cells (rBMSCs). Further, we locally administrated SEC2 (10 ng/ml) or PBS into the distraction gap in Sprague-Dawley male rat DO model every three days till termination at 3 and 6 weeks. The regenerates were subjected to X-rays, micro-computed tomography, mechanical testing, histology and immunohischemistry examinations to assess new bone quality. Results: SEC2 had no effect on cell viability. The calcium deposition was remarkably increased and osteogenic marker genes were significantly up-regulated in rBMSCs treated with SEC2. In rat DO model, SEC2 group had higher bone volume/total tissue volume in the regenerates. At 6 weeks, mechanical properties were significantly higher in SEC2-treated tibiae comparing to the control group. Histological analysis confirmed that the new bone had improved quality in SEC2 treated group, where the osteocalcin and osterix expression in the regenerates was up-regulated, indicating faster bone formation. Conclusions: The current study demonstrated that SEC2 local injection promotes osteogenesis and enhanced bone consolidation in DO. The findings support application of SEC2 as a potential novel strategy to expedite bone consolidation in patients undergoing DO treatment. Acknowledgements: The work was partially supported by grants from National Natural Science Foundation of China (NSFC No.81371946 to Gang Li and No.81572122 to Yimin Chai). Hong Kong Government Research Grant Council, General Research Fund (CUHK470813 and 14119115) and a project grant from China Shenzhen City Science and Technology Bureau (GJHZ20140419120051680) to Gang Li, a project grant from the Shanghai committee of science and technology research projects (11JC1409400) to Yimin Chai are gratefully acknowledged.


  PP 14: Effect Of SDF-1/Cxcr4 Signaling Antagonist AMD3100 On Bone Mineralization In Distraction Osteogenesis Top


Gang Li1, Jia Xu2, Yimin Chai2

1. The Chinese University of Hong Kong, Shatin, Hong Kong SAR

2. Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China

Background: Distraction osteogenesis (DO) is a widely applied technique in orthopedics surgery, which involves rapid stem cell migration, homing, and differentiation. Interactions between the chemokine receptor Cxcr4 and its ligand, stromal derived factor-1 (SDF-1), regulate hematopoietic stem-cell trafficking to the ischemic area and induce their subsequent differentiation. Here, we examined SDF-1 expression and further investigated the role of SDF-1/Cxcr4 signaling antagonist AMD3100 during bone regeneration in rat DO model. Methods: SDF-1 expression and early osteogenic marker levels were compared between the DO and fracture healing in rats. AMD3100 (400 μM) was administered locally to DO rats from the initiation of bone lengthening until the termination every 2 days. Callus formation was monitored by X-ray radiography; the regeneration process was assessed by micro-computed tomography (μCT), mechanical testing, and histological analyses. The effects of AMD3100 on the osteogenic differentiation of rat bone marrow-derived mesenchymal stem cells (MSCs) were evaluated using alkaline phosphatase staining, Alizarin Red S staining, and the determination of the expression levels of specific osteogenesis-related genes. Results: Expression levels of SDF-1 and osteogenic genes were shown to be higher in DO zones than in the fracture zones, and SDF-1 expression level was the highest at the termination of the distraction phase. Radiological, mechanical, and histological analyses demonstrated that the local administration of AMD3100 to DO rats significantly inhibited new bone formation. In the rat bone marrow mesenchymal stem cells culture, comparing to the group treated with osteogenic induction medium, AMD3100 supplement led to a considerable decrease in the expression of alkaline phosphatase and early osteogenic marker genes. However, the amount of calcium deposits in rat MSCs did not differ between the groups. Conclusions: DO process induced higher expression of SDF-1, which collates to rapid induction of callus formation. Local application of SDF-1/Cxcr4 signaling antagonist AMD3100 significantly inhibited bone mineralization and osteogenesis in DO, which may represent a potential therapeutic approach to the enhancement of bone consolidation in patients undergoing DO. Acknowledgements: The work was partially supported by grants from National Natural Science Foundation of China (NSFC No.81371946, 81374568) to Gang Li. Hong Kong Government Research Grant Council, General Research Fund (CUHK470813 and 14119115) and a project grant from China Shenzhen City Science and Technology Bureau (JGJHZ20140419120051680 and JCYJ20150630165236960) to Gang Li are gratefully acknowledged. This study was also partly supported by SMART program, Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong.


  PP 15: Analysis Of Body Weight Distribution On The Lower Limbs And Balance After Ankle Arthrodesis With Ilizarov Fixation And Internal Fixatiion Top


Piotr Morasiewicz1, Lukasz Pawik2, Maciej Dejnek1, Leszek Morasiewicz1, Szymon Lukasz Dragan1, Szymon Feliks Dragan1

1. Wroclaw Medical University, Wroclaw, Poland

2. Wroclaw University of Physical Education, Wroclaw, Poland

Background: Various techniques for achieving ankle arthrodesis have been reported including external fixators or internal fixation with screws or staples. Symmetrical distribution of the load of the lower limbs and balance are among the determinants of proper biomechanics of the musculoskeletal system We asked whether the type of ankle joint arthrodesis stabilization will affect. (1)balance,(2)and lower limb load distribution. Methods: We retrospectively studied47 patients who underwent ankle arthrodesis with Ilizarov external fixator stabilization(group1,n =21)or internal stabilization with screws or  Blount staple More Details(group2,n=26) at our institution from2007 to 2014. The evaluation assessed the distribution of the load of the lower limbs and balance using pedobarographic platform. Results: In the group 1 operated limb bore47,6% of the load on average, while the healthy limb52,4%. In the group with internal stabilization, operated limb bore 44%of the load on average, while the healthy limb56%. These differences were statistically significant. The average percentage of diseased limb load in the group 1 and the group 2 did not differ significantly. In the group1, the average length of path of the center of gravity was157,9cm. In the group2, the average length of path of the center of gravity was 154 cm. In the group1, the average area of the center of gravity was 9,9cm2, while in the group2it was7,46 cm2.These differences were statistically significant. Conclusions: Ankle deformity, despite their compensation and correction adversely affect the biomechanics of the musculoskeletal system. Ankle fusion with Ilizarov fixation and internal fixation does not ensure the achievement of completely normal value of the load distribution of the lower limbs and balance. Acknowledgements: There was no Conflict of Interest for all authors. Sources of founding. internal university grant. ST.C080.16.073


  Bone graft and bone substitutes Top



  PP 16: Bone autograft versus recombinant human BMP-2 at bone docking site in tibial bone transport. A randomized clinical trial. Top


Søren Kold1, Martin Lind1, Knud Stenild Christensen2

1. Aarhus University Hospital, Aarhus, Denmark

2. Aalborg University Hospital, Aalborg, Denmark

Background: We investigated the union-rate and the risk of refracture of the bone docking site treated with open debridement and application of either bone autograft or 12 mg rhBMP-2. Methods: 41 patients treated for segmental defects of the tibia with bone transport in a circular frame were randomized to either bone autograft (n=21) or rhBMP-2 (n=20) at the docking site. The investigation was performed according to Good Clinical Practice guidelines. Patients were followed with monthly radiographs. Union was defined as bony bridge in 3 out of 4 cortices. The minimum follow-up after frame removal was 12 months. Results: Radiographic union occurred in 21 out of 21 treated with autograft and in 20 out 20 treated with rhBMP-2. Mean time to union was 7 months (range. 4 – 9 months) with autograft and 7 months (range. 4 – 9 months) with rhBMP-2. Mean time in hospital stay at time of docking procedure was 6 days (range. 2 – 12 days) with autograft and 5 days (range 1 – 16 days) with rhBMP-2. There were no clinical signs of infection at the docking site in either group. Refracture at the docking site after frame removal occurred in one patient in the autograft group compared with 2 patients in the rhBMP-2 group (p=0.5). The risk of refracture was higher when the docking site was located at the mid-diaphyseal tibia (3 out of 15) compared to the metaphyseal tibia (0 out of 26) (p=0.02). Conclusions: No differences in radiographic union rate or time to union were found between autograft and rhBMP-2. Refracture at the docking site occurred in 3 out of 41 cases, and mid-diaphyseal docking might carry a higher risk of refracture compared with metaphyseal docking. Acknowledgements: rhBMP-2 (Inductos®) was provided by Medtronic.


  PP 17: Reconstruction Of Long Bone Defects With Free Vascularised Fibular Graft After Bone Tumors Ressection Top


Pedro Teixeira Mota1, Vânia Oliveira2, Pedro Serrano2, João Rosa2, Pedro Cardoso2

1. Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal

2. Centro Hospitalar do Porto, Porto, Portugal

Background: Musculoskeletal neoplasms treatment must be individualized for each patient, but there are some common principles to their treatment. Currently, most musculoskeletal malignancies and some aggressive benign lesions are treated with wide resection and reconstruction. Methods: We present four patients with musculoskeletal neoplasms submitted to wide resection and reconstruction of the defect with free vascularised fibular graft. Results: Case1–11 years old male, with low grade osteosarcoma of femur was submitted to segmental resection of the femur and a FVFG was used for reconstruction. 13 years after surgery, the graft is fully integrated at the receptor site. Case2- 45 years old female, with tibia osteosarcoma was submitted to segmental resection of the tibia and a FVFG was used for reconstruction. 11 years after surgery, the graft is integrated but the patient has been submitted to multiple surgeries for infection, which maintains suppressed by antibiotics. Case3–16 years old female, with proximal humerus desmoplastic fibroma was submitted to segmental resection of the humerus and a FVFG was used for reconstruction. 3 years after, the fibula showed resorption on x-ray and another internal fixation was made, using iliac tricortical graft. 6 years after the first procedure, the patient has an excellent functional result and the graft is consolidated. Case4–42 years old male, with tibia adamantinoma was submitted to segmental resection of the tibia and a FVFG plus allograft were used for reconstruction. 4 weeks after surgery the patient went to surgical debridement, with extraction of allograft and skin coverage with hemisoleus muscle flap. 4 months after the first procedure, the infection is eliminated and the x-ray shows signs of graft consolidation. Conclusions: Musculoskeletal neoplasms treatment poses a challenge. free margins versus functionality. Thus, it is not rare the surgical treatment results in a huge bone defect. Reconstruction using FVFG has disadvantages. long operating time, high level of skill in performing microsurgery, sacrifice of autologous tissue; but as living bone is utilized, this approach promises to provide an excellent method of reconstruction in terms of a high bone-union rate, ensuring long-term strength and a low rate of infection. Although our rate of complications was high, the patients have acceptable functional outcomes, which lead us to conclude that FVFG is a good option to reconstruct segmentar bone defects after wide resections for neoplasms treatment. Acknowledgements: The authors has nothing to disclose


  Complications of osteotomies and lengthening Top



  PP 18: Distraction osteogenesis in children. Treatment of delayed consolidation with biphosphonates. initial results. Top


FRANCISCO Javier Downey-Carmona1, Adelaida Vivas2, José Francisco Lirola1, José Manuel Martínez-Salas1

1. Hospital Virgen del Rocío, Sevilla, Spain

2. Hospital Virgen de Valme, Sevilla, Spain

Background: Bone distraction by external fixator is used in reconstructive surgery of orthopedic deformities. Once the desired correction is obtained, the fixator must be maintained until there is bone healing. If there is a delay in the formation of bone regenerate, its use will be prolonged, which causes stress-shielding, increasing the osteopenia and the risk of fracture when the fixator is removed. Bisphosphonates have been shown to decrease bone resorption and their experimental use shows encouraging results in this field. Methods: Three patients aged between 7 and 13 years undergoing bone distractions have been evaluated. two tibiae and one metatarsal. They presented a prolonged index of consolidation, reason why it was proposed to treat with bisphosphonates. Informed consent was obtained for the off-label use. One patient was given intravenous pamidronate and alendronate orally in the other two. Follow-up was 4 to 5 months. Results: After assessing bone consolidation in all patients, the fixator was removed. Immediate complications of bisphosphonate administration were self-limited in pamidronate and none in alendronate. Conclusions: Bisphosphonates are safe in pediatric orthopedics and very useful in cases of delayed consolidation in patients undergoing elongation surgery. In our cases, bisphosphonate allowed us to avoid the prolonged use of the external fixator, reducing the rate of healing. We have started a clinical trial to assess the use of bisphosphonates in bone healing in children. Acknowledgements: No conflict of interest.


  PP 19: A Prospective Study Of Complications Of Lengthening With Intramedullary Nails. Preliminary Results From A 15 Years Study Top


Jean-Marc Guichet, Filippo Parisi

Princess grace Hospital, London, United Kingdom

Background: Published complications of limb lengthening surgery are often retrospective, and not taking into account the actual rate of complications obtained prospectively. More than 15 years ago, we decided to prospectively follow all our lengthening with intramedullary nailing. We are providing here results of the preliminary 5-year study on VTE, infection, fractures and DEXA evaluations. We recorded all results on our server and we are presenting preliminary results (5 years for VTE and Fractures, 1 year for DEXA). Methods: From 2010 to 2014, we had 84 lengthening (83 femurs, 1 tibia) with 12 unilateral (among them 1 bilateral case performed in 2 surgeries) and 72 bilateral lengthening (for fracture, infection, blood transfusions, VTE). For DEXA, we gathered 12 patients in one year (23 femoral lengthening). We prospectively studied some specific fields:. - VTE with systematic assessment with post-op vascular ultrasound . - Fractures, assessed by X-rays. - DEXA study (only one year result gathered for this abstract), with hip, spine and full body DEXA before surgery, during lengthening and at the end of lengthening. Results: - Infection. 1 bone infection and 12 skin problems. - VTE. 3 cases on systematic ultrasound screens. - Blood transfusion. 0 case on the whole series. Decreases of the rate of heterologous blood transfusions from 10% (Albizzia Nail, in the 90's) to 0%, and autologous blood transfusions in the same period of time from 66% to 0%. - Fractures . 4 fractures (i.e. a decrease from 14% to 5%). - DEXA/Body composition. Increase of fat mass at 60 days (33.8% left side, 28.3% right side), decrease in lean mass(-11.6% left side, -15.8% in right side), increase in total BMC of 6.6%, with on the measurement of the femur +25% (right side), and +15% (left side). All patients were right handed. Conclusions: The study shows a clear picture of the possible complications of limb lengthening with intramedullary nail. Risk of complications is lower than thorough studies with external fixator. Accurate statistics allow improving techniques and knowing better the actual complication rate. Acknowledgements: Dr Sergio Criseo, Physiotherapist, who helps gathering files and data for the study.


  PP 20: Problems, Obstacles And Complications Of The Ilizarov Method In The Treatment Of Deformities In The Lower Limbs In Rickets. Top


Paulo Roberto Dos Reis, Márcio Batista De Carvalho, Jose Henrique Peres Dos Santos, Guilherme Pelosini Gaiarsa, Walter Hamilton De Castro Targa, Roberto Capoccio

Hospital das Clínicas- Faculdade de Medicina da USP, São Paulo, Brazil

Background: Rickets are the most common form of metabolic disease in children. Such deficiency may be caused by nutritional deficits or changes in metabolic vitamin D or liver, kidney, pancreas and bowel dysfunction leading to lethargy, muscle weakness, and irritability. Bone alterations can be evidenced from early childhood, such as the presence of rickety rosaries, pectus carinatus, delay in the appearance of teeth. The angular deformity is the main bone alteration evidenced in an initial evaluation where the characteristic of the same changes according to the age of onset of the illness requiring surgical treatment to correct it. The present study aims to evaluate surgical complications related to the correction of angular deformity using the Ilizarov method treated at the Institute of Orthopedics and Traumatology of the Faculty of Medicine of the University of São Paulo (IOT-FMUSP) during the year 2016. Methods: Data were collected from patients' charts that assessed the initial deformity pattern and after the surgical treatment and described complications. Associated with this, pre-and postoperative radiographs were evaluated to obtain additional information on the degree of correction, consolidation, regenerative quality and possible signs of bone infection. After collecting the information, these data were divided into problems, obstacles and complications according to Paley, 1990. Because this was a retrospective study of the evaluation of radiographic images and data collection, it was not requested to sign the Patient Informed Consent Form. Results: In total, 20 patients were evaluated and all had as diagnosis Routine Resistant Vitamin D (RVDR). Four types of complications were seen; Difficulty in rotational control in 5 cases, joint stiffness in 8 cases, Hypocorrection or hypercorrection in 6 cases. Problems were sedo 19 cases Pin tract infection and neuropraxia in 2 cases; And obstacles in 3 cases with difficulty in adherence and understanding about treatment. Conclusions: Therefore, it is concluded that the angular deformities of rickets corrected by Ilizarov method present the same pattern of complications associated with any correction of deformities and due to the fact that this pathology causes a severe rotation of the limbs, the implemented method presents significant restriction in the correction of the Rotational deviation. Acknowledgements: The authors declare that there are no conflicts of interest in the production of this article.


  PP 21: A proposed new method of classification for corticotomies for more streamlined research of corticotomy techniques in the future Top


Rukmanikanthan Shanmugam1, Luvan Markandan2, Roshan Gunalan1

1. University of Malaya, Kuala Lumpur, Malaysia

2. Queen Elizabeth Hospital, Kota Kinabalu, Malaysia

Background: Osteoclasis is the surgical procedure of fracturing the bone. Common means of achieving this is by either osteotomy or corticotomy. The method of choice is corticotomy where the bone is fractured through only its cortex compared to osteotomy where the bone is divided through all its layers. We are proposing a classification of the pattern of corticotomy as this has not been described before. Methods: All corticotomies done between January 2010 and December 2013 were reviewed. The indications for the corticotomies were for limb lengthening, angular correction and bone transport for bone defects secondary to either trauma or infection. The inclusion criteria were corticotomies done either on the femur or tibia, complete pre-and post-operative radiological assessment, while those with incomplete radiological assessment were excluded from the study. Immediate and delayed post-operative x-rays films were assessed independently from the operating surgeon. Surgery was performed using a novel drill sleeve which is inserted down to raw bone after a small longitudinal skin incision is made and the periosteum circumferentially elevated off the drill area. On an average, 5 drill holes were made and connected together with an osteotome to complete the corticotomy. Results: A total of 41 patients with corticotomies were identified. The osteoclasis pattern of the corticotomy was identified from the radiological films. We found 4 distinct patterns. Our proposed corticotomy classification is based on the stability of the osteoclasis is not dissimilar to the Winquist femur fracture classification. Type I is a clean transverse cut while type II is a transverse cut with a “winglet”. Type III is a transverse cut over the near cortex and a butterfly fragment over the far cortex but not extending into a fixation point of the frame. Type IV is similar to type III with the exception that the fracture comminution extends into a fixation point rendering it unstable. We had 29 patients with type I, 2 patients with type II, 9 with type III and 1 with type IV. Conclusions: We propose a simple and easy to remember classification of corticotomy which is familiar to all orthopaedic surgeons. This classification system has clinical relevance as the higher the type the poorer the stability of the corticotomy site It can also be used for future studies to assess the outcome based on the type of corticotomy. Acknowledgements: There is no conflict of interest with any commercial party with the outcome of this research.


  PP 22: Two times fractured tibia in an 10-year-old girl with neurofibromatosis type 1 after bone leghtening: A case report Top


Maurizio Angelo Catagni1, Danielle Pili1, Diogo De Vasconcellos Sabido2

1. Ospedale GB Mangioni, Lecco, Italy

2. Hospital da Baleia, Belo Horizonte, Brazil

Background: The authors report a case of a 10-year-old girl with the diagnosis of neurofibromatosis type 1 and consequent congenital pseudarthrosis of the right tibia which was previously treated with bone transport using a circular external fixator. 3 years later the patient presented a fracture on the docking site treated with a locking plate, this fracture healed. A new trauma event occurred 1 year after the healing of the first fracture. Surgical exploration of the re-fracture site was performed to define treatment. Methods: The authors report a case of a 10-year-old girl that underwent tibial deformity correction, resection of the tibial neurofibroma and bone transport with physeal distraction using a circular fixator at the age of 4. After 5 years the patient presented a fracture at the docking site and was treated with a locking plate by another surgical team, the fracture healed. The patient suffered another minor trauma event 1 year later and another fracture at the same site within the locking plate. She was presented to the first surgical team 2 months after this event using and ankle foot orthosis (AFO) and doing partial weight bearing with 2 crutches. X-rays 2 months after the fracture showed that it didn't healed. It was chosen to remove the plate and explore the fracture site to resect any remaining fibrous tissue and, if necessary, do another bone transport. Results: During surgical procedure the plate was remove but clinically the bone was healed. Degenerate periosteal tissue was send to histological study and the result showed neurofibromatosis tissue. Clinical examination of the healed bone during procedure showed a healed and remodeled bone with elastic features and mostly a good blood supply. It was decided not to do any kind of fixation. The patient and parents were oriented to maintain the use of the AFO and to keep partial weight bearing for 2 weeks. Conclusions: Surgical exploration of a radiographically non-healed bone after a long time after fracture is mandatory especially when a history of neurofibromatosis is present. The recurrence of neurofibromatosis tissue is mostly due to poor resection during the first procedure but it can occur after large resections like in this case. Clinical examination of bone morphology although invasive is the most reliable way to take the most successful surgical decision even when it might find a situation like the one described in this abstract. Acknowledgements: .


  PP 23: Bone Regenerate Complications During Lengthening: Incidence, Predisposing Factors And Treatment, Special Focus On Regenerate Infection. Top


Mohamed El-Sayed1, Gamal Hosny2

1. Tanta University, Cairo, Egypt

2. Benha University, Cairo, Egypt

Background: The Ilizarov Frame is considered as one of the most successful measures for the management of bone defects. This study was proposed to detect regenerate site complications if any. Furthermore, can infection take place in the regenerate, (corticotomy) site? . Methods: This is a retrospective study, with level III evidence; performed at an academically supervised University Trauma Center. The number of subjects included in this study was 90 patients with tibial defects (3-10 cm), of different etiologies. Bifocal segment transport was used in 62 cases, and trifocal technique was applied in 28 cases. Paley's classification was used to differentiate encountered problems during lengthening. Solid union was defined as union of three of four cortices on AP and lateral radiographs, in both corticotomy and docking sites. A minimum post-operative follow up period of two years was an inclusion criterion in this study. Results: Corticotomy or regenerate site complications took place in 28 cases. Infection of the regenerate site took place in this study in 4 cases, and according to our knowledge this was never recorded in the literature. This was treated using the Ilizarov technique till solid union took place. Conclusions: Infection of the regenerate site could be anticipated and do take place in cases with severe infection and chronic osteomyelitis that led to bone resorption and bone defects. This could be simultaneously and adequately managed using the Ilizarov frame. Acknowledgements: Tanta University,. Benha University


  PP 24: Application Of A Custom Made Brace To Treat Knee Flexion Contractures In Femoral Deficient Patients After Femoral Lengthening Top


Monica Paschoal Nogueira, Paloma Yam Lam Wun, Sandra Prado, Rodrigo Motta, Cristina Reuter, Vanessa Oliveira

HSPE - State Hospital of São Paulo, São Paulo, Brazil

Background: Introduction/Background. Flexion contractures after femoral lengthening in limb lengthening procedures are common in congenital femoral deficiency, due to the combination of pressure in the joints and ligament insufficiency. A custom-made brace described by Anil Bhave has the advantages of efficiency, low cost, and also it is relatively easy to construct. This paper describes the application of Bhave's brace construct in CFD patients by a Brazilian lengthening rehabilitation team. Methods: Methods. Two patients with CFD with subluxation and flexion contracture are treated with an intensive rehabilitation protocol, enhanced by the use of a custom-made brace, following the principles described by Bhave. The brace application includes correct placement of a hinge, correct molding of the brace, observation of adequate arm levels, tension of extension force and correct use protocol. The brace was proposed to maintain physical therapy results, and passively stretch the knee flexors, anteriorize the tibia, and allowing the patient to mobilize actively the knee in flexion. Brace is made of scotch cast, with fixed hinges and a rubber band. Patients were followed during rehabilitation protocol and after it. Results: Results. The 2 patients were in protocol of femoral deficiency lengthening and had used the custom-made brace to treat flexion contractures after femoral lengthening. Brace was applied by rehabilitation team in a clinical set up, and patients were also undergoing usual rehabilitation protocol, based on stretching program, strengthening, proprioception and fascia mobilization. The patients had complete correction of flexion contractures/subluxation. Conclusions: Conclusions. The 2 patients could optimize the results obtained in the physical therapy program, and had complete correction of subluxation of the knee without surgical procedures. The custom-made brace is a valious noninvasive tool to treat flexion contractions in congenital deficiency patients undergoing femoral lengthening. Acknowledgements: Authors have nothing to disclose


  PP 25: Comparison Of Gigli Saw Versus Multiple Perforations. A Prospective Study On Bilateral Leg Osteotomy Using The Two Different Techniques. Top


Daniele D. Pili, Murizioa A. Catagni, Andrea A. Poli

Ilizarov Centre Lecco, Lecco, Italy

Background: Both Gigli saw and Multiple Perforation osteotomy are commonly used in limb lengthening and reconstruction. Both techniques have advantages and disadvantages. The aim of this prospective randomised study is to evaluate the differences in complication rate and speed of new bone formation in patients undergoing bilateral leg lengthening. Methods: 20 consecutive patients undergoing bilateral leg lengthening have been selected for this study. Each patient had one osteotomy performed with a Gigli saw on one side and one with multiple perforation technique on the opposite side. The choice of side was randomised. Results: No relevant difference found between the two different osteotomy techniques. Conclusions: There is no difference between the two techniques with regard of treatment lengthening, risk of nonunion, delayed union or serious complications. Acknowledgements: Both techniques are valid and safe. The surgeon should use the technique on which he/she is more comfortable.


  PP 26: Does The Position Of The Patella Change During The Distraction Osteogenesis Of The Femur? Top


Donghoon Lee

Severance Children's Hospital, Yonsei University, Seoul, South Korea

Background: Iliotibial band and quadriceps muscle produce distraction-resisting force during femoral lengthening. A tight iliotibial band through its attachment of the lateral retinaculum into the patella could cause lateral patella tracking, patella tilt and compression. A tight quadriceps muscle which is directly attached to the patella could cause patella alta. We asked (1) Does the position of the patella changes during femoral lengthening? (2) What are contributory factors associated with the changes?. Methods: From Jan. 2011 to Nov. 2015, total 51 patients(99 femurs) of femoral lengthening with lengthening nail had full regular follow-up for at least 1 year. We checked the position of the patella using plain radiograph obtained before surgery and at each follow-up. CT scan was done preoperatively to evaluated the rotational alignment. We evaluated the amount of patella tilt by lateral patellofemoral angle and congruence angle, the patella shift by lateral patella shift, and the patella height by Insall-Salvati ratio and Blackbure-Peel ratio. Patient-associated factors including the tightness of the soft tissues checked by Ober's test or Ely's test and Distraction-associated factors including final length gain were analyzed for the contributory factors. Results: Based on linear mixed model, the change of lateral patellofemoral angle, congruence angle and lateral patella shift, was significant as time pass (p<0.001). These values were significantly larger than preoperative ones, and continued after one year of surgery. These differences were largest during 8 to 12 weeks after surgery (Mean difference 9.62, SD 8.89, p<0.001). Patients with increased preoperative femoral anteversion more than 25°, or increased lateral patellofemoral angle more than 3° showed more distinguishable changes (p=0.016). Blackburne-Peel ratios were also increased during lengthening. But, the average BP ratios after 1 year of operation was 0.83 which is not enough to define as patella alta. Other distraction- or patient- related factors including Ober or Ely test didn't affect the position of the patella. Conclusions: Our results show the possibility of the adverse effect of femoral lengthening on the patellofemoral joint. Preventive release of lateral retinaculum or iliotibial band could be considered to avoid over-pressure on patellofemoral joint during femoral lengthening, especially when preoperative femoral anteversion is more than 25°, or lateral patellofemoral angle more than 3°. Further studies are in need. Acknowledgements: Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.


  PP 27: Complications Of Tibia Lengthening In Achondroplasia Patients Top


ANNA Isart, Pilar Rovira, Jordi Tapiolas, Ignacio Ginebreda

HOSPITAL UNIVERSITARI QUIRON - DEXEUS, Barcelona, Spain

Background: The objective of our work is to analyse our results and complications in the tibia lengthening procedure with monolateral external fixation systems in patients with achondroplasia. Methods: This is a descriptive and retrospective study of 65 patients with achondroplasia. All lengthening procedures of both tibias were performed between 1986 and 2015, with monolateral external fixator. Pre, during and postoperative radiographs were performed and radiographic measurements were obtained. We studied the complications during and after the lengthening using the Paley classification. Results: In all patients, there were 37 males and 28 females, with an average age of 12.2 years (6.8-23.6). We achieved an average lengthening of 14.84cm (6.15-22.4) in tibia right and 15.1cm (5.74-21.8) in tibia left, with an external fixation index of 18.69 days/cm (10.45-42.88). According to the classification of Paley, we found 22 obstacles, 41 minor complications and 1 major complication. Conclusions: Although significant lengthening of the lower extremities are surgeries which are non-exempt of complications, we still consider them to be safe techniques for patients. The procedure achieves a final result that allows the patients to perform all activities of daily living without the need for aids or adaptations. Acknowledgements: Our thanks to all patients for the participation and all members of our team, especially Miriam Garcia.


  PP 28: Magnetic Limb Lengthening Nails: Mechanical Failure Rate And Types Of Failures Observed In 245 Limb Segments Top


Hamza M. Alrabai1, Ahmed I. Hammouda2, Martin G. Gesheff3, Shawn C. Standard3, Janet D. Conway3, John E. Herzenberg3

1. King Saud University, Riyadh, Saudi Arabia

2. Department of Orthopaedic Surgery, Al-Azhar University, Cairo, Egypt

3. International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, United States

Background: Mechanical failure rate of magnetic limb lengthening nails has not yet been determined. The aim is to present the mechanical failure rate of magnetic nails and the types of failure observed. Methods: Retrospective medical record review was conducted of 180 patients (245 segments) who underwent limb lengthening using magnetic nails. Mechanical failure was recognized as (1) instrumentation/nail mechanical breakage or (2) internal mechanism failure that resulted in backwinding or stopped the nail from lengthening. Premature consolidation cases were excluded when caused by physician-prescribed lengthening rates that were too slow. Results: Mechanical failure was observed in 23 nails (22 patients, 23 limb segments) with mechanical failure rate of 9.3% (23 of 247 nails). Only 4.9% (12 of 245 segments) required an additional, unplanned surgery as a result of the mechanical failure. Mechanical failure rates of the original nail and a redesigned nail were 11.3% (11/97 nails) and 8.0% (12/150 nails), respectively. During insertion, 2 nails failed the intraoperative distraction test and were replaced with functional nails during the same procedure. Mechanical failures during the lengthening stage were observed in 8 nails (3 nonfunctioning mechanisms, 2 proximal fixation failure, 1 lead screw failure, 1 backwinding, and 1 crown fragmentation). Mechanical failures were observed in 8 nails during the consolidation period (2 nail fractures, 2 nail plastic deformations, 2 combined plastic deformations and crown fragmentations, 1 isolated crown fragmentation, and 1 backwinding). Extraction-related mechanical failures were reported in 6 nails (2 crown fragmentation, 1 backwinding, 1 set-screw fracture, 1 extractor assembly breakage, 1 mechanism disassembly). One nail with an extraction-related failure (mechanism disassembly) also had a failure during the lengthening stage (nonfunctioning mechanism). Conclusions: In this large series (247 nails), an overall 9.3% mechanical failure rate was observed. However, only 4.9% (12 of 245 limb segments) required an unplanned surgery as a result of the mechanical failure. Frequency of mechanical failure incidents tends to decrease with newer device models. Close monitoring of nail function should be emphasized throughout the lengthening phase. Magnetic nails offer reliable, less invasive, bidirectional length management with less risk of nail malfunction. We recommend that efforts continue to be made to improve the strength and reliability of the nail. Acknowledgements: MGG, AIH, and HMA have nothing to disclose. SCS receives royalties from NuVasive Specialized Orthopedics and Pega Medical and is a consultant for NuVasive Specialized Orthopedics. JDC is a consultant for Biomet, Cerament, and DePuy Synthes; receives research support from Microbion, CD Diagnostics, and Acelity; receives royalties from the University of Florida; and receives fellowship support from Biocomposites. JEH is a consultant for Orthofix, OrthoPediatrics, NuVasive Specialized Orthopedics, and Smith & Nephew; receives research support from NuVasive Specialized Orthopedics; and is on the editorial board of the World Journal of Orthopaedics. The following companies supported a non-profit organization that is part of Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). CS Medical Supply, Metro Prosthetics, and Stryker. The following organizations supported an annual course for orthopedic surgeons that is held by Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). Baxter, DePuy Synthes, Merete Technologies, MHE Coalition, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Smith & Nephew, Stryker, and Zimmer Biomet.


  PP 29: Femur Lengthening In Patients With Achondroplasia. : What Are The Most Remarkable Complications We Have Had? Top


Pilar Rovira Martí, Anna Isart Torruella, Jordi Tapiolas Badiella, Ignacio Ginebreda Martí

Hospital Universitario Dexeus, Barcelona, Spain

Background: The objective of our work is to analyse our results and complications in the femur lengthening procedure with monolateral external fixation systems in patients with achondroplasia. Methods: This is a descriptive and retrospective study of 64 patients with achondroplasia (37 males - 27 females). All lengthening procedures of both femurs were performed between 1988 and 2016, with monolateral external fixator. The mean age of the patients was 15 years (9 years 11 months - 26 years). Pre, during and postoperative radiographs were performed and radiographic measurements were obtained. We studied the complications during and after the lengthening using the Paley classification. Results: In all patients, we achieved an average lengthening of 13.8cm (8.3-19.7) in femur right and 13.8 cm (20-8.7) in femur left, with an external fixation index of 23.86 days/cm (11.3-51.2). According to the classification of Paley, we found 36 obstacles, 28 minor complications and major complications 2. Conclusions: Although significant lengthening of the lower extremities are surgeries which are non-exempt of complications, we still consider them to be safe techniques for patients. The procedure achieves a final result that allows the patients to perform all activities of daily living without the need for aids or adaptations. Acknowledgements: Our thanks to all the patients and all members of our team.


  PP 30: A Novel Fixator Configuration For Cable Bone Transport Technique To Prevent The Entrapment Of Clipses In The Bone After Extraction Top


Muharrem Kanar, Raffi Armagan, Hasan Basri Sezer, Yunus Öç, Osman Tugrul Eren

SBU Sisli Hamidiye Etfal Training and Research Hospital Orthopedics and Traumatology Clinic, Istanbul, Turkey

Background: Cable bone transport technique has many advantages over other techniques of bone lenghtening. However, the technique has also disadvantages requiring solution. Methods: One of the challenging issues of the cable bone transport technique was the application of the wire from the bone to the cannulated screw and back to the medulla of the bone again which requires substantial effort and much periostal stripping. Moreover the clipses of the cable wire would stay in the regenerated bone and it was hard to remove those clipses which were stuck in the bone. Results: Our solution is a modification of cable application in order to prevent entrapment of cable wire clipses in the medulla of bone. In the proposed technique, first the cable wire is folded up and applied to the medulla of the bone. Then a cannulated screw is applied bicortically inside the loop of cable wire under image intensifier control. By this way the cannulated screw is able to act as a pulley. Both ends of the cable is taken out of the bone after passing the target site. An anteroposteriorly introduced Schanz screw whisch is adapted to the docking fragment acts as a second pulley to reorient the cable wire towards the external motor unite. One side of the cable is anchored to the fixator and the other was fastened to the clamp which acts as the motor unite. After the lenghtening operation ends the cannulated screw is extracted under image intensifier control than one side of the cable is cut and the remaining cable is taken out of the bone leaving no metallic implants inside without any dissection. Conclusions: We applied this technique in 7 cases. We experienced no complications involving cable wire. We observed that the new cable configuration has enough resistance to achieve the expected compression at the target segment. Acknowledgements: Authors declare no conflicts of interest.


  Congenital dislocation of the hip Top



  PP 31: Slaoti agreement protocol for early detection of hip displasya: How web survey will help to decrease congenital hip dislocation surgeries Top


Dalia Arriagada Sepulveda1, Estefania Gonzalez Birrer2, Cristian Pueller Artigas3

1. COTI, Santiago, Chile

2. Hospital de Valdivia, Valdivia, Chile

3. Universidad Austral, Santiago, Chile

Background: Abstract Text. based on a previous monkey survey to all SLAOTI members, we built a protocol for early detection of hip displasya in latin america; the protocol has been established in Chile for more than a decade and has dramatically decreased the number of dislocated hips needing surgical reconstruction. In latin america today there are many countries that still do not have a good standardized government program in order to do an early diagnosis to prevent patients from primary and secondary reconstructive surgeries; so we do hope that this new protocol will in future be a powerful tool in early hip displasya detection and treatment. the full protocol for a universal, affordable, on time detection is fully presented. Methods: Results: Conclusions: Acknowledgements: .


  PP 32: Results Of Management Of Bilateral DDH Walking Patients 2-8 Years: Pearls And Pitfalls. A Long-Term Follow-Up Study. Top


Mohamed El-Sayed1, Mahmoud Mahran2

1. Tanta University, Tanta, Egypt

2. Ain Shams University, Cairo, Egypt

Background: The aim of this study was to evaluate the clinical and radiographic results of management of bilateral DDH cases in walking patients, between the ages of 2 and 8 years of age. Methods: Between Jan. 1981 and May 2009, there were 51 bilateral cases of DDH, (102 hips). The age of the patients ranged between 2 and 8 years old. Inclusion criteria included bilateral DDH cases not operated upon before, a minimum follow-up period of 5 years post-operatively. Femoral shortening was performed in all but 3 cases, (2 years old cases). Salter innominate osteotomy was performed in 41 cases, (82 hips), and Dega acetabuloplasty was performed in 10 patients, (20 hips). Results: The postoperative follow-up period ranged between 5 - 30 years, with a mean of 20 years. Favorable clinical outcomes were reported in 61.7%, while unfavorable results took place in 38.3% of the cases. There were many complications recorded, including, Pain, osteoarthrosis, limb length discrepancy, avascular necrosis, residual acetabular dysplasia, and many minor complications as well. 10 of the studied 51 patients had another surgery during the follow-up period, and were considered as failure. Conclusions: Bilateral DDH is even more difficult to treat. Symmetrical results are required and are aimed for, but sometimes not achieved. The older the age of the patients the more difficult and more challenging is the surgery. All the major complications occurred in children older than 6 years in this study. Acknowledgements: Tanta University. Ain Shams University


  PP 33: The Effect Of Dega Acetabuloplasty And Salter Innominate: Osteotomy On Acetabular Remodeling Monitored By The Acetabular Index In DDH Patients. Top


Mohamed El-Sayed

Tanta University, Tanta, Egypt

Background: The surgical management of neglected developmental dysplasia of the hip (DDH) in walking children has always been a challenge to orthopaedic surgeons. The aim of this study was to evaluate the short- to middle-term clinical and radiographic results of the management of DDH patients less than 6 years old. Methods: Two of the most commonly used osteotomies, namely; Salter innominate osteotomy and the Dega acetabuloplasty, were used for all the selected cases. Special attention was paid to acetabular remodeling after concentric reduction, which was monitored by the acetabular index. That, in turn, was measured preoperatively, immediately postoperatively, every 6 months, and at the final follow-up examination. Results: The final overall clinical end results were favorable (excellent or good) in 93 hips (85.3 %). There was a marked improvement of the acetabular coverage during the follow-up period, which proved the good remodeling potential of the acetabulum for this particular age group after concentric reduction was achieved and maintained. Conclusions: Although both osteotomy types were found to be adequate for the management of neglected walking DDH patients under the age of 6 years, Salter osteotomy was found to provide a higher acetabular coverage and a better ace tabular index in the younger age groups. On the other hand, Dega acetabuloplasty was able to provide a better femoral head coverage in older walking children. Acknowledgements: Tanta University


  PP 34: A New Vey Stable Capsulloraphy Technique After Open Reduction Of Developmental Dysplasia Of The Hip (DDH). Top


Mohamed El-Sayed

Tanta University, Tanta, Egypt

Background: Capsulorraphy is considered as the single most important step in open reduction of developmental dysplasia of the hip (DDH). In neglected cases of DDH after the walking age, the capsule is adherent to the outer table of the iliac bone and is difficult to be exposed. Furthermore, in high-riding dislocations, it is not always an easy task to plan and perform an adequate capsulorraphy, especially to decide for the exact location of transverse limb of the classic (T-shaped capsulotomy). Methods: We have designed a new very stable and promising capsulloraphy technique, that was performed in 309 DDH hips, whom first presented after the walking age. A minimum period of two-year follow-up post-operatively was needed for inclusion of the cases in this study. Results: In all, except 5 hips, a good primary stabilization and stable concentric reduction during the follow-up period was achieved. Redislocation took place in only five cases. In four cases, a poor family compliance and loss of stabilization of the concentric reduction by destruction of the hip spica led to early re-dislocation. In only one hip, an excess derotation of the femur led to posterior dislocation. The need for another surgery was considered a failure and a revision was done. Conclusions: The new technique provided adequate, stable, and simple closure of the capsule and maintained the head at the reduced position without any short-term complications. Acknowledgements: Tanta University Staff members,. Cairo University Children's Hospital staff members.


  PP 35: Reduction Of High Hip Dislocation (Hartofilakidis C) Before Arthroplasty Using A Fully Implantable Motorized Distraction Nail Top


Rainer Paul Baumgart

ZEM-Germany Limb Lengthening Center Munich, Munich, Germany

Background: Treatment options for reduction of chronic proximal migration of the femoral head prior to total hip arthroplasty (THA) include acute distraction, femoral shortening and continuous soft tissue distraction with external distractors. Acute distraction is associated with a high risk of nerve palsy. Femoral shortening results in a limb length discrepancy and commonly in functional deficits. Continuous distraction of soft tissue with external fixators may be complicated by the risk of infection. Which results can be expected by using a fully implantable motorized distraction nail for continuous soft tissue distraction?. Methods: Fully implantable distraction devices have been used frequently worldwide for leg lengthening. For soft tissue distraction of the thigh in case of high hip dislocation (Hartofilakidis C) a telescopic motorized distraction nail can be used with a pelvic-support device, which allows partial weight bearing and a sufficient range of motion during distraction. The energy necessary for the distraction can be delivered wireless through the skin by an external power and control unit. 9 patients (6m, 3f) with a mean age of 35 years (20-59) were treated using a fully implantable nail before arthroplasty. The mean distraction amount was 54mm (32-60). In an initial surgery, the femoral head was resected and the cup of THA was implanted in anatomic position with or without enhancement of the acetabulum. After surgery distraction was started with 2-4mm/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. Results: In all patients the soft tissue distraction of the thigh was finished as planned preoperatively, so that THA could be performed in anatomic position. No infection occurred. The pelvic support was done in the first 7 patients with a modified custom-made plate. For the last 2 patients, a patented pelvic-support device was available. During distraction 3 patients with the modified plate need high dosage of analgesics and got temporarily contractures of the hip and the knee joint. The 2 patients with the new pelvic support device could be mobilized easily with a significant better range of motion and a lower pain level. Conclusions: A fully implantable motorized distraction nail seems to be a favourable option to reduct a high hip dislocation by continuous soft tissue distraction before THA avoiding acute intraoperative stretching. Acknowledgements: The author is a paid consultant of Wittenein intens and implantcast, Germany


  Correction of Limb length inequality and cosmetic limb lengthening for short stature in adults Top



  PP 36: Deformity Correction And Lengthening With Motorized Lengthening Nails – The Results Of 45 Consecutive Lengthenings Top


Joachim Horn, Stefan Huhnstock, Ivan Hvid, Harald Steen, Anne Berg Breen

Oslo University Hospital, Oslo, Norway

Background: Limb lengthening with intramedullary motorized nails is a relatively new method. The purpose of this study was to see if lengthening nails are reliable constructs for limb lengthening and deformity correction in the femur and the tibia. Methods: We performed 45 lengthenings in 44 patients by means of motorized lengthening Nails (16 Fitbone, 29 PRECICE Nails). The patients mean age was 25 (11-61) years, 22 were male and 22 female. 25 lengthenings were done due to congenital deformity, and 20 because of posttraumatic deformity (22 retrograde femur, 18 antegrade femur, 5 tibia). Initial deformities included shortening in all patients; mean 40 (25-65) mm. 9 patients had an additional valgus deformity [mean 6 (3-15) °] and 5 patients had a varus deformity [mean 9 (3-16)°]. One patient had a prokurvatum deformity of 26°. Results: The planned amount of lengthening was achieved in all patients. No loss of length was found during further follow-up. Five patients showed residual axis deviation when lengthening was completed and long-standing radiographs could be obtained. 3 of these patients had varus deformity with 3, 4 and 5° of varus respectively, one patient had residual valgus deformity of 5° and one patient developed a procurvatum deformity of 7° during the course of lengthening. All but 1 patient consolidated without further interventions. In the femur consolidation index was mean 1.2 (0.7-2.5) months/cm, whereas lengthening index for the antegrade technique was 1.0 (0.7-1.5) months/cm and 1.3 (0.8-2.5) months/cm for the retrograde technique. Lengthening index in the tibia was 2.6 (1.6-4) months/cm. 1 patients (tibia, amniotic band syndrome) received autologeous bone grafting and healed within 3 months after the procedure. In 1 patient, an antegrade Precice nail had to be exchanged due to failure of the lengthening mechanism. 3 patients had to be revised due to migration of locking screws, and one patient due to insufficient connection of the receiver in a Fitbone® nail. No other obstacles or complications occurred. Conclusions: Controlled axis correction and lengthening can be achieved with motorized lengthening nails. However, a thorough preoperative planning and intraoperative control of alignment are required in order to avoid residual deformity. In femoral lengthening, relatively fast consolidation could be observed, especially in antegrade nailing, whereas healing seems slow in the tibia. The number of complications was very low, and might rather be defined as obstacles. Acknowledgements: .


  PP 37: Ilizarov lower limb lengthening and deformity correction in cosmetic cases: Correction vs lengthening Top


Evgeny B Grebenyuk1, Magomedsaigit O Muradisinov1, Faye R Grebenyuk2

1. Russian Ilizarov Center, Kurgan, Russia

2. Private Practice, Philadelphia, United States

Background: The market of cosmetic lower limb orthopedic surgery has been rapidly growing within the last decades starting from Ilizarov technique spreading all over the world. Lower limb lengthening and deformity correction has been established as a comprehensive technique of lower limb elongation and shape modeling in cosmetic cases due to it's minimal invasion and the ability to provide good biological and mechanical conditions for bone regeneration and complete 3-dimensional deformity correction. But the rate of complications and the duration of treatment still limit the indications and don't allow it to become a genuine cosmetic procedure. The objective of this study was to compare different kinds of Ilizarov cosmetic lower limb procedures and to determine if they are safe enough to be indicated for cosmetic purpose. Methods: We reviewed 27 cosmetic Ilizarov limb lengthening and deformity correction cases. Patients divided into two groups according to main goal of the treatment. (1) cosmetic lower limb lengthening and (2) mild varus deformity correction. We analyzed the duration of treatment, rate of complications and patient satisfaction with the result. Results: We found distinct differences between two groups of patients. Even though the goal of treatment has been achieved in all cases, the group of cosmetic leg lengthening had longer mean term of external fixation (217 days) compared to deformity correction group (81 days) and higher rate of complications (by 0 to 42% - ranged depending on type of complication). Patient's satisfaction rate had no significant difference in two groups. Conclusions: Ilizarov method remains a reliable and accessible technique for cosmetic orthopedic lower limb surgery. The indications for cosmetic lower limb lengthening compared to cosmetic deformity correction should be limited due to significantly higher duration of treatment and complication rate. Acknowledgements: N/A


  PP 38: Assessment of regenerate in patients treated by Ilizarov external fixation: A retrospective & prospective analysis Top


Harshad Mohanlal Shah, Sandeep Reddy, Naveen Kumar Lokesh, Abhilash Palla

Ramaiah Medical College & Hospitals, Bengaluru, India

Background: Limb lengthening procedures are performed to correct limb length discrepancies, in the upper or lower extremities, that have resulted from various congenital or acquired abnormalities. The new bone formation due to the procedure is known as the regenerate. This new bone formation is of various types and dependent on many factors. To investigate bone regeneration after corticotomy and distraction lengthening & to assess treatment of post-traumatic shortening of limbs using the Ilizarov distraction device. Methods: In this retrospective and prospective study, 133 Corticotomies in 113 patients for various causes have been included. 131 Regenerates are analyzed 2 patients were lost for follow up. All patients where regenerate is produced for limb lengthening or bone transport by means of Ilizarov external fixator with age above 5 years were analysed. For all patients Ilizarov external fixator was applied and corticotomy done, distraction was started at 1mm/day after latent period (5-10 days).X rays were taken at intervals of 1 month. Occasionally, ultrasound was used to assess the early regenerate before it was visible on X-rays. Results: Results were clinically and radiologically evaluated under the categories Consolidation of regenerate, Absence of deformity, Limb length discrepancy & Absence of Infection. Total of 131 regenerates in 113 patients are analyzed. 83 (73.5%) were males and 30 were females. The maximum number of patients (38) were in the age group of 21 – 30 years.the lengthening achieved ranged between 3cm to 23cm. The average increase in length was 6.4 was cms. Conclusions: In metaphyseal corticotomies distraction of 1 mm/day (0.25 mm/day) is enough for a good regenerate. In post-polio residual paralysis with thin femora and tibiae, in diaphysial corticotomies, the distraction rates should be reduced to 0.5mm/day. Acknowledgements: No conflict of interest


  PP 39: Hidden Complications. Is Cosmetic Limb Lengthening As Safe As Told? A Review Of Complications Found On The Internet. Top


Daniele D. Pili

Ilizarov Centre Lecco, Lecco, Italy

Background: Often complications in Correction of Limb length inequality and cosmetic limb lengthening for short stature in adults is not correctly estimated. We carried out a research on complications found on the internet to bring to light hidden cases. Methods: A search on the internet of highly ranched sites have been carried out to find cases that have had obvious complications such as non union, mal union, delayed union, fracture, nerve damage, permanent joint contracture, infection, DVT, thrombosis and death. Only the cases that were clearly documented have been considered. Results: The number of complications in Correction of Limb length inequality and cosmetic limb lengthening for short stature in adults is underestimated. Conclusions: Correction of Limb length inequality and cosmetic limb lengthening for short stature in adults can bring to serious complications that are often underestimated. Acknowledgements: Correction of Limb length inequality and cosmetic limb lengthening for short stature in adults can bring to serious complications. Often the number of this complications is underestimated.


  PP 40: The Differential Choice Of The Method In Correction Of Limb Length Inequality (Lengthening And Shortening). Top


Elena A. Shchepkina1, Leonid N. Solomin2, Ivan V. Lebedkov3, Konstantin L. Korchagin3, Fanil K. Sabirov3

1. Vreden Russian Research Institute of Traumatology and Orthopedics; Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia

2. Vreden Russian Research Institute of Traumatology and Orthopedics; St. Petersburg State University, Saint Petersburg, Russia

3. Vreden Russian Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia

Background: In correction of limb length inequality most commonly used Ilizarov method or lengthening over nail (LON). An alternative may be shortening the contralateral limb. The choice of method requires individual tactics based on pathology, patient's age and growth and social requirements. Methods: We analyzed the treatment of patients with congenital and posttraumatic shortening. 25 cases of femur lengthening (3,8±1,7 cm) and 16 cases of lower leg lengthening (4,9±1,7 cm) by Ilizarov, 24 cases of femur LON (4,5±1,2 cm) and 11 cases of lower leg LON (3,4±0,7 cm). Sequential external fixation and nailing (SEFaN) was performed in 8 cases (6-femur, 2-tibia), an average lengthening at 4,6±1,5 cm. In 17 cases was performed shortening osteotomy (femur-15, tibia-2), the average shortening - 3,7±0,8 cm. When was performed the shortening osteotomy we used dynamic locking and allowed early walking with full weight. Results: In femur lengthening by Ilizarov distraction period (DP) was 60.8±23.1 days, the ExFix period - 223.4±69.3 days. In tibia lengthening by Ilizarov DP was 64.3±34.9 days, the ExFix period – 318.6±93.4 days. In femur LON DP was 52.4±23.5 days, the ExFix period – 82.6±38.3 days. In tibia LON DP was 39.1±12.9 days, the ExFix period - 71.1±36.8 days. In SEFaN group DP was 67.8±25.3 days, the ExFix period – 100.6±42.7 days. In femur LON group were observed 7 complications (29%). pin-hole fracture 1-4.1% (ExFix–0%), soft tissue inflammation around transosseous elements 2–8.3% (ExFix-31%), fracture of transosseous elements 1–4.1% (ExFix-10%), hypotrophic regenerate 1–4.1% (ExFix-8%), fracture or deformity of regenerate 0 (ExFix-8%), premature consolidaion 1-4.1% (ExFix-4.3%), knee joint stiffness 1–4.1% (ExFix-4.3%), deep infection 1–4.1% (ExFix-4%). Complications in tibia LON group were observed in 4 cases (36.3%). joint stiffness 3–27.3% (ExFix-25%), soft tissue inflammation around transosseous elements 0 (ExFix-18.7%), fracture of transosseous elements 0 (ExFix-6.2%), hypotrophic regenerate 0 (ExFix-18.7%), fracture or deformity of regenerate 0 (ExFix-1.7%), premature consolidation 1–9.1% (ExFix-6.2%), deep infection 0 (ExFix-6.2%), neuropathy 0 (ExFix-12.5%). In SEFaN group complications observed in 2 cases (25%) - joint stiffness. In the group of shortening osteotomies were observed non-union in 3 cases (17.6%). Conclusions: LON, SEFaN and shortening osteotomy reduces the number of complications, prevents the deformation and fracture of the regenerate, increase the comfort of treatment. Acknowledgements: to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, Pavlov First Saint Petersburg State Medical University


  PP 41: Leg length discrepancy after a childhood trauma: A double approach in the treatment of a femur malunion Top


Ana Ferrão1, Ruben Caetano1, André Simões1, Paulo Figueira1, Nuno Carvalho2

1. Centro Hospitalar de Lisboa Central, Lisboa, Portugal

2. Centro Hospitalar do Medio Tejo, Abrantes, Portugal

Background: Leg length discrepancy is a very debilitating condition for the patients. The solution for this problem in most cases includes techniques of distraction osteogenesis, mainly by internal or external fixation methods. Methods: This clinical case reports a 42 years old woman who sustained a traumatic dyaphiseal femur fracture in her childhood (10 years old), malunited and giving her a short right femur (about 4 centimeters). She presented at our clinic with a waddling and painful gait. We treated her with a femur osteotomy and a double approach with intramedullary nailing and a ring external fixator (Ilizarov) for the femur lengthening over the rod. Results: Four months after the surgery, the external fixator was removed and the nail was locked with 2 static distal screws. After several months without evolutive signs of bone healing, we assumed the patient had an oligotrophic nonunion and we exchanged the nail, after reaming and colecting bone marrow aspirate as a graft. Four months later, the bone was healing and the distal screws were removed for nail dynamization. In three months, the x-ray revealed union in 3 cortices and the patient was pain-free and walking with no aids. Conclusions: Using combined methods of internal and external fixation to improve femur lengthening is a demanding and laborious procedure, sometimes giving way to complications. Despite this, we were able to improve this patient's quality of life. Acknowledgements: No conflicts of interest


  PP 42: Considerations In Cosmetic Stature Lengthening : From The Experience Of More Than 500 Cases In South Korea Top


Donghoon Lee

Severance Children's Hospital, Yonsei University, Seoul, South Korea

Background: Distraction osteogenesis can be used not only for the patients with dwarfism and deformities from congenital anomalies or trauma, but for the individuals want to be taller. Cosmetic stature lengthening has been the subject of controversy since it has high risk of complications. We aimed to describe several considerations in deciding and performing the cosmetic leg lengthening. Methods: October 2009 to December 2015, we performed 512 patients who underwent stature lengthening. All patients underwent bilateral lower limb lengthening at femur or tibia. All the femoral lengthening was done using lengthening nails, and tibial lengthenings were done using lengthening over nail technique, lengthening and then nail technique, or lengthening nails. Patient assessment included complication according to the Paley's classification (problem, obstacle, and sequela), change of calf diameter, change of body ratio (femur to tibia, arm span to height), the recovery of the level of physical activities, and the change of self-esteem. Results: We encountered 'problem', 'obstacle' and 'sequela' in 99%, 5%, 0% of whole lengthening segments respectively (We described the technical considerations to prevent complications in detail in the presentation). Calf hypertrophy was observed at postoperative 2 years of tibial lengthening (average 2cm, range 0 -4.5cm). Body ratio changed according to the amount of lengthening each segment. Patient's self-reported physical ability level to perform activities of daily, light sports, strenuous sports were 97.8, 91.7, and 70.6 percent of pre-operative state respectively at postoperative 2 years. The index of well-being score and Rosenberg self-esteem scale improved significantly at postoperative 2 years. For overall satisfaction, response for the degree of satisfaction on the surgery was very satisfied 68.1%, satisfied 31.9%. Conclusions: Although there are lots of technical considerations to avoid complications, a satisfactory result could be obtained from the view point of conventional complications and patient's satisfaction. But, the recovery of physical abilities, especially strenuous exercise was not same as pre-operative state at postoperative 2 years, calf hypertrophy was observed in tibial lengthening, and body ratio changed (excessive lengthening can make body ratio abnormal). These findings should be considered as a sort of complications of cosmetic leg lengthening and should be informed to the patients before deciding the surgery. Acknowledgements: Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.


  PP 43: Cosmetic Limb Lengthening Using Salamehfix1 Device Top


Ghassan Salameh1, Michael Schmidt2

1. Salamehfix Limb Lengthening & Reconstruction Center, Tartous, Syria

2. Waldhof Praxis, Frankfurt, Germany

Background: Cosmetic Limb lengthening must be very fine work and must done by experienced hands, it can have many complications with discomfort if it's not done in corrected way, Lengthening with keeping right bone alignment with minimal pain and discomfort need using a special external hinge distraction system which allows stable fixation ,smooth bone formation , regeneration and simultaneous correction of bone bowing if it is exists or if it happens is very essential also ,for this purpose Salamehfix 1 External fixation Device was designed. Methods: 148 cosmetic limb lengthening cases was done since 2001, with various original height from 140 cm up to 170 cm, using a new hinge distraction external fixation system / Salamehfix 1 / its advantages over classic Ilizarov is. The fixator is an arc hinged system rather than ring system with deferent special connecting bars between arcs so the patient can lay his legs easily on bed without metal on the back of leg so it's more comfortable. The fixator consists of three adapted small arcs Deferent size arcs in the mean of diameter and perimeter preassembled to take the shape of the extremity on which it applied, so that the fixator is small and fit on the extremity on which it's applied. The fixator supported with hinges at the level of osteotomy so that any combined angulation or mal alignment can be corrected during lengthening so it's possible to do simultaneous lengthening and axis correction. Mostly pin fixation is in deferent levels and angles which make stable fixation and very good early weight bearing. All pins or wires don't pass throw the muscles, so it is less painfully. Mostly used half pins not wires. Results: Amount of lengthening was from 5 cm to 13 cm, one case 16.5 cm, two surgeries at the same cut in two times. Most of them did 7.5 cm. Complications were local infection mostly treated locally ,one case deep infection needed curettage and pin replacement , mostly who did lengthening over 8 cm had ballerina foot and knee bended and needed percutaneous tendon Achill lengthening after lengthening period .In long term results all patients returned to previous physical activity. Conclusions: Cosmetic limb lengthening is a fine work , and used System Salamehfix 1 ,have a multiple functions which allows stable fixation ,early weight bearing , simultaneous lengthening and correction ,small size and comfortable to patients in motion. Acknowledgements: Cosmetic limb lengthening using Salamehfix 1 Device is a hinged, small size fixator can be hidden under pants, allows early weight bearing and its three dimension fixator allows correction with lengthening and good tolerable by patients.


  PP 44: Aesthetic Surgery Of Legs By Ilizarov Technique Top


Prof Md. Mofakhkharul Bari

Bari-Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Background: The shape of legs is changing from varus in newborns to normal biomechanical axis in adults, which can be varying up to 50 from average data. However, even in normal range and the absence of clinical symptoms, many people wants to correct legs alignment surgically, because of dissatisfaction of shape and proportions. Constitutional short stature also can cause significant psychological discomfort. All this causes the increasing of number of patients who admit to surgeons to lengthen and/or to correct the shape of their legs. Methods: In last 25 years, 39 healthy adults (height ranging from 155 to 160 cm) with aesthetic dissatisfaction of lower extremities underwent surgical correction using Ilizarov technique. The major complaints included social discomfort, difficulties in finding a job, and problems in personal relations. The following surgical procedures were performed. Bilateral lengthening (up to 8 cm) of tibias from one level osteotomy- 16 patients; bilateral lengthening (up to 6 cm) of tibias from double level osteotomy 8. Tibia and femur cross lateral lengthening (up to 14 cm)- 8 patients. Lengthening with simultaneous correction of tibia axis (bowleg deformity- 18), (X-leg deformity-12), was performed in 30 cases. In 6 cases correction of varus curve was performed without lengthening. Results: Results were evaluated subjectively and objectively. Proportion, aesthetical alignment, scars, gait, and joint ROM were taken into consideration. Maximal deformity correction was up to 150, and lengthening upto 14 cm. Complications included. Pin site infection- 5 (did not affect result or duration of treatment); Significant joint stiffness-7 (all in group of cross lateral lengthening, ROM restored after extensive physical therapy); Broken wire-2 (reinsertion of wire needed). Conclusions: Ilizarov method is an encouraging tecnique for the people with constitutional short stature and disproportion and unattractive shape of the legs. The treatment requires constant co-operation between patient and medical team. surgeon, therapist, nurses, and requires patience on the both (patient and physician) sides. Double level osteotomy shortens duration of the treatment. Although this surgical concept is not new, it has certain specifics for aesthetic applications. Patient's motivation is important for achievement of better results. Acknowledgements: Dr. Md. Shahidul Islam, Prof. MD; FCPS, Bari-Ilizarov Orthopaedic Centre. Dr. Nazmul Huda Shetu, M.S (Ortho), Consultant, Bari-Ilizarov Orthopaedic Centre. Dr. Md. Mahfuzer Rahman, D. Ortho- Consultant, Bari-Ilizarov Orthopaedic Centre.


  PP 45: Three-Six Years Of Supervising Of The Patients After Correction Of Legs Shape: Knee Joints Reaction To The Surgery Top


Pavel Nikolaevich Kulesh1, Leonid Nikolaevich Solomin2

1. St-Petersburg St. George Hosp., Saint-Petersburg, Russia

2. Russian Scientific Research Institute of Traumatology and Orthopedics named after R.R. Vreden, St.-Petersburg State University, Saint-Petersburg, Russia

Background: The patients, who asking for cosmetic correction of legs shape usually aren't interested in orthopedic parameters and don't pay attention to the possible remote negative consequences of correction. Supervision of these patients gives useful information about influence of valgus osteotomy on the knee joint. Methods: 21 patients operated in 2010-2014 were evaluated. The average age - 23 y.o. (19-32). They had no orthopedic complaints. After treatment “ideal” (i.e. desired by patient) legs shape was achieved in all cases. We performed standing long-film X-ray before surgery and in 3-12 months after frames removal and standing radiography of the knee joints in 3-6 years after treatment to all patients. Ultrasound examinations of the knee joints were performed before surgery and in 3-6 years after treatment. Results: Long-films parameters. mechanical axis deviation - 19,07±6,68 mm med before surgery, 8,40±5,49 mm lat after (deviation from optimum value - 15,21±6,31 mm before, 8,60±5,13 mm after) (P<0,5). Fujisawa criterion - 24,38±8,52% before, 61,52±7,57% after (deviation - 37,62±8,52% and 5,95±4,70%) (P<0,5). Mechanical tibiofemoral angle - 5,64±1,81° med and 2,79±1,92° lat (deviation 5,64±1,81° and 2,88±1,78°) (P<0,5). Mechanical proximal medial tibia angle - 84,62±2,12° and 91,40±2,47° (deviation 1,05±1,36° and 1,79±1,99°) (P>0,5). Mechanical distal lateral tibia angle - 91,79±3,89° and 88,45±3,75° (deviation 1,19±1,82° and 1,02±1,39°) (P>0,5). Signs of arthrosis of knee joints were not revealed by a radiography before operation and in the postoperative period for 3-6 years. Ultrasound examinations. cartilage thickness of internal femoral condyle before surgery - 1,66±0,41 mm, after – 1,69±0,38 mm (P>0,5). Cartilage thickness of external condyle – 1,43±0,35 mm and 1,40±0,26 mm (P>0,5). Chondromalacia was revealed on external condyle of a hip at 1 patient, on internal condyle of a hip at 8 patients before operation; after surgery on external condyle of a hip at 1 patient, on internal - at 6 patients. Conclusions: The obtained data demonstrates that after correction of legs shape the majority of the studied parameters approach normal values. During from 3 to 6 years at X-ray and ultrasound examinations of knee joints negative reactions were not revealed. Acknowledgements: Authors express the gratitude to the ultrasonographer S.Y. Ledyaeva (RSRI of TO n.a. R.R. Vreden) for the performed ultrasound examinations.


  PP 46: Total hip arthroplasty and femoral nail lengthening for hip dysplasia and limb length discrepancy: Case series Top


Elizabeth Harkin1, S. Robert Rozbruch2, Mitchell Bernstein1, William Hopkinson1, Tomas Liskutin3

1. Department of Orthopaedic Surgery and Rehabilitation Loyola University Medical Center, Maywood, United States

2. Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, Cornell University, New York, United States

3. Loyola University School of Medicine, Maywood, United States

Background: Distraction osteogenesis has been used to correct limb length discrepancy (LLD) resulting from a wide range of etiologies. The application of magnet operated, remote controlled intramedullary (IM) lengthening nail continues to provide new opportunities for accurate limb equalization and precise lengthening with excellent functional outcomes, better consolidation indices, and decreased complication rates compared with conventional external fixation. While limb length discrepancy and deformity can also be addressed by total hip arthroplasty (THA) alone, the magnitude of achievable correction is limited by the soft-tissue envelope and concern over associated complications such as nerve palsy. In this case series, we present the combination of total hip arthroplasty and intramedullary femoral nail lengthening for the correction of both hip dysplasia and LLD, which has not previously been described. Methods: After receiving IRB approval, a retrospective multicenter case series was performed. Three patients that underwent staged ipsilateral total hip arthroplasty and retrograde intramedullary femoral nail lengthening for deformity and limb length discrepancy between July 2013 and September 2016 were included. The mean age at surgery was 28.3 years (range, 17 to 40 years) and the minimum follow-up was 14 months from the index procedure (range, 14 to 40 months). The etiology of the original deformity was neonatal septic arthritis. Results: In our cases series the mean original LLD was 63.2mm (range, 43 to 83mm). The mean total lengthening achieved through THA was 15.3mm (range, 13 to 18mm) and the mean total lengthening achieved through the retrograde IM femoral nail was 29.8 mm (range, 24 to 40mm). On final radiographic assessment, the mean final total direct LLD was 0.67mm (range of 0 to 2mm) and the mean final total indirect LLD was 1.33mm short (range of 0 to 4mm). At the end of treatment all three patients reported leg length equalization and were able to ambulate independently without assistive devices or the use of a shoe lift. Upon final assessment, all patients met criteria for excellent ASAMI bone and functional scores. No complications were observed. Conclusions: Targeted lengthening and deformity correction through combined THA and retrograde intramedullary femoral nail lengthening was achieved in all three cases with excellent clinical outcomes. Acknowledgements: Dr. Bernstein is a consultant for Smith & Nephew, Synthes, Nuvasive Orthopedics. Dr. Rozbruch is a consultant for Smith & Nephew, Stryker, Nuvasive Orthopedics. Dr. Harkin or an immediate family member is an employee for Globus Medical. Dr. Hopkinson and Tomas Liskutin have no conflicts to disclose.


  PP 47: LIPUS In Tibial Lengthening: Comparison Of Outcomes Of 'Standalone LIPUS' With 'LIPUS And Other Adjuvants' Top


Pratik Haresh Lakhani, Kwang Won Park, Hae Ryong Song, Akshat K Sharma

Korea University Guro Hospital, Seoul, South Korea

Background: Low Intensity Pulsed Ultrasound (LIPUS) is one of the non-invasive technique that has been used in Distraction Osteogenesis (DO) to reduce the duration of external fixator application. We aim to (1) Compare the External fixation indices (EFI) of the patients undergoing tibial lengthening where only LIPUS was used as adjuvant, with the patients in which other adjuvants were used along with LIPUS and and (2) Find out the patterns of callus progression observed during the treatment. Methods: In this retrospective study, 25 patients (44 tibiae), of tibial lengthening, who received LIPUS with or without another adjuvant therapy, from October 2009 to July 2015 were included. We divided the patients into two groups. Group A, consisted of 10 patients (19 tibiae) who received (LIPUS) as an adjunct and Group B, consisted of 15 patients (25 tibiae) who received bone graft and/or BMAC and/or BCP and/or PRP injection and/or DBM injection in addition to LIPUS. The difference between the EFI was evaluated statistically using general linear model with compound symmetry covariance structure and independent two-sample t- test. Results: In Group A, the mean gain in length was 7.76 cm (4.42 to 9.82 cm), the mean EFI was 37.58 days/cm (18.64 to 66.75 days/cm). In Group B, the mean gain in length was 7.79 cm (3.35 to 9.87 cm), the mean EFI was 39.68 days/cm (25.84 to 68.01 days/cm). The average follow up patients was 33 months (8 to 73 months). The difference in EFI between two groups was not found to be statistically significant (p>0.05). The most common callus shape was lateral which progressed to cylindrical in both groups. The most common pathway of callus maturation was “homogeneous” in group A and “heterogeneous” in group B. Conclusions: There is no significant difference in the EFI between the two groups. Use of other adjuvants along with LIPUS does not provide any added benefit in terms of accelerated callus maturation. Acknowledgements: None


  PP 48: Cosmetic leg lengthening improves quality of life of with constitutional short stature: A Report Based On Validated Patient-Reported Questionnaires Top


Hyun-Gon Kim, Kwang-Won Park, Hae-Ryong Song, Ju Ih Shin, Ruel Agranum Dela Cruz

Institute for Rare Diseases and Department of Orthopaedic Surgery, Korea University Medical Center, Guro Hospital, Seoul, South Korea

Background: In a patient with constitutional short stature, studies showed that cosmetic leg lengthening improves one's self-confidence, psychological status and creates several changes, both in professional and personal life. However, the magnitude of the effects on QOL has not yet been documented using validated questionnaires. Methods: We asked whether cosmetic leg lengthening in a patient with constitutional short stature would improve the QOL after surgery based on validated questionnaires. We also report the complications that we encounter during treatment. Patients and Methods We retrospectively reviewed 22 patients (average age, 21.1 years) with constitutional short stature who underwent cosmetic leg lengthening between 2004 to 2014. Patients answered a set of questionnaires, including Lysholm Knee Scores, SF-36, AAOS Foot and Ankle and Lower Limb Scores, and Rosenberg Self-Esteem Scores before and after surgery. The post-operative questionnaires were answered 12 months after removal of the fixator. Complications were tallied and reported. Results: Patients gained a mean of 7.4cm after surgery. Significant increases were documented on general and mental health aspect of SF-36, while significant decreases were seen on Lysholm Knee Scores, Foot and Ankle and Lower Limb Questionnaires, and Physical Function aspect of SF-36. A higher Rosenberg self-esteem score was noted post-operatively however is not significant. A total of 56 complications were reported. Conclusions: Our data suggests that, despite the complications, cosmetic leg lengthening improves the patients QOL and self confidence based on patient-reported validated questionnaires. Acknowledgements: Thanks for corresponding author, Hae-ryong Song and Korea university medial center


  PP 49: Callus patterns in limb lengthening over nail procedures: A Retrospective Analysis In Bilateral Tibial Lengthening. Top


Akshat K Sharma, Kwang Won Park, Hae Ryong Song, Pratik Haresh Lakhani

Korea University Medical Center, Seoul Hospital, Seoul, South Korea

Background: The development of combined use of Intramedullary nail and external fixator by Paley and Herzenberg has revolutionized limb lengthening procedures allowing better alignment, early fixator removal and rehabilitation. Callus progression poses the greatest dilemma to the young orthopaedic surgeon to decide the future course of action. Callus patterns have been studied by a number of researchers for lengthening over an external fixator, but there persists a void of literature over callus patterns and progressions in limb lengthening procedures using combined External fixators and intramedullary nails. Methods: A retrospective analysis of 26 patients of idiopathic short stature, who underwent bilateral tibial lengthening (52 tibiae), using combined Ilizarov External fixator and interlocking nail, from 2005 to 2013 at our hospital was performed. There were 25 male patients and 1 female patient, with an average age of 20 years. The radiographs were examined at subsequent visits for shape, the homogeneity and density of the regenerate formed. Pixel value ratios (PVR), with respect to original bone, were calculated using Picture Archiving and communications System. The regenerate thus formed was classified as Good, Intermediate and Poor. We used the External fixator index and maturation Index to assess the clinical outcome. Interobserver and Intraobserver studies were performed to ascertain reproducibility of the data. Results: The mean lengthening achieved was 8.8 cm (7.2 - 9.9 cm). The average follow up was 52 months (35 – 94 months). The mean maturation index was 16 days/cm (7.6 – 40.1 cm). The mean External fixator index was 30 days/cm (19 – 66 cm). The regenerate formed was classified as Good in 16 segments (31%), intermediate in 16 segments (31%) and poor in 20 segments (38%). The classification of regenerate was observed to be statistically correlating with the maturation and external fixator indices. Callus appearance, correlating with PVR ratios, was first seen in lateral followed by posterior followed by anterior and medial cortices. No cases of refracture were noted. Equinus was the most common complication (50 segments, 96 %) for which foot frame was applied in 28 segments. Conclusions: The type of regenerate seen on radiographs provides a useful measure of clinical outcome in tibial lengthenings over nail. The evaluation of radiographs for regenerate characteristics and PVR provides a reliable guide for the orthopaedic surgeon on the progress of Lengthening over nail procedures. Acknowledgements: None


  PP 50: Femur Lengthening: A Comparison Of Internal Lengthening With A Remote Controlled Magnetic Internal Lengthening Nail Versus Lengthening Over A Nail Top


S Robert Rozbruch1, Anton Kurtz2, Austin T Fragomen1

1. Hospital for Special Surgery, New York, United States

2. private, Maine, United States

Background: Bone lengthening with an internal lengthening nail avoids the need for external fixation and requires one less surgical procedure than lengthening over a nail (LON). We asked which technique (LON or MILN) better achieved the lengthening goals, better distraction rate control, yielded optimal quality of the regenerate bone and resulted in fewer complications with the least impact on knee motion. 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. Results: 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). 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). 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). 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). Conclusions: 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. Acknowledgements: I am a consultant for Nuvasive and Smith and Nephew.


  PP 51: Assessment Of Bone Healing During Antegrade Intramedullary Rod Femur Lengthening Using Radiographic Pixel Density Top


S Robert Rozbruch1, Ettore Vulcano2, Austin T Fragomen1

1. Hospital for Special Surgery, New York, United States

2. Mount Sinai, New York, United States

Background: Femur lengthening using intramedullary (IM) rods represents an extraordinary innovation, but patients must restrict their weight bearing until sufficient bone healing is observed at the regenerate site, and this evaluation is subjective. We investigated bone regenerate pixel density on a picture archiving and communication systems (PACS) monitor. Can pixel density be used to assess the progression of bone healing at the regenerate site during femur lengthening with a motorized IM rod? Is there a threshold pixel density ratio (PDR) value that determines when the regenerate bone is sufficiently united? Does pixel density value at bone healing correlate with patient gender, age, laterality, or distraction length?. Methods: Thirty-two consecutive patients who underwent antegrade femur lengthening using an IM rod at a minimum of 1-year follow up were included in this retrospective study. Mean age was 26 years (range, 12 to 52 years). Serial, 2-view radiographs of the femur were assessed by a single operator starting at the completion of lengthening (week 0). The pixel density of the lateral, medial, anterior, and posterior cortices was measured in each patient at every postoperative visit. These values were then compared to the adjacent 2 cm of bone just distal to the regenerate. The pixel density ratio (PDR) was calculated, and correlated with subjective assessment of bone union. Results: Bone regenerate healing was clinically declared by the treating surgeon at mean 8.5 weeks (range, 4 to 18 weeks). The mean PDR at bone healing was 0.83 at the lateral cortex, 0.88 at the medial cortex, 0.91 at the anterior cortex, and 0.97 at the posterior cortex. The overall PDR corresponding to bone healing was 0.90, which was significantly (p<0.001) greater than the value at the previous clinic visit (0.82), when the bone was not yet clinically declared healed. The PDR at bone healing did not correlate with patient gender, age, laterality, or distraction length. Conclusions: We introduce the PDR as an objective measurement that can be used to monitor bone healing and establish a threshold value for bone union. The PDR is a rapid, objective, and easy method for the detection of bone density changes in distraction osteogenesis of the femur using an antegrade IM rod. This will be particularly useful to less experienced surgeons, and serve as a valuable aid to senior orthopedists in unclear cases. Furthermore, the PDR can be useful as an objective measurement in clinical research. Acknowledgements: I am a consultant for Nuvasive and Smith & Nephew.


  PP 52: Clinical significance of longitudinal overgrowth of the femur stimulated by a short-leg ambulation in children. Top


Mahmoud Abdel-Monem El-Rosasy1, Ashraf Ahmed Khanfour2

1. Tanta University, Faculty of Medicine, Tanta, Egypt

2. Damanhur National Medical Institute, Damanhour, Egypt

Background: Stimulation of accelerated growth of the ipsilateral femur has been noticed in walking children with leg length discrepancy due to different etiologies. Methods: The cases of 26 children were reviewed. All have leg length discrepancy (LLD) either due to congenital deficiency or lesions acquired in early childhood. All of them were ambulatory and shoe lift to compensate for LLD was not used regularly. Their ages ranged from five to fourteen years. There were 19 males and seven female children. The leg shortening resulted from. Chronic Haematogenous Osteomyelitis of the tibia in infancy (7 cases), Congenital Pseudarthrosis of the Tibia (6 cases), Tibial hemimelia (2 cases), Post-traumatic physeal growth arrest (1 case) and fibular hemimelia (10 cases). Long leg radiographs and scanograms were studied for measurement of. length of both femora and tibiae, femoral neck-shaft angle, total limb length and LLD. Results: Femoral overgrowth ranged from 3-6 cm. and increased femoral neck-shaft angle contributed to the increased femoral length. Femoral overgrowth in congenital conditions has corrected up to 6 cm of LLD. In acquired conditions, the younger the child when tibial shortening occurred resulted in more femoral overgrowth. Children who used shoe lift to correct LLD developed less femoral overgrowth. No cases of fibular hemimelia were associated with femoral overgrowth. Conclusions: The development of the adult value of the femoral neck-shaft angle is due to axial loading during walking. This indicates that the shorter limb is subjected to much less axial stresses than the normal side and contributed to the development of coax valga. Fibular hemimelia is part of the longitudinal limb deficiency which affects the femur to variable degrees and hence no femoral overgrowth occurred in this condition. Clinical significance. in children who have LLD, femoral overgrowth could be profound and should be considered when planning limb lengthening. Acknowledgements: The authors have no conflict of interest.


  Legg-Calvé-Perthes disease Top



  PP 53: Treatment Of Legg-Calve-Perthes. Comparative Study Between Arthrodiastasis And Intertrochanteric Osteotomy And Fixation With Plate And Screws. Top


Nuno. Craveiro Lopes

Orthopedic Department, Red Cross Hospiital, Lisbon, Portugal

Background: 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 15 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 12 boys and 3 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 8-10mm for an average of 4 months. 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 mean age, follow-up, the severity of injury in both groups Herring Group B and C, was not statistically different. The. operative time, blood loss and time until walking with crutches, had a statistically significative difference with lower values for ADT. The cervical index, the angle of Wiberg and coxa breva, were not statistically different. The epiphyseal Index with mean value of 40% and 31%, acetabular angle, 12° and 16° and the final Stulberg type superior to II with 20% and 54%, the epiphyseal angle and the leg lenght discrepancy and the Harris Hip Score, all showed statisticaly significative diferences, with better values for the ADT group. The ADT group had frequent superficial pin infection problems, whereas the OTM group presented 4 patients with complications including two cases of more than 2.5cm of discrepancy, one exagerated coxa vara with osteochondritis dissecans and one deep infection. Conclusions: This study demonstrated, with evidence based data that ADT has superior results than OTM conserning congruence, sphericity, residual sequels and funcional score when used for the treatment of patients with Perthes disease that evolve to collapsed hinged hips. Acknowledgements: No conflict of interests to report


  PP 54: The Role Of Distraction In The Surgical Treatment Of Legg-Calvè-Perthes Disease: The Results At Maturity Top


Roberto R Guarniero, Rui Maciel De Godoy Jr, Nei Botter Montenegro, José Roberto Bevilacqua Guarniero

University of Sao Paulo School of Medicine, Sao Paulo, Brazil

Background: Despite all modern advances in the scientific investigation the indications and possibilities of treatment in Legg-Calvé-Perthes Disease (LCPD) are still controversial nowadays. Several conservative and surgical methods are available to treat LCPD difficulting the ideal choice. In the past 15 years trying to improve the outcome we started using arthrodiastasis of the hip with monolateral external fixator creating negative pressure over the avascular femoral head in some selected cases of LCPD in the active phasis of the disease. In this paper, we present our experience with distraction in the last 15 years in cases of LCPD in the active phasis of the disease. Methods: From 1994 to 2015, 67 patients with LCPD were operated on by hip arthrodiastasis; 51 males and 16 females, ranging in age from six to 13 years (avg 8.2 years). All patients with bad prognosis, in Catterall Groups III and IV, 45 and 22 respectively. All patients in the active phasis of the disease. Our follow-up ranged from three to 11 years, with an average of 6.4 years. The patients were divided in three Groups accordding to the age at operation. A (six to eigth), B (eight to 11) and C (>11). The results were assessed at the maturity, based on Stulberg' s classification and according to age and gender. The results were assessed using the Stulberg's classification . Results: Group A. 23 satisfactory and 1 unsatisfactory; Group B. 21 and 9 respectively; and, Group C. 6 and 7. Conclusions: The results were better in the groups of patients aged six to 11 years with the operative methodology used. Complications were observed in only two patients. one infection in the proximal pair of Shanz screws in one patient and one medial migration to the pélvis of the proximal pair of Shanz screws in another. Acknowledgements: The authors would like to thank the staff of the radiological section in our institution which contributed to much for the analyze of the results.


  PP 55: Legg-Calvé-Perthes Disease: Remodelling Phase.Comparative Study Between Distraction And Femoral Varus Osteotomy Top


Roberto R Guarniero, Rui Maciel De Godoy Jr, Nei Botter Montenegro

University of Sao Paulo School of Medicine, Sao Paulo, Brazil

Background: The indications and possibilities of treatment in Legg-Calvé-Perthes disease (LCPD) are still controversial nowadays. Arthrodiastasis of the hip with external fixation is nowadays indicated trying to improve the outcome in LCPD, creating negative pressure over the avascular femoral head, in some selected cases of the disease. This is a prospective comparative study among two groups of patients with LCPD submitted to surgical treatment, aiming to evaluate the period of femoral head reossification (healing stage) after the operative procedure. It is a prospective surgeon controlled study to assess the duration of the healing stage after the procedure among two types of surgical treatments. femoral varus osteotomy and hip arthrodiastasis. Methods: Thirty-six patients with the diagnosis of LCPD were prospectively studied. In Group A, 18 patients were submitted to femoral varus osteotomy. In Group B, 18 were treated with distraction of the hip with external fixator. The indications for surgical treatment were exactly the same in both groups. hip pain, necrosis or fragmentation stage, Catterall groups III and IV with at least two “head at risk signs”. The study was designed to answer a . question. which surgical technique is capable to decrease the period of reossification of the femoral head (healing stage). femoral varus osteotomy or hip arthrodiastasis. Results: The results obtained were consistently good in both groups with femoral head remodelling faster in the patients treated by arthrodiastasis of the hip. Group A the reossification phase ranged from four to eleven months with na average of 7.16 months; in Group B the reossification ranged from two to 4.5 months, with an average of 3.16 months . Conclusions: The main point of this prospective study is to find that is possible to achieve cartilaginous growth on the femoral head stimulated by the traction offered by the monolateral external fixator, in a very short period of time. Distraction may be one method to effect a good treatment for patients aged six years or older with Legg-Calvé-Perthes disease . Acknowledgements: The authors would like to thank the members of the radiological staff of our Department whose suport was very important to assess our results


  PP 56: Leg - Calf - Perth'S Disease From The Classic Old Fashion Treatment To Modern Treatment By Hinged Arthrodiastasis And TFNHD And Soft Tissue Release. Top


Yasser Ali Elbatrawy

Al-Azhar Uni, Cairo, Egypt

Background: Abstract Text. Leg - Calf - Perks disease is a challenging problem in Orthopedic surgery with different method of treatment starting from. wait and see to aggressive surgical interference. Recently, the idea of hinged distraction combined with trans-physeal neck drilling and adductor tendon tenotomy is gaining a popularity in the last years with promising results. In this lecture, I am exploring the pathology of Perth's disease and the different classifications as well as the different options for treatment for every stage of the disease with focusing to the results of the hinged arthrodiastasis technique based on clinical, X rays and MRI studies. Methods: .Results: .Conclusions: Acknowledgements:.


  PP 57: Ilizarov Technique For Legg-Calvé-Perthes Disease Top


Prof Md Mofakhkharul Bari

Bari Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Background: This study presents the results of prospective consecutive cohort of patient with Legg-Calvé- Perthes disease treated by Ilizarov technique between 1995 and 2014. The primary aim is to determine the maintenance of head coverage and joint congruity and functional outcomes of this Ilizarov technique. Methods: Methods. 26 patients with a mean follow up of 12 years (range 4 to 12) were included. Results: Results. Cumulative maintenance of head coverage and joint congruity rate for all was (95%) at 12 years. Conclusions: Conclusion. Articulated hinge distraction in LCPD gives satisfactory and reproducible long term clinical results. Acknowledgements: Dr. Md. Shahidul Islam, Prof. MD; FCPS, Bari-Ilizarov Orthopaedic Centre. Dr. Nazmul Huda Shetu, M.S (Ortho), Consultant, Bari-Ilizarov Orthopaedic Centre. Dr. Md. Mahfuzer Rahman, D. Ortho- Consultant, Bari-Ilizarov Orthopaedic Centre.


  New procedures and apparatus Top



  PP 58: The new model of unilateral external fixatoin device for limb lengthening and fracture management Top


Petr Vvedenskiy1, Nikolay Nenilin1, Dmitriy Kazakov2, Dmitriy Zhegalov2

1. Privolzhsky Federal Medical Center, Nizhny Novgorod, Russia

2. Lobachevskiy State University of Nizhny Novgorod, Nizhny Novgorod, Russia

Background: A new model of unilateral external fixation device was developed in Privolzhsky Federal Medical Center. The main constructive features of the device include two support blocks comprising of triangular plates and bars for transosseous bone fixation interconnected by three distractors via lockable hinges. This three-point distractor-to-support plate connection allows gradual or acute deformity correction within the range of 25 degrees simultaneously in three planes. The purpose of the present study was to investigate stiffness of bone fragment fixation using new unilateral device and review results of its initial clinical applications. Methods: The series of bench tests were performed on the MTS machine with axial and tangential loading. Clinically, the new unilateral device was applied for femoral and tibial fractures (8 patients) and femoral, tibial, and humeral lengthening (28 patients). The age of patients ranged from 6 to 25 years. The amount of lengthening varied from 3 to 8 cm. Results: The bench tests showed the high stiffness of bone fragments fixation in new device in axial and tangential loading. Thus, the stiffness was significantly higher in the new device than in Orthofix monorail apparatus (up to 1.4 times in axial loading). The duration of diaphyseal femoral fractures healing ranged from 109 to 131 days while diaphyseal tibia fractures healed from 100 to 140 days. The average external fixation index in femoral lengthening was 31.6 days per 1 cm of lengthening (ranged from 16 to 42), in tibial lengthening – 34.4 (ranged from 28 to 44), in humerus - 24.3 (ranged from 20 to 32). In two cases, premature consolidation of distraction regenerate occurred during femoral lengthening, which required additional surgery for re-osteotomy. One case of delayed regenerate consolidation in tibial lengthening was noted more likely due to poor vascularization of the segment as a result of prior injury with severe damage of soft tissues. In this case, the locking nail intramedullary osteosynthesis was required. In all cases the planned limb lengthening was gained. There were no infectious complications that affected the outcome of treatment. No vascular or neurological complications were noted. Conclusions: The results of bench tests and experience of clinical application of new unilateral external fixation device showed that it provides a high level of stability of bone fragments, it is easy to use for surgeon and much more convenient for the patient in comparison with the circular fixator. Acknowledgements: The authors declare that they have no conflict of interests, any grant, or financial profit related to this clinical study. This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.


  PP 59: Osteotomy Protection System For Performing Safer Ostetomies Decreasing Neurovascular And Soft Tissue Injuries. Top


Martin Russi1, JUAN Miguel Del Castillo2, Alejandro Azziz3

1. Crami - Sanatorio Americano, Montevideo, Uruguay

2. Depto. Anatomia Facultad de Medicina- INOT, Montevideo, Uruguay

3. INOT, Montevideo, Uruguay

Background: Osteotomies have a potential risk of vascular and soft tissue injuries. The purpose of our study was to create a device which perform a safer osteotomy decreasing vascular and soft tissue injuries. Methods: Tubular stainless steel with an internal cleft which acts as a safe zone for Gigli saw, wire or cable. This device can be use with a hook or like a claw. This device allows to pass the Gigli saw through it performing a safer osteotomy. Test were done on bones models, cadaveric demonstrations and live surgery with the authorization of the respective Ethic Committees. Results: The osteotomies done were effective as planned without any vascular or soft tissue injuries. Compare with the conventional osteotomy the OPS use mini invasive surgical approaches. Conclusions: This device allows to perform osteotomies inside a safe zone of action in a minimal invasive guided proccedure We believe that more tests are necessary however results are promising related to more effective and safer osteotomies. Acknowledgements: Departamento de Anatomia Facultad de Medicina UdelaR


  PP 60: Tibial Condylar Valgus Osteotomy (TCVO) for correction of intra-articular deformity in Medial Compartment Osteoarthritis (MCOA): Rationale & Results Top


Milind Madhav Chaudhary, Aniruddha Sinhasarkar, Yugal Varandani

Int. Deformity & Lengthening Institute, Akola, India

Background: Varus deformity excessively loads the medial compartment of knee with pain and arthritis(MCOA). Mechanical Axis Deviation(MAD) measures varus and alignment of the limb. High Tibial osteotomy(HTO) is commonly done for MCOA. Closing wedge, open wedge, dome & focal dome osteotomies correct the extra-articular varus deformity. In patients with large MAD (≤10%), the MAD correlates well with MPTA (medial Proximal tibial angle) & JLCA (joint line convergence angle). Hence large varus deformities may need correction by performing an extra-articular HTO as well as an intra-articular HTO to correct the deformity arising from the joint line. Methods: We measured full length xrays of 104 knees in 52 patients with significant MCOA in 2 years. The avg MAD was 9.48%. 53 limbs had a MAD of≤≥10%. 51 limbs had MAD of ≤ 10%. Pearson's r between MAD and MPTA was high in both groups (≥10% & ≤10%) at 0.517 and 0.457. Pearson's r between MAD & mLDFA, NSA and age were not significant. Pearson's r between MAD & JLCA was strong at 0.62 in the ≤10% group but poor at 0.0145 in the ≥10% group. Patients with large varus deformities & high JLCA (intra-articular deformity) were treated using a Tibial Condylar Valgus osteotomy(TCVO). This is a L shaped osteotomy medial to the patellar ligament which elevates the medial tibial condyle & ensures both tibial condyles are in simultaneous contact with both femoral condyles. This osteotomy ensured adequate correction of mechanical axis in 9 patients and was fixed with a locking plate. The axis could not be completely corrected with this osteotomy alone and an additional upper tibial extra-articular osteotomy was performed in 12 limbs in 9 patients using an Ilizarov fixator(TCVO+HTO). Results: Avg pre-op MAD(TCVO) was -31% vs -73% (TCVO+HTO). Mean postop MAD was 43.3(TCVO) and 57.3% (TCVO+HTO). Mean MAD correction was 62.8%(TCVO) vs 130.6% (TCVO+HTO). The difference in condylar angles, joint orientation line and JLCA were not significant in the two groups. Two patients in TCVO group had plates removed for late infection. There were no infections in the TCVO+HTO group. Pain relief was significant in both groups. Conclusions: Large varus deformities causing MCOA can be well corrected by an intra-articular osteotomy(TCVO). Very large varus deformities with severe MAD need a combined intra & extra-articular correction in the tibia which is best done with the Ilizarov fixator. Excellent deformity correction and pain relief are possible. Acknowledgements: The author acknowledge the help & guidance of Prof Tsukasa Teramoto, the inventor of the TCVO surgery from Koriyama City, Japan


  PP 61: Double level fixator assisted nailing for lengthening, deformity correction, arthrodesis & nonunion treatment Top


MILIND Madhav Chaudhary1, Pratik H Lakhani2

1. International Deformity & Lengthening institute, Akola, India

2. Int Deformity & Lengthening Inst, Akola, India

Background: Performing a double level procedure using External fixation is common and easy. However, a double level procedure using fixator assisted nailing in the same segment is difficult and uncommon. Deformity correction, Lengthening, nonunion healing and arthrodesis can be simultaneously performed. Special instruments like straight rigid reamers, straight nails with extra locking holes & Poller screws are needed. Methods: 23 patients with 26 segments were operated over the last 10 years There were 22 femora and 4 tibiae with 15 Right &11 left segments. 11 patients had Polio, five had Bowing deformity, two had Rickets, two had a Nonunion and one each had a Malunion, CP & Ollier's disease. 16 lengthening were performed (2 femur, 4 tibia). 11 had LRS for femur, 4 tibiae & 1 Femur had ilizarov fixator for lengthening. Ten femora had double level deformity correction using IM Nails. Eight had varus -antecurvation and two had Valgus-antecurvation. 18 nails had distal & 8 had proximal entry portal. Most femora had straight custom made nails. 5 Polio patients had supracondylar osteotomies for FFD and lengthening. 4 Polio patients had Tibia lengthening & ankle fusion. Two had recurvatum correction with lengthening. Results: Avg length gain was 3.7cm. EFI was 16.9 days/cm. CI was 39.3 days/cm & Healing index was 56.7 days/cm. Avg SF12 PCS score was 47 & MCS was 52.1. Operative time, C-Arm use, blood loss, antibiotic usage were more than for a double level ex-fix procedure. Two nails broke. one caused under correction, 2nd was converted to Ilizarov. 6 pts had residual deformity but were significantly improved from their pre-op status. One tibial lengthening failed & was successfully completed using Ilizarov. One femur did not distract over the nail. Two knees became stiff and needed Quadricepsplasty to restore motion. No pin or deep IM infections resulted. Conclusions: Deformity correction, lengthening, nonunion cure & arthrodesis can be done in combination as double level fixator assisted nailing. Lengthening needs lower exfix duration. Deformity correction, nonunion and arthrodesis doesn't need ex- fix maintenance. Though double level exfix procedures are easy, long exfix duration creates many problems. Though Internal Lengthening Nails are popular, they cannot perform a double level procedure. Using simple IM nails and standard ex- fix devices, complex double level surgeries are possible which are cost effective and highly beneficial to the patient. Acknowledgements: We are thankful to the staff of Chaudhary Hospital Akola and to Mr Datta Deshmukh for his help in gathering patient data.


  PP 62: 3D concept of external fixation in fractures treatment and bones reconstruction – Results of 26 thousand applications Top


Milorad Borivoje Mitkovic1, Sasa Milenkovic1, Ivan Micic1, Milan Milorad Mitkovic2

1. Medical faculty University of Nis, Nis, Serbia

2. Orthopaedic and traumatology clinic, Clinical center Nis, Nis, Serbia

Background: It is presented 3D concept of new simple unilateral external fixation device for use in fractures treatment and bone reconstructions. Methods: As material we have used 3D unilateral external fixation system which consists of three components only. clamp, carrier of the clamp and bar. Each clamp can be combined with other two components on 2-3 different ways. Chess-like possibilities of combining of these three components it is possible to make different frames. This creative feature provides big freedom for surgeon in resolving variety of different fractures. The main idea of the system is convergent configuration of pins. It provides balanced 3D stability similar to natural long bones stability, which has been proven on series of experimental animals as big advantage in fracture healing. Also, this system can be used as accurate reduction device and it is provided possibility of dynamic joint bridging frame. Materials for these different frames were stainless steel, Al alloys, Titanium, carbon fiber and plastic. Biomechanical investigations of the system have been performed in three independent biomechanical laboratories. One of them was AO institute in Davos (Switzerland). It has been used in all segments. Results: This system is in wide clinical use and has already been applied to 26 thousand patients but here is presented results of series of 512 patients with tibial fractures. Mean union time was 11.3 weeks (8-24 weeks). Bone callus has been equally distributed around the circumference of fracture side. Mean application time was 12 min (3-56 min). Superficial pin tract infection rate was 12.6% and deep infection 0.8%. There were no other complications as DVT, joint stiffness, neurovascular injuries. Conclusions: This high mobile external fixation system is extremely simple having 3D balanced biomechanical stability which provides optimal conditions for fractures union, it can be used as accurate reduction device and all pins can be applied using free hand technique. It is suitable for routine use in fracture treatment and reconstruction. Acknowledgements: Author of this system has license agreement with producer as owner of the patent.


  PP 63: Preliminary results of the use of osseointegrated titanium implants for the reconstruction of trans-tibial amputees Top


Munjed Al Muderis1, R Atallah2, J Li3, Willam Lu3, Kevin Tetsworth4

1. Macquarie University Hospital, Sydney, Australia

2. Radboud University, Nijmegen, The Netherlands

3. Osseointegration Group of Australia, Sydney, Australia

4. Royal Brisbane Hospital, Brisbane, Australia

Background: Osseointegration has emerged as a novel approach to resolve persistent socket mounted prosthesis issues by attaching the prosthetic limb directly to the skeletal residuum. Until recently, this procedure has been performed mostly in trans-femoral amputee (TFA) patients. However, since August 2012 osseointegration has been performed on eligible trans-tibial amputee (TTA) patients in our center. This paper is the first pilot study to examine the results of performing osseointegration in the tibia. The objective of this study is to describe the reconstruction strategy and clinical management protocol used in the treatment of TTA patients with osseointegrated implants. We report hear our preliminary assessment of the safety and efficacy of the protocol in this particular group of patients. Methods: This is a prospective pilot study of 15 patients, consisting of 8 males and 7 females, aged 37-77 (mean 55.1 years), with minimum two-year follow-up. Selection criteria included age over 18 years, unilateral TTA patients, with significant socket-related problems. All patients received osseointegrated implants which were press-fit into the amputated limb. Principle outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation (Q-TFA), Short Form Health Survey 36 (SF-36), Six Minute Walk Test (6MWT), anTimed Up and Go (TUG). Adverse events recorded included infection, revision surgery, fractures, and implant failures. Results: Comparisons were made using differences between the mean pre-operative and mean post-operative values for each outcome measure. Significant improvements for all four outcome measures were observed. The prevalence of adverse events including the infection rate and revision rate were similar to trans-femoral osseointegration cases. Conclusions: These preliminary results suggest that osseointegration surgery for trans-tibial amputees is a safe and effective alternative treatment for amputees experiencing socket-related discomfort. This protocol has the potential to expand the application of osseointegration to help patients who have below knee amputations. Acknowledgements: MAM discloses a financial relationship with the manufacture, distribution, and sales of the implants used in this study. The other authors (RA, JL, WL, and KT) have no conflicts of interest to declare relevant to the current study.


  PP 64: Preliminary results using infrared thermal imaging to determine bone viability and assess resection margins in open tibial fractures Top


Kevin Tetsworth, Peter Wong

Royal Brisbane Hospital, Herston, Australia

Background: Debridement is a necessary but irreversible component in the management of orthopaedic trauma and infection. Debate exists regarding how much bone should be debrided following open tibial fractures. Inadequate debridement of avascular bone is common and this can be a source of chronic infection and treatment failure. There currently are no definitive, established, or validated criteria to assess bone viability intra-operatively. We have begun preliminary investigation into the efficacy of use of an infrared thermal imaging camera as an adjunct for the evaluation of bone viability in open tibial fractures. Methods: Prospective case series of four tibias with severe open fractures were photographed intraoperatively with a FLIR One infrared thermal imaging camera, using an iPhone as the platform. Ambient temperature, patient temperature, demographics, and clinical information were recorded. The FLIR One images automatically document the temperature of bone and tissue in the images obtained, with an accuracy within 0.2 degrees C. Following bony resection (in one case, amputation), histology was completed to confirm bone viability or acute necrosis. The histologic appearance was compared directly to the infrared appearance, as well as the temperature profile of the bone in vivo as documented in thermal images. Results: Necrotic bone had a documented temperature at least 5 degrees C less than surrounding normal viable and well perfused tissue, and in one case necrotic bone was more than 10 degrees C lower than surrounding normal tissue. Markedly lower temperature of bone in vivo directly correlates with a significant reduction in bone viability on photomicrographs of the histology specimens. There was a distinct absence of viable osteophytes in necrotic bone, with empty lacunae and Haversian canals. However, limitations in the resolution of the image with the currently available FLIR One camera makes it difficult to determine the resection margins with adequate precision. Conclusions: The FLIR One thermal imaging camera is an easily accessible tool that is relatively inexpensive and may have widespread applications in other areas of orthopaedic surgery. Preliminary results suggest it could serve as a useful adjunct for the evaluation of bone necrosis intraoperatively. This would provide surgeons with valuable information that aids in decision making during the debridement of bone. However, improvements in camera design will be necessary before its use can be supported for general use. Acknowledgements: The authors have no conflicts of interest to declare relevant to the current study.


  PP 65: Corrective Accuracy And Biomechanical Performans Of Hexapodal External Fixators (Clinical And Biomechanical Study) Top


Ilker Eren1, Ali Bas1, Levent Eralp2, Mehmet Kocaoglu2, Ergun Bozdag3, Emin Sunbuloglu3

1. Koc University Hospital Dept of Orthopaedics and Traumatology, Istanbul, Turkey

2. Istanbul University Istanbul Faculty of Medicine Dept of Orthopaedics and Traumatology, Istanbul, Turkey

3. Istanbul Technical University Faculty of Mechanical Engineering, Istanbul, Turkey

Background: In this study, we have questioned the stiffness of two different fixator types and compared clinical consolidation characteristics of these devices. It was hypothesized that hexapodal fixators would show inferior consolidation characteristics than the circular ilizarov type external fixator due to their inferior stability. Methods: Consolidation data from 77 bone segments (40 male, 37 female) of 57 patients treated with a hexapodal fixator were compared with 94 bone segments (51 male, 43 female) of 68 patients treated with a circular ilizarov fixator. The mean age of the hexapod group was 20.69 ± 12.94 years old, and the mean age was 22.45 ± 12.18 years old for the circular external fixator group. 15 hexapodal type external fixator and 15 ilizarov type external fixator frame was formed for biomechanical testes. Polyethilene bone models fixed by using 1 K wire and 2 schanz pins at the proximal and 3 schanz pins at the distal ring levels. 30 mm length gap zone was created in the middle of bone model as a consolidation area. 300 N axial loading, 300 N bending and 10 N tortional forces were applied to constructs. Clinical and biomechanical data of these two devices were compared. Results: A longer correction period was found with Ilizarov patients (66.53 ± 47.7 days) compared to Smart Correction patients (49.05 ± 35.6 days). The bone healing index of the Ilizarov group was significantly better, compared to the spatial group. Residual deformity after treatment was significantly lower with the hexapodal frames compared to the Ilizarov apparatus. When hexapodal and ilizarov type external fixators compared each other's as biomechanically, statistically higher axial and bending stability values were found at Ilizarov type circular external fixator when compared with hexapodal fixators (p<0,05). According to the Ilizarov type circular external fixators, torsinal stiffness values of hexapodal fixators were determined higher. Conclusions: The Smart Correction fixator is an accurate device that allows ease of application and planning. It demonstrates higher accuracy for correcting deformities compared to an Ilizarov external fixator. However, the fact that the ilizarov type external fixators are more stable than the hexapod systems biomechanically, especially against axial and bending forces, result in better bone healing index. Acknowledgements: Thanks to Meral Tuna and Buğra Bekler for their assistance in the biomechanical testing process at Istanbul Technical University Faculty of Mechanical Engineering


  PP 66: New Treatment Regime In Tibial Chronic Osteomyelitis Associated With Shorthening Performing Femoral Lengthening Top


Gerald Eliot Wozasek1, Alex Lerner2,Lukas Zak1, Thomas Tiefenböck1

1. Medical University of Vienna, Vienna, Austria

2. Ziv Medical Center, Zefat, Israel

Background: Chronic tibial osteomyelitis is frequently associated with bone loss, severe deformity and especially with limb shorthening. Treatment option until recently included contralateral shorthening or lengthening. Lengthening of the chronically infected tibia is more than dangerous and most patinet do not accept an external frame. Methods: We are presenting our cases of severe tibial shortening after chronic osteomyelitis. A new method, which until today was not published, was used in selected patients to equalize the limb discrepancy. We performed femoral antegrade and retrograde femoral lengthening using a telescopic nail to compensate the shorthening of 6-8 cm. Results: Leg length equality was achieved in our patients. The knee joint line naturally changed obviously. However, having had to wear a shoe lift for many years the activities of daily living improved significantly. No recurrence of infection occurred at the ipsilateral lengthened femur. One case was successfully performed in a smoker having had vascular femoral stent surgery. Conclusions: Ipsilateral femoral lengthening is a new treatment regime in infected shortened tibial osteomyelitis. The cases have to be carefully selected and knee joint line discrepancy does not to appear to be disabling for the activities of daily living. Acknowledgements: none


  PP 67: Comparison On Fracture Pattern And Healing Index For Corticotomy Using Standard Drill Sleeve And Double Barrel Drill Sleeve Top


Sung Siang Mooi, Rukmanikanthan Shanmugam, Siew Ghim Gooi, Aik Saw

University Malaya Medical Centre, Kuala Lumpur, Malaysia

Background: Corticotomy is defined as low energy breakage of the bone cortex with minimal injury to surrounding soft tissue to allow bone regeneration. We designed a double barrel drill sleeve to facilitate and reduce the complication of corticotomy procedure. This study is designed to compare between pattern of drill holes and eventual bone healing index (BHI) between the use of double barrel drill sleeve and standard drill sleeve. Methods: Part I study involved performing corticotomy on sawbones by a group of junior doctors. We compared the distribution, total number, and distance between the drill holes for the two methods of corticotomy. Part 2 study involved retrospective comparison of BHI between the two corticotomy methods over two periods of time. Results: In part 1 study, the mean time to perform corticotomy using double barrel drill sleeve was 96 seconds, compared to 179 seconds with the use of standard drill sleeve. Difference between mean number of holes between near and far cortices were not statistically significant. However, longtitudinal deviation of the drill holes were significantly lower with the use of double barrel drill sleeve for both the near (0.21 mm vs 0.81 mm) and far cortices (0.00 mm vs 1.62 mm). For the part 2 study, the mean BHI for 31 consecutive patients using double barrel drill sleeve was 84.5, compared to 68.0 for 29 consecutive bone lengthening using standard drill sleeve, and the difference was not statistically significant. Conclusions: Corticotomy using double barrel drill sleeve may reduce the operating time and reduce the risk of fracture extension. However, there was not significant benefit in terms of reducing the BHI. Acknowledgements: Muhamad Luthfi


  PP 68: Intramedullary Humeral Lengthening - Planning And What To Think About Before Performing This Procedure Top


Gerald Eliot Wozasek, Lukas Zak, Thomas Tiefenböck

Medical University of Vienna, Vienna, Austria

Background: Long bone lengthening using telescopic nails have become a routine procedure. Public media have recently sensitized patients with unilateral congenital and posttraumatic humeral shortening and only a small number of cases have been published and presented. Methods: Our congenital cases show similar good results as in the lower extremity. However, we prefer the use of tibial proximally bent telescopic nails because of the humeral head entry point. Results: All cases healed uneventfully. However, in one case of 7 cm humeral length discrepancy using the 8,5-mm nail only 5 cm of lengthening was achievable. Conclusions: Humeral lengthening is definitely more challenging than lower extremity lengthening. The bent proximal design in antegrade nailing facilitates the insertion of the implant. The maximum of 5 cm distraction is in certain cases not sufficient. Acknowledgements: None


  PP 69: Long Subcutaneous Wire Technique Help From Soft Tissue Complication During Bone Transport Treatment. Top


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

Department of Traumatology, Fukushima Medical University / Trauma & Reconstruction Center, Southern TOHOKU General Hospital, Fukushima, Japan

Background: Ilizarov method (callotasis, distraction osteogenesis) is a good technique for treat shortening, deformity, or bone defect. Bone transport is one of good technique for treat large bone defect, but some cases occur many type of skin trouble. Soft tissue moves with bone transport fragment, so extra skin sagging and stuck between bone fragment, or depression on the anterior skin surface and transport fragment cut out the skin. For against these soft tissue complications, we develop long subcutaneous wire technique. Methods: At operation of osteotomy for bone transport, put a wire longitudinal anterior of bone transport fragment, through subcutaneous of bone defect area, put again anterior of distal bone fragment. Fix this wire to proximal Ilizarov ring. We use this technique to 3 cases who had bone transport surgery for bone defect more than 5cm at tibia. Results: No conventional soft tissue complication has occurred at these 3 cases using this long subcutaneous wire technique. Possible troubles of this technique are infection of wire insertion, cut out at bone defect area, but not appear in these 3 cases. Conclusions: Long subcutaneous wire technique is useful for against soft tissue complication During Bone Transport Treatment. Acknowledgements: I would like to thank Professor Tsukasa Teramoto, Professor Takashi Matsushita, President Kazuo Watanabe, supervisors of this work, and also thank Professor Yoshinobu Watanabe (Department of Orthopaedic Surgery, Teikyo University School of Medicine) for advice this technique.


  PP 70: Plating Assisted Bone Transport In The Femur Using A Motorized Lengthening Device - A New Technique Top


Ulrik Kähler Olesen, Tobias Nygaard

Rigshospitalet, Copenhagen, Denmark

Background: A new surgical technique to treat femoral bone loss, using a plate and a standard motorized lengthening nail is presented, through 3 illustrative cases. Methods: Three patients with extra articular femoral bone defects from open fractures were operated in 2016. The patients were evaluated for LLD, MAD, time to weight bearing, defect size, complications. Follow up was minimum 20 weeks. Surgical technique. After thorough debridement and external fixation, a lateral plate spanning the defect is inserted, maintaining length and rotation. The plate can also address a concomitant condylar fracture. A local antibiotic filler serves as dead space management and prevention of infection. Meticulous surgical planning was done using long standing radiographs and radiographs of contralateral femur with calibration device to estimate correct length. After 6 weeks, negative biopsies and negative infection count (WBC, CRP) the nail is inserted in a retrograde or antegrade fashion and a transport segment is created with a drill bit osteotomy. Some shortening was necessary to allow soft tissue closure in two cases. In one case, the nail was pre-distracted to allow retrograde transport (pulling the segment). In the same case with very short distal segment, the nail was recompressed, while the transport segment was temporarily fixated, to allow for full length transport. Results: Average defect size was 75 mm. All patients were fully weight bearing at 14 weeks. LLD was zero,15 and 45 mm respectively. MAD was within normal limits in all cases. All patients displayed some degree of heterotopic ossification and reduced knee motion. Conclusions: Open femoral fractures with bone loss are prone to cause quadriceps fibrosis and heterotopic ossification, that may require further surgery, irrespective of which bone substitution method is used. Strict infection control in open fractures and meticulous surgical planning is required. The presented technique is a valuable addition to the arsenal in treating femoral bone defects. It eliminates the side effects of external fixation and may reduce treatment time compared to alternative methods. Acknowledgements: The present work was initiated during the LLRS traveling fellowship in 2016


  PP 71: Osteotomy Technique On Long Bones, For Bone Lengthening, With The Association Of Two Different Techniques: Gigli Saw And Delicate Osteotome. Top


Mario Cavalcanti Albuquerque, Guilherme Valdir Baldo, Gracielle Silva Cardoso, Renato Amorim, Juliano Teixeira Sa, Bruno Cunha Mota

Hospital Governador Celso Ramos, Florianopolis, Brazil

Background: Osteotomies are fundamental bone section procedures in surgery for angular corrections, bone transport and bone lengthening. Several techniques have been described, each one of them maintaining the principle of protecting osteogenic and neo-vascular elements in order to obtain better quality of bone formation in less time. Our technique associates a Gigli Saw in the first phase of the osteotomy, and then finishes it with a delicate osteotome, preserving the periosteum for better consolidation of the regenerated bone. Methods: The technique is proposed for the tibia, starting by incising the skin on the anteromedial and anterolateral aspects of the leg. The access to the virtual space between the periosteum and the bone is made with a longitudinal incision. After this step, the periosteum is gently dissected with delicate instruments, and, using a Kelly and a Mixter, a nasogastric catheter, with a Gigli Saw inside of it, is passed through the incisions and the dissected periosteum. Then, palpating the distal pulses and confirming that there is no interpositioning of soft tissues, the saw is tensioned against the bone and the catheter is removed. After double checking the correct position of the saw, the osteotomy is initialized. The osteotomy is stopped in the last third of the remaining bone, the gigli Saw is removed, and the residual bone is osteotomized with a delicate osteotome, always carefully preserving the periosteum. Results: This technique is expected to show that associating the use of these instruments, with the Gigli Saw technique, more of the periosteum, and its blood supply, is preserved in the final aspect of the procedure, benefiting the consolidation of the regenerated bone. Conclusions: There are many osteotomies techniques described in the literature, and Gigli saw osteotomy is a low energy osteotomy that leaves a smooth cut, but it can be a gross procedure and sometimes affect the anterior healthy periosteum. This technique maintains the many advantages that osteotomies with Gigli Saw has, and adds a more refined finish to it, helping to preserve the blood supply, which we believe that will be determinant to help in creating a good quality regenerated bone. However, this technique is based and limited to a theoretical experimental model, considering the biological principles of osteotomies and bone regeneration physiology. It is known that there is a need for more studies applying this biologics principle in practical models. Acknowledgements: There was no conflict of interest in this study


  PP 72: A new transosseous calcaneal pin for use with Ilizarov external fixator and also for skeletal traction New procedures and apparatus Top


Harshad Mohanlal Shah, Rahul Hemant Shah, Abhilash Palla, Rahul P, Naveen Kumar Lokesh

Ramaiah Medical College & Hospitals, Bengaluru, India

Background: The versatile Ilizarov External Fixator has many components and again it has many sizes in each component types. This allows it to be used in many permutations and combinations in almost in all situations. The commonest use of the Ilizarov External Fixator is in the Tibia. It is extended onto the Calcaneal and forefoot as required. The Calcaneal attachment is generally by a U-Ring connected with two tensioned transosseous Ilizarov plain wires placed almost at 90x90 degrees to each other. These are in turn connected in a standard way to the foot ring and the tibial rings. Alternatively, in the absence of a U-Ring, a half ring is connected with an extension connecting straight plates on either ends of the half ring to convert it into an almost U-Type ring and used similar to a U-Ring. Methods: We have designed and used a simple pin, which is used transosseous through the Calcaneum. This pin has a central threaded portion the width of calcaneun, and ends which are threaded to hold at least four nuts and two female posts. One end is trocar shaped and the other end is triangular. This is connected to both the foot and the tibial rings using female posts and threaded rods like in a hinge. Results: Having initially successfully used a 6 mm calcaneal pins, we made 4.5 mm pins also of various lengths. It was seen that only the 6 mm pins were good for use in deformity corrections and withstood the forces of treatment. The thinner pins bent under the pressure of deformity corrections and we had to replace with Ilizarov wires. All patients were seen to be comfortable with the transosseous pin. A few pin tract infections were successfully treated with antibiotics and dressings. Conclusions: This Calcaneal pin does not replace Prof Ilizarov's method of cross wire fixation of the Calcaneum which seems to be the best way. This new calcaneal pin adds to the paraphernalia of Ilizarov External Fixator and its components. It also allows us for one simpler, easier method of including the Calcaneum in many of the conditions treated by Ilizarov External Fixator. It is easy to insert the pin to reduce the fracture fragments. It has the advantage of lesser hardware, lesser operative time, and less cost. It can be used with any fixator and can be used in all indications of Ilizarov method and other fixators. Acknowledgements: No conflict of interest


  PP 73: Reconstruction Of Congenital Extremely Short Femur With Supracondylar Nonunion Using External Fixtures And Our Original Components Top


Takashi Matsushita, Tsukasa Teramoto, Nobuyuki Takenaka

Trauma and Reconstruction Center, Southern TOHOKU General Hospital, Fukushima Medical University, Koriyama, Japan

Background: Limb lengthening over 20cm is not easy, especially for a very short femur. In congenital long-lasting supracondylar nonunion, sometimes knee motion is achieved at a nonunion site -- not at a true knee joint, and lower extremity function worsens after bone healing of the nonunion. Methods: The patient was a 19-year-old female with congenital short femur and congenital nonunion at just above the femoral condyle. Her femur was 155mm and the proximal fragment above the nonunion was only 115mm including head and neck. Her knee joint did not move at all, and (pseudo) knee motion was achieved at the nonunion site. We preserved the nonunion by distraction and lengthened the femur at just below the lessor trochanter using a combination of Ilizarov, Monotube, and Hoffmann external fixators and our original components. Results: Her femur was successfully lengthened by 21cm, and leg length discrepancy disappeared. Both her supracondylar nonunion and pseudo knee motion were preserved during lengthening. Her resulting pseudo knee joint range of motion was 0 to 60 degrees with no pain on motion. She can walk without pain with a knee brace and one Lofstrand crutch. She is now 25 years old and has graduated a university. She is doing desk work and commutes to work by public transportation. Conclusions: A case of congenital extremely short femur with functional supracondylar nonunion was treated successfully without loss of lower extremity function. Acknowledgements: We have no conflict of interest.


  PP 74: Hexapodalic systems for treatment of congenital and post traumatic deformity: Comparison between systems in our experience Top


CARLO Salomone1, ANTONIO Biasibetti2

1. MIOS-MIOA, Albenga, Italy

2. MIOS-MIOA - CTO, Albenga - Torino, Italy

Background: It is difficult to think of any substantial improvements of the systems currently available. There are key features that have been implemented in leading systems for each feature. The circularity is derived from the concept of Ilizarov. This concept has created a method, one and only. circular external fixation. I followed several tools, circular external fixators, created for the same purpose and based on this one and only method. The hexapod computer assisted system, first presented by Adam Taylor, uses the concept of a potential multiplanar movement using the hexapod system. The hexapod method was not developed from external fixation but found an important application in the in the field of deformities. Today there are different hexapodalic systems each of which with different characteristics in designation, application and correction. Methods: At the MIOS Center (Infectious Diseases and Septic Orthopedics) in Albenga, three hexapodalic systems are used. Taylor Spatial Frame, True Lock Hex and Orthosuv. From 2010 to date, the following were performed. 36 TSF, 8 TLH and 42 Orthosuv for a total of 86 implants in the lower limb. Results: From this experience we found a remarkable reliability and accuracy of the systems used. However, it was found that in some situations (i.e. proximal femur and multiplanar deformity) indicating the use of a system over another could be helpful and instrumental in reaching a correction. Vice versa mon o biplanar deformities can depend on the surgeon knowledge with respect to the different systems. Conclusions: From the analysis of the cases, the special features of each system are evident. There is still a need for strong knowledge of the underlying methods and basic principles of circular external fixation, without which it is difficult to propose and use hexapodalic systems. Also there is always the great importance of the surgeon's role in identifying the correct indication, calculation and execution of the correction of the deformity. These fundamental principles are released by the potential of software systems. In conclusion, all the systems are reliable and require a knowledge of circular external fixation and they differ based on the duplicability and representation of the deformity and its correction. Acknowledgements: .


  PP 75: Application Of The External Transpedicular Fixation In Staged Correction Of Severe Spine Deformities Top


Oxana Germanovna Prudnikova

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: Main problem of expressed deformities correction is risk of neurological complications, typical for acute correction. [V. Vora, Reyes-Sanchez A., Rinella A.]. That is why many researchers use different variants of gradual spine distraction in order to correct the deformity. Methods: Basing on retrospective analysis of treatment results to prove effectiveness of external transpedicular fixation for staged deformity correction. Treatment results of 42 patients with severe scoliosis. 5 years follow-up with evaluation of clinical and radiological data. before surgery, after the surgery, 6 months follow-up and 1-year follow-up. We inserted half-pins transpedicularly, assemble external construction and gradually corrected deformity with clinical neurological and radiological check. Results: Primary curve correction was corrected for 70,5%, secondary curve – 48,9%. Mean term of deformity correction was 24,9±5,9 days. Mean term of surgery duration was 53,1±46,3 min, blood loss - 102,3±36,2 ml. Neurological complications caused by fixing elements insertion were diagnosed in 4 (9,5%) patients, liquorrhea – Bin2 (4,7%) of cases. There were no neurologic complications caused by spinal cord traction. Infection was diagnosed in 4 (9,5%) patients. superficial – in 3 (7,1%) patients, deep - with spondilodiscitis development in 1 (2,3%) patient. All patients achieved satisfactory clinical result of treatment. Conclusions: Conclusion application of external transpedicular osteosynthesis is justified in staged correction of severe scoliosis. Acknowledgements: there is no conflict of interest


  PP 76: Ilizarov Fixators Or Hexapods It'S A Real Advance Or Market E Industry Result In Reconstructive Surgery. Top


León Gonzalo Mora H. Md

CORA Group - Clínica El Rosario, Medellin, Colombia

Background: Abstract Text. The Ilizarov Method has passed the threshold of time and history for over 60 years, as one of the pillars in reconstructive surgery of limbs, has gone through different stages with the appearance of circular devices, monoplanar and now with so-called Hexapods that use sophisticated software to correct deformities on all possible planes. Ilizarov's method, which was initially not widespread in the West and Europe, required the emergence of several centers for the study and application of these treatments. In the 1990s and at the beginning of the century, there was a deepening of the application and understanding of the principles and Understanding of the deformities, with a great growth of the specialty. Subsequent to this has been applied state-of-the-art technology to try to facilitate the application of the hardware, with pieces of better design and additionally applied systematization and software for analysis of deformities and multiplanar correction of deformities, this has brought to the market sophisticated devices, with costs that can quintuple the value of conventional circular tutors and generating a need and anxiety in the Ortopedica community for having these modern devices. We perform a critical analysis on the real advantages of these devices, the problems that can generate their indiscriminate use and rationally we make an invitation to evaluate the real usefulness of these devices, we insist on the fundamental that is the knowledge of the principles in correction of Deformities and we demonstrate that more than 90% of angular problems are successfully solved by the traditional method with conventional tutors. We opened a window to what would really be a breakthrough in the external or internal fixation devices and what is the next future in reconstructive limb surgery. Methods: .Results: Conclusions: Acknowledgements


  PP 77: A New Concept In Orthopedics And Traumatology: Damage Control Caused By Infection In Orthopedics, Damage Control Orthopaedics Infection (DCOI) Top


Carlo Salomone1, Antonio Biasibetti2

1. mios, Albenga, Italy

2. MIOS-MIOA / CTO, Albenga - Torino, Italy

Background: In orthopedics, the rise of high energy trauma cases, complex surgeries, metaphyseal and joint reconstructions and the development of multidrug resistant bacteria strains have led to an ever-increasing number of infections in orthopedics and traumatology. Infections should be recognized and managed not only for local complications but often for systemic ones. In addition to a correct diagnosis of the severity and dispersion, it is necessary to have a multidisciplinary approach and from the orthopedic point of view the knowledge of the technique of external fixation. Methods: The paper aims to classify infections in the orthopedic practice in such a way as to identify a therapeutic protocol dividing them by severity. local-to-systemic. Recognizing the priority of the preventive role that the orthopedic surgeon must always adopt, in the event of an occurrence, the infection should be recognized, classified, properly and quickly treated to avoid the complications that it can cause the patient. Results: Three infection situations:. 1. The open fracture. by definition can be considered a local infection even without bone involvement independent of the type of exposure and tissue injury. What matters in the surgical treatment, even acute, is to handle as if there were already an infection and plan future treatment for maintenance or complications of the infection. The use of external fixation plays a dominant role. 2. Post traumatic acute Infection. once recognized an infection in a range of less than 60 days from probable start or trigger (trauma, prosthesis, etc.) should be immediately treated with recovery and often conversion of synthesis (using external fixation in most cases). The development should be monitored in order that in a second phase the definitive treatment can be performed (multidisciplinary. orthopedic, plastic surgery, infectious management). 3. Septicemia. a situation where the infection is widespread involving a risk of life for the patient. It requires urgent. Conclusions: The diagnosis and classification of infections in orthopedics for the preventative treatment of injury are more readily available in a multidisciplinary manner and executable in facilities where the orthopedic surgeon works on a daily basis alongside infectious disease specialists, microbiologists, and plastic surgeons in order to manage this complex, severe and debilitating disease. The DCOI as the DCO is a concept that should be part of the daily practice of all orthopedic surgeons. Acknowledgements: Damage Control Orthopaedics. Evolving Concepts in the Treatment of Patients Who Have Sustained Orthopaedic Trauma. Craig S. Roberts, MD; Hans-Christoph Pape, MD; Alan L. Jones, MD; Arthur L. Malkani, MD; Jorge L. Rodriguez, MD; Peter V. Giannoudis, MD. J Bone Joint Surg Am, 2005 Feb; 87 (2). 434 -449. Semin Plast Surg. 2009 May; 23(2). 59–72. doi: 10.1055/s-0029-1214158. PMCID. PMC2884908. Osteomyelitis. Guest Editors Christopher J. Salgado M.D. Lawrence B. Colen M.D. Osteomyelitis of the Long Bones. Jason H. Calhoun, M.D., F.A.C.S.,1 M.M. Manring, Ph.D.,2 and Mark Shirtliff, Ph.D.3. Cierny G, III, Mader J T, Penninck J J. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003; 414:7–24. Lew D P, Waldvogel F A. Osteomyelitis. N Engl J Med. 1997; 336:999–1007.


  PP 78: The Choice Of Optimal Method Of Fixation After The Osteotomy Of The Femur In The Treatment Periprosthetic Deformity. Top


Elena A. Shchepkina1, Leonid N. Solomin2, Fanil K. Sabirov3, Konstantin L. Korchagin3, Sergey A. Lasunsky3

1. Vreden Russian Research Institute of Traumatology and Orthopedics; Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia

2. Vreden Russian Research Institute of Traumatology and Orthopedics; St. Petersburg State University, St. Petersburg, Russia, Saint Petersburg, Russia

3. Vreden Russian Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia

Background: In cases of such periprosthetic deformities when acute deformity correction and/or internal fixation are contraindicated, external fixation should be used. In these cases, insertion of K-wires and half-pins is complicated due to prosthesis, inefficient and can lead to dangerous complications. There is special device – extracortical clamp defice (ECD, www.ortho-suv.org) that allows to fix bone fragment that contains the stem of the prosthesis rigidly to the ring of ExFix frame. It is ensured due to ECD fixes the bone from outside, extracortically. Methods: Correction of periprosthetic deformities was performed in 16 patients. Gradual deformity correction was used in 16 patients (9 with hip replacement(HR) and 1 with knee replacement(KR)). In each case for fixation of the bone fragments that contain stem of the prosthesis ECD were used. Acute deformity correction and plate osteosynthesis was used in 4 patients (only HR), in one case from this group external fixation assisted plating was used. In 3 patients that had limb length discrepancy (2 HR and 1 KR) shortening osteotomy and nailing were performed. Results: Period of deformity correction was 29,6 ± 3,4 days. Period of osteosynthesis was 259,57±72,3 days. In gradual deformity correction, we faced with 2 complications (20%). In one case inflammation of soft tissues at place of ECD insertion which was successfully treated by its removal and partial renewal of the frame. In another case there was observed partial loose of deformity correction. We performed acute deformity correction and plate fixation in this case. In use of plate fixation in 1 case varus deformity 5° remained but MAD was in range of normal values. Among patients with nailing in one case formation of non-union and collision with femoral component of prosthesis was observed. Reosteosynthesis using customized locking nail was performed and consolidation achieved. Conclusions: Acute deformity is more comfortable for the patient but requires careful preoperative planning. Presence of femoral component of the prosthesis limits the choice of metal construction, in variety of cases internal fixation can't be used due to levels of osteotomy and necessary translation. Use of ECD allows to use the advantages of external fixation in cases when insertion of traditional transosseus elements is difficult or impossible and is alternative to internal fixation. Acknowledgements: to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, Pavlov First Saint Petersburg State Medical University and Ortho-SUV Ltd.


  PP 79: Minimal Invasive Lengthening After Resection Of Malignant Bone Tumors With A New “Bio-Expandable” Prosthesis Top


Rainer Paul Baumgart

ZEM-Germany Limb Lengthening Center Munich, Munich, Germany

Background: 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 create a “bio-expandable” prosthesis which is lengthening the remaining bone by callus distraction as it is performed frequently in cases of congenital or posttraumatic limb length discrepancies. After surgery, the skin is closed completely. In case of bone lengthening with the “bio expandable” endoprosthesis, the relationship of the prosthesis length compared to leg length develops in favour of the remaining bone. Further developments allow a minimal invasive surgery for the lengthening procedures. 7 patients (4m, 3f) were treated with the bioexpandable prosthesis. In 5 cases, the femur and in 2 cases the tibia was lengthened after resection of an osteosarcoma (4) or an Ewings-sarcoma (3). The mean age of the patients was 16 years and the mean amount of lengthening was 72mm. In 2 cases lengthening was performed in 2 steps and in 1 case it was performed in 3 steps. Results: All lengthening procedures could be finished without complications. There was no infection and no technical problem. The bone regenerate in one tibia case was poor so that bone grafting had to be performed from the iliac crest. In one case, 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 planned. Conclusions: The “bio expandable” prosthesis is a new concept for limb lengthening after tumor resection. The BioXpand is the first prosthesis which is able to perform callus distraction. BioXpand II and III in addition allow a minimal invasive approach for lengthening procedures for all frequent locations of malignant bone tumors of the lower limb. Especially for children the concept is a favourable option after tumour resection because limb length equality and better long-term stability of the prosthesis can be expected. Acknowledgements: The author is a paid consultant of Wittenstein intens and implantcast, Germany


  PP 80: The Combined (Soft Tissue Release + Software-Based ExFix) Surgical Treatment Of The Patients With Flexion Knee Joint Stiffness Top


Elena A. Shchepkina1, Leonid N. Solomin2, Dmitry G. Nakonechny3, Konstantin L. Korchagin3, Fanil K. Sabirov3

1. Vreden Russian Research Institute of Traumatology and Orthopedics; Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia

2. Vreden Russian Research Institute of Traumatology and Orthopedics; St. Petersburg State University, St. Petersburg, Russia, Saint Petersburg, Russia

3. Vreden Russian Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia

Background: Flexion knee joint stiffness is characteristic for neurological disorders with symptoms of lower spastic paraparesis, accompanied by dysfunction of adjacent joints, scar processes around the peroneal nerve and require an integrated approach to surgical treatment. Methods: We analyzed the treatment of flexion knee joint stiffness in 20 patients (25 joints). Etiology. consequences of severe traumatic brain or spinal injure in 11 cases; cerebral palsy - 3, myelodysplasia – 5, lesions of peripheral nerves - 2, trauma - 1, amputation of the lower leg without immobilization - 3. Standard staged operative treatment included. release of peroneal nerve, elongation of the posterior group of muscles tendons. In 9 cases was performed adductorotomy, in 3 - extension of the proximal rectus femoris tendon. In 18 cases of foot equinus achilles lengthening were performed. In 4 patients with knee ROM 140/50/0 we could reach extension simultaneously. Fixation by brace was used. In 21 cases after release of the knee ExFix was used. in 19 cases by Ortho-SUV Frames (OSF, www.ortho-suv.org) in 2 cases Ilizarov hinges were used. The program for extension was calculated using a special option OSF-software. multi-total residual. It provided a “physiology” of the trajectory of motion in the knee joint with the required rate of 2-5 deg / day. Fixation in frame 4-6 weeks. Later we trained the ROM in the knee, at the same time for 3 months remained fixation by splint while sleeping and walking. Results: Period of gradual extension was 44,8 ± 20,4 days, the period of fixation of 43,4 ± 38,5 days. Complications occurred in 5 patients (20%). pin-hole fracture - 2 (8%), instability of the external fixator - 1 (4%); cyst formation in the popliteal area - 1 (4%); deep infection - 1 (4%). In all cases, complications did not affect the final result of treatment. 4 patients estimated the result as unsatisfactory (16%). in flagrant violation of rehabilitation regimen 2 cases complicated by extensor contracture and patella-femoral synostosis, 2 - there was a complete loss of correction. In 4 cases (16%) was observed in a partial loss of extension within 20° or flexion in the range of 40°. In other cases, were observed good results with the amount of movement of at least 90 ° and the possibility of movement without additional support. Conclusions: Soft tissue release combined with software-based ExFix allows gradually and “physiologically” to make the elimination of contractures. Acknowledgements: to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, Pavlov First Saint Petersburg State Medical University and Ortho-SUV Ltd.


  PP 81: Humeral Lengthening With A Magnetic Limb Lengthening Nail System: A Retrospective, Multicenter Study Top


Ahmed I. Hammouda1, Shawn C. Standard2, S. Robert Rozbruch3, John E. Herzenberg2

1. Department of Orthopaedic Surgery, Al-Azhar University, Cairo, Egypt

2. International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, United States

3. Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, United States

Background: Different types of external fixation have been used for humeral lengthening, and successful outcomes have been reported in literature. Magnetic limb lengthening nails have evolved as an alternative to external fixation for lengthening of the lower limbs. This study is the first report on using this lengthening technology for humeral lengthening. Methods: A multicenter, retrospective study was conducted that included 6 humeri in 5 patients (2 males and 3 females; mean age, 20 years) who underwent lengthening with magnetic nails at 2 centers in the USA. The etiology was humeral growth arrest after bone cyst (2 segments), post-septic growth arrest (2 segments), and multiple hereditary exostosis (2 segments in 1 patient). The outcomes measured were length achieved, distraction index (DI), consolidation index (CI), complications, and functional outcomes. Consolidation was described as healing of 3 of the 4 cortices. Results: Mean follow-up period was 1.4 years (range, 0.7-1.9 years). All segments achieved the lengthening goal; mean lengthening amount was 5.1 cm (range, 4.5-5.8 cm). Mean DI was 0.7 mm/day (range, 0.5-0.8). Mean CI was 36 days/cm (range, 25-45 days/cm). No complications were observed. At the last follow-up, all patients had maintained preoperative shoulder and elbow range of motion. QuickDASH score and upper extremity functional index showed postoperative improvement compared with the preoperative scores. Conclusions: This study is the first in the literature to report humeral lengthening using magnetic nails. Magnetic limb lengthening nails can provide the same results and fewer complications than humeral lengthening with external fixation. Magnetic nails are able to provide accurate control over the lengthening process. Acknowledgements: AIH has nothing to disclose. SCS receives royalties from NuVasive Specialized Orthopedics and Pega Medical and is a consultant for NuVasive Specialized Orthopedics. SRR is a consultant and a paid presenter/speaker for NuVasive Specialized Orthopedics, Smith & Nephew, and Stryker; receives publishing royalties from Informa and Springer; and receives IP royalties from Stryker. JEH is a consultant for Orthofix, OrthoPediatrics, NuVasive Specialized Orthopedics, and Smith & Nephew; receives research support from NuVasive Specialized Orthopedics; and is on the editorial board of the World Journal of Orthopaedics. The following companies supported a non-profit organization that is part of Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). CS Medical Supply, Metro Prosthetics, and Stryker. The following organizations supported an annual course for orthopedic surgeons that is held by Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). Baxter, DePuy Synthes, Merete Technologies, MHE Coalition, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Smith & Nephew, Stryker, and Zimmer Biomet.


  PP 82: How To Evaluate The Amount Of Correction In The Simultaneous Femoral And Tibial Correctional Osteotomy Around Knee? Top


Donghoon Lee

Severance Children's Hospital, Yonsei University, Seoul, South Korea

Background: Many methods including grid method, able method and navigation are used to evaluate the alignment during the corrective osteotomy. When the deformities are in the distal femur and proximal tibia simultaneously, evaluation of the amount of correction of the first segment is difficult since conventional method for checking the alignment is useless. We designed a new protractor (D-protractor) for this. This study aimed to the accuracy of the correction and the complications using a new protractor in the simultaneous distal femoral and proximal tibial correctional osteotomy. Methods: From January 2013 to December 2015, a total of 24 segments of simultaneous distal femoral and proximal tibial correctional osteotomy with a fixator-assisted less-invasive technique were evaluated. No limbs were excluded. During the period in question, no other techniques were used for the same deformities. The amount of correction of each segment were planned preoperatively. Distal femur was corrected first and the amount of correction was confirmed using a new protractor method (D-protractor). Radiographic review to evaluate the accuracy of the correction was performed by two of the authors not involved in clinical care of the patient. Complications were assessed by chart review. Delayed union was defining as union occurring later than 4 months. Results: The overall completeness of reaching the target correction was excellent. In the coronal plane, the difference between the amount of real correction and the amount of target correction in lateral distal femoral angle was 0.3 ± 0.5 degrees. There were no complications associated with this new protractor technique. All osteotomies healed before 4 months with no delayed or nonunion, and no deep infection. Conclusions: A new protractor (D-protractor) method is a valid option for correcting the valgus or varus deformity, especially in the simultaneous distal femoral and proximal tibial correctional osteotomy. Acknowledgements: Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.


  PP 83: Lower Limb Malalignment: Development Of A New Learning Model Top


Joao Esteves, Joao Rosa, Diogo Pascoal, Paulo Pereira, Adelio Vilaca

Centro Hospitalar do Porto, Porto, Portugal

Background: Gait is the mechanism of moving the body's center of mass forward. The shape of the lower limbs will change the way the different acting forces will affect the knee joint. There is great variability in the morphologic features of the human lower limb. Anterior knee pain, patellar instability and knee osteoarthritis are among some of the conditions that may be directly related to an abnormal alignment. Two main variables contribute to what Stan James described as the miserable malalignment. Femoral anteversion and tibial external rotation. Methods: To properly evaluate these variables, we need to, first of all, establish how to calculate them. The femoral anteversion is usually calculated as the angle between a line joining the center of the femoral head and the center of the neck, and the posterior condylar line. Some authors also propose the use of the interepicondilary line instead. As to the tibial torsion, it can be measured as the angle between a line joining the posterior tibial plates and the line between the center of the medial malleolus and the midpoint of the fibular sulcus. The best imaging method is a CT scan that includes the full length of the lower limb (at list proximal femur, knee and distal tibia). With it, one can calculate both the tibial torsion and the femoral anteversion. Even with the calculated angles, it is not easy to perceive the full picture of the lower limb and to properly propose a surgical treatment. With that difficulty in mind, we decided to create a model that allowed us to better study these patients. Results: We got a real size lower limb bones model (femur and tibia) with ligament models, and decided to mark all these points in the bone. posterior condylar line, femoral head-neck line, posterior tibial line, inter-malleolus line, and also tibial tubercle, femoral groove and interepicondylar line. After referencing all these points we proceeded to perform various osteotomies – proximal femur, distal femur, proximal tibial, distal tibial, tibial tubercle, and kept the bones connected in those points with strong magnets. With these magnet connections, we could rotate de bone ends and adjust them in anyway we need. Conclusions: This model allowed us to reproduce our patients' real deformities and evaluate the best way to correct them. The use of reconstruction models can give the surgeon a new perspective over the patient's deformities and allow a better understanding of the variables that are specific to every patient. Acknowledgements: No disclosures.


  PP 84: Patient Comfort And Satisfaction In Limb Lengthening And Reconstruction Surgery – External Vs Internal Fixation Top


Minoo Keki Patel

Centre for Limb Reconstruction, Melbourne, Australia

Background: Whilst external fixation has been extensively studies, not much has been written about psychological effect of external fixation. Since the introduction of better internal fixation implants, mainly motorised intramedullary nails and locking plates, our use of external fixation has a definitive treatment modality has decreased. We monitored patient comfort levels using the SF-12 score, PROMs and complications. Methods: Over 5-year period 56 consecutive patients were evaluated. 18 had external fixation with or without internal fixation. 38 patients had internal fixation. In 12 of these external fixation was used as a correction tool intra-operatively, but the fixator was removed at the end of the surgery. Results: All patients with external fixation reported problems managing their external fixator. All would have preferred to have internal fixation, if it was a safe and viable alternative. The ability to bear weight on their external fixators, versus non-weight bearing with internal fixation, did not constitute a good enough reason for the patients to have an external fixator. Patients did not mind the external fixator if no other safe alternative was available. Conclusions: Patients tolerate external fixation, but prefer internal fixation, if available as a safer alternative. Safe internal fixation alternative should be offered to patients when available. Acknowledgements: nil


  PP 85: Comparative Evaluation Of Free Play In Hexapod Circular External Fixation Frames Using Mathematical Modeling. Top


Petr Vvedenskiy1, Konstantin Mikheev1, Mikhail Samchukov2, Alexander Cherkashin2

1. New Orthopaedic Instruments LLC, Nizhny Novgorod, Russia

2. Texas Scottish Rite Hospital For Children, Dallas, United States

Background: The stability of bone segment fixation within the external fixation device is one of the important parameters influencing the activity of distraction osteogenesis. It is well known that all existing hexapod external fixators have a certain degree of free play between the external supports due to numerous hinge connections in their struts. The purpose of this study was to investigate how does the free play between the rings of hexapod fixators 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 to recreate 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). The ring sizes and their relative location (angle and separation distance) as well as all other necessary deformity and mounting parameters were entered into the program to simulate a specific device configuration. Beside this the experimentally measured individual struts axial free play parameters were utilized. Based on the data entered, the program calculated the total amount of rings free play along the axis of the frame. Alongside with theoretical calculations the real measurements of axial free play in equivalent frame models were performed in experiment. Results: The obtained data revealed that he axial free play values increased in respond to decrease of the distance between 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 2 to 4 times less than those for other hexapods. Obtained theoretical free play values correlates with the experimentally received data in the similar frame configurations. Conclusions: 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. Acknowledgements: Alexander Cherkashin and Mikhail Samchukov are consultants for Orthofix. All authors receive royalty from Orthofix.


  PP 86: Trajectory Analysis Of Bone Segments Movement In Hexapod Circular External Fixation Frames Using Mathematical Modeling Top


Petr Vvedenskiy1, Konstantin Mikheev1, Mikhail Samchukov2, Alexander Cherkashin2

1. New Orthopaedic Instruments LLC, Nizhny Novgorod, Russia

2. Texas Scottish Rite Hospital For Children, Dallas, United States

Background: Two different approaches were revealed in the prescribing of daily adjustment in two hexapod frames. TSF and TL-Hex. In the TSF prescription, the overall strut length adjustment (total number of clicks) is equally divided throughout the duration of deformity correction. TL-Hex prescription is different and producing daily amount of strut adjustment without such averaging. The purpose of this investigation was to analyze the trajectory of bone segments movement using those 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 bone fragments movements in two commercially available hexapod frames. TSF (Smith & Nephew Orthopaedics, Memphis, TN) and TL-Hex (Orthofix, Verona, Italy). Also, the close-up photography of bone fragments movement in those two frames while deformity correction in experiment were performed to confirm theoretic calculations. Results: Using those two approaches of prescription scheduling, the trajectories of bone segments movement were calculated for different deformities correction. The analysis of trajectories modeled using the TL-Hex prescription algorithm revealed that bone segments are always moving with minimal deviations (less than 1.5 mm) from the straight line with minimal differences in movement per each increment. All the trajectories of bone segments movement modeled using the TSF prescription approach were curvilineal with significant deviations (up to 15 mm) from the straight line. The experimental data of bone fragments trajectories in deformity correction in models correlates the theoretical calculations. Conclusions: Prescription algorithm of the TL-Hex hexapod frame is more optimal for bone segments movement than that for the TSF. The TSF approach with the same amount of daily adjustment for the same strut is less confusing and more convenient for the patient. But the implementation of the algorithm used in the TL-Hex software allows moving the bone segments during deformity correction and limb lengthening within the trajectory nearly close to the straight line at a predetermined movement speed. The prescription approach utilized in TL-Hex software is more preferable from the biological point of view in order to achieve active osteogenesis. Acknowledgements: Alexander Cherkashin and Mikhail Samchukov are consultants for Orthofix. All authors receive royalty from Orthofix.


  PP 87; Osteointegration of customized implants in tubular bone in Ilizarov external fixation (experimental study) Top


Artem Vladimirovich Reznik, Elena Nikolayevna Gorbach, Andrey Alexandrovich Emanov, Viktor Pavlovich Kuznetsov, Alexander Vadimovich Gubin, Dmitry Yuryevich Borzunov

Federal State Budgetary Institution “Russian Ilizarov Scientific Center, Kurgan, Russia

Background: New technology of osteointegration using customized implants manufactured by the method of additive technologies was developed. One of the essential problems of osteointegration is provision of stability of the implant in the medullary canal in the first post-operative period. We proposed to use an external fixator in order to solve this problem. The purpose of the study is to evaluate primary signs of osteointegration of customized implants made of heat-bonded powder Ti6Al4V in Ilizarov external fixation in experimental study in rabbits. Methods: We operated 6 chinchilla rabbits at the age of 6-8 months with the weight 3.12±35.3g. Based on the computer 3D model of the tibial stump by the method of laser melting we made a customized implant. All the animals under general anesthesia underwent amputation of the tibia in the upper part and the implant was installed. Then abutment was attached to the implant; the biomechanical system “bone – abutment” was fixed with the Ilizarov external fixator. Permission of the Ethics Committee for conducting the experimental study was received. We used clinical, radiographic and morphological methods of study. Results: Clinical condition of the rabbits was satisfactory during the experiment. Support function of the limb, as a rule, recovered on the 4-5th day after surgery and was present throughout the experiment. By the 21st day after implantation the signs of osteoporosis of the compact plate were moderate in the distal and insignificant – in the middle part of the “bone – implant” interface. The study of adhered on the surface of implanted device tissue substrate showed presence on the surface and around the implanted device new bone tissue, which was a part of a unified implantation-tissue block. Conclusions: Received experimental data proves primary stability of the implant. We continue studying further processes of mineralization and bone tissue remodeling in order to receive long-term data. Acknowledgements: We have no conflict of interest.


  PP 88: A new method for the long bone fracture spatial reduction based on computer assisted 3D reconstruction and Stewart platform calculation Top


Yan Shi Liu1, Si Da Liu2, Xin Long Ma1, Wei Sheng Ye1, Zhen Hui Sun1, Tao Zhang1

1. Department of trauma, Tian Jin Hospital, Tian Jin, China

2. School of mechanical engineering, Tian Jin University, Tian Jin, China

Background: The Taylor spatial frame is extensively applied for the limb deformity and communicated fractures clinically, which can correct the multiplanar rotation, angulation, and translation deformity in an unlimited degree in theory. However, there are some inherent limitations for Taylor frame due to its design and its adjustment depends on 2D X-ray. So, it is useful to put forward a new algorithm to overcome the limitations of Taylor frame above. Methods: We retrospectively reviewed 16 patients (12 males and 4 females) with fresh or delayed fractures and displacement, average age of 41 years (range 14 to 76 years), deformities of open tibial fracture who underwent a Stewart platform for the guidance of reduction from Feb 2016 to Aug 2016. Then we got the whole postoperative tibial CT data of all the patients and generated the 3d reconstruction model by Mimics. Next, we registered the ring of Stewart platform of 3d reconstruction model used the precise ring, and merged the precise ring with the 3d model of bone segment to implemented synchronous virtual restoration and recorded the key points of multiple movement. With the aid of Solidworks, we extracted the relative position of distal ring and proximal ring of the Stewart platform. And then used Matlab to kinematics solution, computing the targeted length of every branched chain in the movement, so we obtained the accurate adjustment scheme. Lastly, standard anteroposterior and lateral X-ray of the injured limb after adjustment were evaluated for the residual deformity. Results: Fracture deformity of displacement and angulation of all patients corrected well. After reduction, the mean residual deformity of displacement was 1.3mm (range 0 to 2.8mm) and 0.8mm (range 0 to 3.1mm) on the anteroposterior and lateral X-ray. The mean residual deformity of angulation was 0.9° (range 0°to 2.5°) and 0.6° (range 0°to 2.9°) on the anteroposterior and lateral radiograph. The function of the entire injured limb recovered well. Conclusions: In this paper, the method based on 3d reconstruction and Stewart platform to reduce the deformity of long bone fracture has high reset accuracy. It can compensate to the remaining adjustment deviation of the mainstream external skeletal fixation. At the same time, it provides a certain reference for intraoperative automation restoration technology. Acknowledgements: All the authors do not have any possible conflicts of interest.


  PP 89: Corrective Osteotomy Of The Distal Femur With External Fixator Assistance - A Novel Technique Of Minimally Invasive Osteosynthesis Top


Chang-Wug Oh, Kyeong-Hyun Park, Joon-Woo Kim

Kyungpook National University Hospital, Daegu, South Korea

Background: Varus or valgus deformity of the distal femur may progress into knee osteoarthritis. To delay or prevent this, various types of corrective osteotomy techniques have been used to shift the mechanical axis from the diseased compartment to the healthy one. We introduced a new, minimally invasive osteotomy of the distal femur with the assistance of temporary external fixation. Methods: We retrospectively studied 25 legs that underwent open-wedge osteotomy of the distal femur, involving insertion of a Schanz pin at the medial femoral condyle and another pin at the distal diaphysis of the femur. At the meta-diaphyseal junction, osteotomy was performed. After achieving angular correction, two pins were locked for temporary external fixation and a locking plate was fixed at the lateral side of the femur submuscularly. Radiological and functional outcomes were evaluated, including mechanical lateral distal femoral angle (m-LDFA), mechanical axis deviation, tibiofemoral angle, osseous union, and knee joint motion. Results: The minimum follow-up was 12 months (mean, 39 months; range, 12-88 months). Bone healing occurred in all legs, with an average of 16.6 weeks. The mLDFA was corrected from 77.7° (18 valgus) and 104.6° (7 varus) to 88.1° after surgery, with an average correction of 12.9°. At the final follow-up, the mechanical axis deviation averaged 7.6 mm and the tibia-femoral angle averaged 5.6°. Most of legs (88%) achieved acceptable m-LDFA (87° ± 3°). Conclusions: A new, minimally invasive osteotomy of the distal femur offers excellent bone healing with few complications, attributable to preserved blood supply. Acknowledgements: No conflict of interest.


  PP 90: Method For Planning Sagittal Plane Midfoot/Hindfoot Deformity Using: New Reference Lines And Angles Top


Leonid N. Solomin1, Konstantin A. Ukhanov2, John E. Herzenberg3

1. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, St. Petersburg, Russia

2. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia

3. Sinai Hospital, International Center for Limb Lengthening, Baltimore, United States

Background: The goal is to describe a new method of analysis / planning for midfoot / hindfoot sagittal plane deformities. Methods: We analyzed 65 standing lateral foot films in normal adults, 23-43 y.o. For the midfoot, we drew a talar joint line (TJL) (Line 1), from the back (a) to the front (b), and a 1st metatarsal line (Line 2). These lines intersect posteriorly at point (a), at a certain angle. Point (c) is where the Line 2 exits the metatarsal head. We measured lines ab and ac, and their ratio ac/ab. For the hindfoot, we drew the same Line 1 and drew a Line 2, the calcaneal line, which starts at the back of the calcaneal tuberosity (d), drawn perpendicular to a line from top to bottom of the calcaneal tuberosity. The intersection of the calcaneal line and the TJL form point (c) anteriorly. We measured lines ab, ac and cd, and their ratios. ac/ab and cd/ab. Results: Midfoot. Line 1 and Line 2 intersect at (a), at an angle 23.6° (+/-3.2°); ac/ab=4.17 (+/-0.19). The distance ac can be calculated by the formula ab×4.17. For deformity cases, draw Line 1, ab. Next, from point (a), draw an idealized Line 2 measuring 23.6° relative to Line 1. The length of Line 2, is abx4.17, defining (c'). Next, draw the deformed 1st metatarsal axis (Line 3) and point (c) where it exits the metatarsal head. The intersection of Lines 2 and 3 is the apex ofthe deformity. Rotate Line 3 piece around this apex, until it is collinear with Line 2, and (c) coincides with('). Hindfoot. TJL (Line 1) and calcaneal line (Line 2) intersect at a point (c), forming an angle 15.2° (+/-3.4°). ac/ab=2.56 (+/-1.1), cd/ab=4.59 (+/-1.0). These ratios are constants for calculating the idealized joint lines for deformity planning. For deformity cases, draw Line 1, ab. Extend that line anteriorly to (c), which is a distance abx2.56 from point (a). From (c), draw an idealized calcaneal line, Line 2, at an angle 15° to Line 1. Place (d) on this line, at a distance abx4.59 from point (c). Next, draw the deformed calcaneal line (Line 3) and point (d') where it exits the calcaneal tuberosity. Use the same technique as for drawing the normal calcaneal line. The intersection of Lines 2 and 3 is the apex of the deformity. Rotate the piece containing Line 3 around this apex, until it is collinear with Line 2, and (d) is coincident with (d'). Conclusions: This normative data can be used for isolated hindfoot, midfoot or combined deformities. It is independent of ankle joint equinus or malpositioned ankle arthrodesis. Acknowledgements: to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University and Sinai Hospital


  PP 91: Treatment outcomes of limb deformity correction using the Ortho Suv Frame: Initial Philippine experience Top


Juanito Sanqui Javier1, Daniel V Dungca2, Ruel A Dela Cruz1

1. Department of Orthopaedics, College of Medicine, University of the Philippines Manila, Manila, Philippines

2. Department of Orthopaedics, Jose Reyes Memorial Medical Center, Manila, Philippines

Background: Complex multiplanar limb deformity correction is a challenge when using the Ilizarov External Fixator. The Ortho-SUV Frame, a six axes external fixator, provides a computer-assisted method in correcting multiple limb deformities. This study aims to evaluate the outcomes of limb deformities corrected using the Ortho SUV frame in the first series of patients in the Philippines. Methods: This is a retrospective study. Patient chart and radiograph reviews were done on patients with completed treatment for deformity correction using the Ortho SUV frame. Patient's demographics, manner or mechanism of how the deformity developed, involved extremity, the details of the correction using the Ortho SUV (total number of days for correction, number of revisions, and if the deformity was corrected), complications, and final outcomes were obtained. Results: Thirty limbs in 29 patients were included in the study. Twenty-nine involved a long bone (18 femurs, 10 tibiae and 1 humerus) and one the knee joint. Eleven were classified as simple deformities, 17 medium deformities and 2 complex deformities. In 90% of cases (27 of 30), the deformities were corrected based on the turning schedule provided by the Ortho SUV application. An incomplete correction in 2 cases was due to soft tissue interposition and another case had a posterior translation. These problems were resolved by simple corrective surgery. In the course of treatment, the turning schedule was recomputed in 13 out of 29 cases (44.83%). Eventually, all deformities were corrected as measured clinically and radiographically. Conclusions: The Ortho SUV frame is an efficient means in correcting limb deformities in different clinical situations. Acknowledgements: The authors have no affiliations with or involvement in any organization or entity with any financial interest or other equity interest, or non-financial interest in the subject matter discussed in this study.


  PP 92: Proximal tibial osteotomy and gradual correction with hexapod for treatment of OA knee with severe varus deformity Top


Subrata Basu

Orthopaedic Hospital, Howrah, India

Background: To study the advantages of closed ostetomy and gradual correction with hexapod over open osteotomy and plate fixation for treatment of OA knee with varus angle > 15 degree . Methods: Within the year 2013 to 2016, 15 patients of OA knee with medial compartment involvement, average age 54.8 years were treated by Proximal tibial osteotomy using Hexapod and gradual correction. In all patients MPTA and MAD were measured from standing X-ray. MA drawn through the Fujisawa point and the desired MPTA and varus angle correction were calculated. Proximal tibia fixed with two Ilizarov rings and hexapod struts and closed osteotomy performed. The software was programmed using the desired MPTA value and gradual correction achieved as per software schedule. Knee bending and weight bearing started from immediate postoperative period. The correction checked with final standing X-ray and if required 2nd program applied for residual correction. Frame removed after consolidation of osteotomy. Results: The average MPTA and MAD before surgery were 73.6 degree and 3.58cm medial which turned into 95 degree and 1.3 cm lateral after surgery. The average varus angle of 15 degrees converted to 5-degree valgus. No change of PPTA hence posterior slope remain unchanged. Mean deformity correction time was 15 days and mean fixator time was 93 days. 11 patients regained 120 degrees of flexion within 2 wks of frame removal. In comparison during open surgery and plate fixation with varus deformity > 15 degree alignment of MA to Fujisawa point is difficult as lateral translation is not possible. Forceful separation of osteotmy may lead to undesirable separation of lateral cortex and alteration of posterior slope. Subsequently there remain chances of nonunion at osteotomy site. Whereas hexapod and gradual correction has the advantage of modification if further correction is required. Conclusions: Due to the capability of simultaneous angular and translational deformity correction, for treatment of OA knee with severe varus accurate lateralization of MA to Fujisawa point is possible with hexapod than open osteotomy and plate fixation. Moreover gradual correction helps in better osteogenesis. Acknowledgements: HTO with TSF frame for OA knee (canJ surg. Vol-49 no-4 Aug 2006) Darius G. Viskontas, Mark D.


  PP 93: Treatment Of Infected Post-Traumatic Intramedullary Nailing With Exchange To A Intramedullary Nail With A PMMA Core Releasing Antibiotics (SAFE Nail) Top


Nuno Craveiro-Lopes

Red Cross Hospital, Lisbon, Portugal

Background: Infections after intramedullary nailing is a cause of recalcitrant osteomyelities. Enhancement of local antibiotic concentrations through different delivery systems has been developed as an effective solution for eliminating musculoskeletal infections. Antibioticcoated interlocking nails are usually thin and the cement around such nails is prone to decoupling and jamming during insertion and extraction. Our study was conducted to evaluate a nail containing the antibiotic-loaded cement inside it, in the management of infected intramedullary nailing after open fractures of the tibia. Methods: In the present study, were enrolled ten patients with osteomyelities following intramedullary nailing and treated with a SAFE nail. It included 2 cases of infected Grosse nails, 4 cases of T2 nails, 2 Expert nails, one Protect nail and one case of a SAFE nail. MSSA, methicillinresistant staphylococcus aureus, Streptococcus, Serratia, Enterobacter, MSSA+Klebsiella and Enteroccocus + Proteus, were identified as causative agents. All the patients were operated with reaming debridement, copious intramedullary lavage and insertion of a SAFE nail with appropriate antibiotics mixed in PMMA cement that was injected inside the nail and systemic antibiotic administration. The antibiotics were guided by AST and included gentamicin in one case, Meropeneme in one, a combination of Vancomycin with Meropeneme in four cases, Vancomycin with flucloxacilin in three cases and Vancomycin and Tazobactan in one. Results: The average follow-up duration was 29 months All the cases were cured in a mean time of 6 months. The case nailed initially in another hospital with a Protect nail, covered with a thin polylactic acid film with gentamicin, was colonized with MSSA and Klebsiella and infection relapsed. After being treated with a SAFE nail with Vancomycin and Tazobactan had consolidated and cured the infection. The patient that was initially nailed with a SAFE nail with Vancomycin was colonized with a Streptococcus Viridans and a infection with fistulae appeared. This patient was operated again using a SAFE nail with flucloxacilin and cured uneventfully. None of the 10 patients showed a relapse of infections and all of them achieved solid bony union at the last follow up. Conclusions: SAFE DualCore Universal Nail with appropriate antibiotics, combined with adequate debridement, lavage, and systemic antibiotic administration, significantly contribute to infection control after intramedullary nailing. Acknowledgements: There are no conflict of interests to report


  PP 94: Successful Treatments With Iodine-Coated Titanium Implants For Patients With Postoperative Infections. Top


Toshiharu Shirai1, Hiroyuki Tsuchiya2, Ryu Tetauchi1, Shinji Tsuchida1, Toshikazu Kubo1

1. Department of Orthopaedics, Kyoto Prefectural University of Medicine, Kyoto, Japan

2. Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Japan

Background: Postoperative infection is one of the most serious complications in orthopaedic surgery. We use iodine-coated implants, which we have developed, to prevent and treat postoperative infection in compromised host. In this study, we evaluate the outcome of iodine-coated implants for postoperative infections. Methods: We have treated 72 patients with postoperative infection. The mean age of the patients was 59.3 years (15 to 83). Thirty-eight patients were male and 34 were female. The mean follow-up period was 152.6 months (11 to 251). The diagnoses included 20 cases of infected THA, infected TKA in 23, infection after tumor excision, and 11 cases each of infected non-union and infected spine instruments. White blood cell (WBC) and C-reactive protein (CRP) were measured pre- and post-operatively. To confirm systemic effects of iodine, thyroid hormone levels in the blood were examined. Radiological evaluations were performed regularly. Basically, if there were active infections, we performed staged-surgery. The survival of iodine-coated implants was determined by Kaplan-Meier analysis. Results: There were 37 patients who underwent one-stage surgery and 35 patients staged revision surgery. Five patients (one-stage 4, staged 1) underwent re-revision surgery. In the five patients, one case underwent two revisions due to implant failure with non-union of recycled bone and one had loosening of stem of endoprosthesis at 24 months. Both were recovered by re-implantation. In three patients (tumor prostheses), periprosthetic infection recurred at an average of 18 months after surgery. Reinfection rate was 4.2%. They were recovered by re-implanting iodine-coated prostheses. Amputation wasn't required for any patients. The survival rate of iodine-coated implants was 91%. In all cases except for one that died of disease, there were no signs of infection at the latest follow up. The median of WBC levels was almost normal range and CRP levels were returned to normal within four weeks after surgery. Conclusions: Iodine-coated titanium implants can be very effective and promising in the treatment of postoperative infections. Acknowledgements: The authors are grateful to Matsuhumi Takaya, Professor, PhD of Chiba institute of technology and Toru Shimizu, Professor, MD, PhD of Kanazawa university for their kind cooperation.


  PP 95: Management Of Infantile Blount'S Disease With: Molded Orthoses: A New Perspective Top


Luiz Renato Agrizzi De Angeli1, Maria Cândida De Miranda Luzo2, Nei Botter Montenegro3, Bruno Sérgio Ferreira Massa4, Felippi Guizardi Cordeiro1, Roberto Guarniero2

1. Universidade de São Paulo, São Paulo, Brazil

2. Faculdade de Medicina, São Paulo, Brazil

3. Hospital das Clínicas, São Paulo, Brazil

4. Instituto de Ortopedia e Traumatologia, São Paulo, Brazil

Background: Abstract Text. Objective. This retrospective study evaluated treatment with individually. contoured molded bracing at early stages of the disease. Methods: We evaluated the medical records of patients undergoing treatment of Blount's disease with molded orthoses for medial decompression between 2010 and 2014. The deformity angle (Drennan's metaphyseal-diaphyseal angle) and Langenskiöld classification were measured before and after treatment by a pediatric orthopedic surgeon with over 5 years of practice, blinded for the study and patients. Results: The mean age was 2.57 years old. Four patients were female and six males. Half of the total sample had bilateral disease. The average deformity angle showed a statistically significant reduction after treatment (p <0.001). Gender and laterality did not statistically influence the change of the deformity angle after treatment (p> 0.05). Conclusion: The nightly use of molded orthoses for medial decompression was effective in reducing the metaphyseal-diaphyseal angle in Blount's disease in children under 3 years of age, regardless of gender and bilateral disease. Patients over 3 years old did not benefit from bracing. Level of Evidence IV, Case Series. Keywords. Genu varum. Orthotic devices. Therapeutics. Braces. Acknowledgements: .


  PP 96: Correction Of Foot Deformities Using Mini External Fixation Device Salamehfix2 Top


Ghassan Salameh1, Michael Schmidt2

1. Salamehfix Limb Lengthening & Reconstruction Center, Tartous, Syria

2. Waldhof Center, Frankfurt, Germany

Background: Correction complex foot deformities need special external fixators which can correct foot deformity in multiplaner directions. In severe cases, the best choice external hinge distraction system to restore function of joints and treat shortening of foot, and correct deformity. Patients prefer stable, small mini external fixators, more comfortable for patient but also which have hinges and can correct deformity. Methods: A small three arc system with hinges \ Salamehfix2, SLDF2 \ allows three dimension corrections of all parts of foot using hinges in deferent levels in order to correct deferent deformities and allows stable fixation and high tolerance, walking ability in most cases much better, enable the patient to walk without any aid accepts orthopedic shoes, Satisfaction rate of all patients was very good; some of the patients were able to walk first time due to correction. Average time correction is 4 to 6 week's followings by 2-3 months of fixation to keep final correction. Results: From 1993 to 2016 we treated 256 cases of severe foot deformities with congenital clubfoot, neuromuscular deformities and posttraumatic deformities age between 3 to 45 years, 123 cases excellent results 83 good, 46 fair and 3 bad results, complications were mostly superficial Pin infection, loosening of wires, no nerve or vascular damage and no thrombosis was seen. In all cases a plantigrade foot was achieved with stiffness of the joints in neuromuscular diseases. Conclusions: The use of external fixation is an ideal treatment in complex congenital or posttraumatic foot deformities to achieve a good correction and good functional and cosmetic result for the patient and Salamefix 2 is small functional and confortable device. Acknowledgements: The external fixation system Salamehfix2 for foot deformity correction is a small hinged suitable tolerable fixator and can correct all foot deformity in addition to lengthen foot elements.


  PP 97: Three-Dimensional Printing As A Technology Supporting The Treatment Of Lower Limb Deformation And Shortening With The Ilizarov Method Top


Piotr Jacek Morasiewicz1, Karolina Burzynska2, Wiktor Orzechowski1, Szymon Lukasz Dragan1, Szymon Feliks Dragan1, Jaroslaw Filipiak2

1. Wroclaw Medical University, Wroclaw, Poland

2. Wroclaw University of Technology, Wroclaw, Poland

Background: Treatment of multiplanar deformations, especially in younger children, requires construction of a complex Ilizarov fixator, frequently with small dimensions. The aim of this study is to verify clinical application of 3D-printed bone model in treatment with the Ilizarov method. Methods: The study included a 6-year-old child in whom clinical and radiological examination revealed multiplanar deformity of the right leg. Then, 3D models of individual bones were printed by means of additive manufacturing and used as a scaffold to install the Ilizarov apparatus. To compare assumed and factual axial correction and lengthening, we measured spatial orientation of bone fragments four times. Factual axial correction and lengthening were determined with a photometric technique. Results: The values of factual lengthening and axial correction are lower than assumed values of these parameters. After construction of the Ilizarov apparatus, corticotomy was carried out at the proximal metaphysis of right tibia, along with osteotomy of the right talus. Conclusions: Planning treatment with the Ilizarov method, orthopedists should consider differences between assumed and factual lengthening and axial correction.3D printing is a useful technology that can be used to support treatment with the Ilizarov method. Acknowledgements: There was no Conflict of Interest for all authors. Sources of founding. internal university grant. STM.C080.16.009


  Other subjects Top



  PP 98: External Articular Fixation Of The Elbow Top


Paulo Sérgio Contador Miras

Hospital Municipal Dr Mario Gatti, Campinas, Brazil

Background: n/a. Methods: We describe in this work, after a series of 26 cases of distal humerus fractures with internal synthesis and 75% of good results by Jupter's evaluation, 12 cases We used external joint fixation techniques to complement the surgical techniques of internal osteosynthesis allowing early movements, with complementary use of external fixation, raising the indexes of good results to 90% with the support of this technique, including in cases of stiffness in which we use interposition arthroplasty and arthrodiastasis. Results: We obtained an increase in the good results with elevation to 90% indices and greater treatment options, with joint fixation and interposition arthroplasty. Conclusions: We conclude that it is an effective method for the most serious cases and a resource to be thought in the face of sequels and rigidity. Acknowledgements: There is not conflict of interests.


  PP 99: Avoiding complications in reconstructive surgery using mono lateral external fixation in children's practice Top


Dalia Arriagada Sepulveda, Juan Carlos Bueno Hernandez

COTI, Santiago, Chile

Background: Abstract Text. monolateral ex fix have a bad reputation mainly because new users do not follow basic principles as they built frames; the purpose is to show frequent mistakes using mono lateral ex fix; also, to show the audience the way to get around possible complications based on instability of the apparatus. this talk points out with clinical examples basic principles applications with external mono lateral fixators with good results in trauma and orthopadic conditions. Methods: .Results: Conclusions: Acknowledgements: .


  PP 100: Depression In Patients Undergo Limb Lengthening & Reconstruction Surgery With Ring External Fixator Top


Yeok Pin Chua1, Ong Hui Koh2, Aik Saw2

1. Sunway University/ Sunway Medical Centre, Selangor, Malaysia

2. university malaya, Kuala Lumpur, Malaysia

Background: The Ilizarov method of external fixation for correction of limb deformities has been widely used for both traumatic as well as congenital deformities. While it is effective and useful, the treatment process is complex with a lengthy duration of treatment. As such, there are concerns that patients who are on this modality of treatment may suffer emotional and mood disturbances, including depression. The aims of the study are to determine the proportion of adult Ilizarov patients attending the LLRS clinic who have depression, to assess the severity of the depressive symptoms in these patients, and to assess other sociodemographic and clinical parameters in this group of patients. Methods: Cross-sectional study conducted from August 2012 until April 2014. Sociodemographic data (age, gender, race, marital status, employment, carer support, education level) and clinical data (duration of treatment, symptoms of depression, presence of complications) were collected once a week. Instruments used for depression in this study were the Mini International Neuropsychiatric Interview (M.I.N.I.) and Montgomery-Asberg Depression Rating Scale (MADRS). Results: A total of 106 Ilizarov patients aged above 18 years were interviewed in this study. The mean age of the study subjects was 36.4 years (SD=15.4), with 78 male and 28 female patients. 48 (45.3%) of the patients were found to be depressed, out of which 32 (30.2%) had mild depression while 16 (15.1%) had moderate depression as measured by MADRS scores. Of all the parameters measured, only gender, employment status and presence of complication had significant correlation with depression in this group of patients with a p value of < 0.05. Conclusions: 45.3% of adult Ilizarov patients attending the LLRS clinic were found to have depression, of mild and moderate severity. Gender, employment status and presence of complication were found to be significantly correlated with depression in this group of patients. The findings show a significant number of adult patients on Ilizarov treatment to be depressed and the importance of identifying clinical depression in this group of patients so that intervention can be initiated to improve clinical outcomes. This also supports the setting up of on-site psychiatric services at the LLRS clinic so that orthopaedic clinicians and mental health professionals can work closely together to better help these patients in their treatment and recovery process. Acknowledgements: no conflict of interest


  PP 101: Knee Arthrodesis Using Different Types Of External Fixators Applying In Serveral Indications In Orthopaedic And Traumatology Top


Carlos Luiz Engelen1, Hilário Boatto2, Osvaldo Clinco2, Alexandre Dias Real2, Toshi Robson Toshimitsu2, Fábio Assunção E Silva2

1. UNIFESP - Escola Paulista de Medicina, Santo André, Brazil

2. UNIFESP - Escola Paulista de Medicina, São Paulo, Brazil

Background: Eighty patients whose functional failure of the knees were treated by Ilizarov's method using different types of external fixators to obtain knee arthrodesis was shown as a propose of standard treatment. All the patients had severe disability, pain and / or signs of active infection. Several etiologies were found, but TKA infected knee arthroplasty were the most frequent. Methods: The group was composed for 24 males (29,6%) and 57 females (70,4%), the average age was 69 years. Staphylococcus aureus Scientific Name Search  was the most frequent infectious agent in TKA in 49 patients (59%). The knee was approached through the previous scar. The removal of the prosthesis and the arthrodesis procedure were done in one step. Different external fixators are used (mono lateral, semicircular and circular external fixators). Results: In 79 patients (98,7%), fusion had been achieved and in 2 cases (2,5%), infection return. Average time treatment was 8,7 months and average time fusion was 7,5 months. All the patients were encouraged to walk as soon as possible, in the way to improve lower limbs better function and decrease muscle hypotrophy. Pain and local infection in pins and wires was observed in 52 patients (64,2%) and should be the most frequent complication during the use of the frame. After removing the frame, they didn't use braces. Conclusions: In fact, the results show a good alternative to knee arthrodesis especially in infected total knee arthroplasty. Acknowledgements: no disclosure


  PP 102: Biomechanical Comparison Of Hexapod Spatial Frames With Different Strut Models. A Biomechanical Study Top


Ali Bas1, Levent Eralp2, Mehmet Kocaoglu2, Ilker Eren1, Ergun Bozdag3, Emin Sunbuloglu3

1. Koc University Hospital Dept of Orthopaedics and Traumatology, Istanbul, Turkey

2. Istanbul University Istanbul Faculty of Medicine Dept of Orthopaedics and Traumatology, Istanbul, Turkey

3. Istanbul Technical University Faculty of Mechanical Engineering, Istanbul, Turkey

Background: The purpose of the study was the comparison of the biomechanical performances of four different strut models which are used in hexapod spatial frames with identical frame height. Methods: Four different hexapod spatial frame groups were composed of medium size four strut models in different joint and body forms which are named as dual joint strut, dual joint express strut, dual varijoint strut and dual varijoint express strut by Smart Correction Spatial Frame System. Uniform strut models were used in each group. For every frame 2 rings which had 180 mm diameter were used. 15 frames for each group were prepared. Polyethilene bone models in all groups were fixed with the same configurations using 1 K-wire and 2 Schanz pins at the proximal ring level and 3 Schanz pins at the distal ring level, then 30 mm unstable fracture model was created in the middle of PE rods. Mechanical performance of fixators was evaluated by 300 N axia loading, 10 N torsional and 300 N bending forces, consisting of 3 separate tests. The biomechanical performances of the groups were compared with stiffness values after the testes. Results: Spatial frames which were prepared with different strut models obtained no statistical difference between axial, torsion and bending stiffness. Conclusions: Different strut models as connection devices of the rings in the spatial external fixators which were prepared as same height and fixed the same configurations by using 180 mm diameters rings did not affect the biomechanical performance. Acknowledgements: Thanks to Meral Tuna and Buğra Bekler for their assistance in the biomechanical testing process at Istanbul Technical University Faculty of Mechanical Engineering


  PP 103: Functional Outcomes Of 90 Children With Arthrogryposis Multiplex Congenita: A Retrospective Chart Review Top


Reggie Hamdy, Noémi Dahan-Oliel, Caroline Elfassy, Kathleen Montpetit, Delphine Hansen

Shriners Hospitals for Children-Canada, Montreal, Canada

Background: Arthrogryposis multiplex congenita (AMC) refers to a large heterogeneous group of conditions involving joint contractures in two or more different areas of the body. Contractures can lead to decreased range of motion and strength, and may affect ambulation and autonomy. There is a current need in gaining a better understanding of the clinical and surgical management of children with AMC to offer evidence-based care and develop future research priorities. The aim of this retrospective chart review was to describe the functional outcomes of children with AMC who were followed at a pediatric orthopedic setting. Methods: A retrospective chart review of all children coded as having AMC followed at Shriners Hospital for Children – Canada between January 1979 and July 2016 were screened. Of these, 5 were excluded due to misdiagnosis and/or insufficient chart information, and 90 were retained. Patient demographic, type of AMC, comorbidity, operative and non-operative treatments as well as community ambulation status and level of autonomy in self-care and transfers were recorded. Results: There were 50 males and 40 females with a mean age at last clinic follow-up of 10 years 5 months. Amyoplasia was the most common type of AMC. Contractures of the LEs were most common in the ankles/feet and contractures of the UEs were most common in the wrists. In terms of walking ability, 43 were independent ambulators and among the 11 ambulators with aid, the most common mobility aid used was the manual wheelchair. Similarly, most children with AMC were independent in self-care and transfers. Conclusions: As AMC is a rare condition, the relatively large sample size of this chart review allowed for a better insight and understanding the challenges associated with AMC. Moving forward, multi-site prospective studies are required in the fields of genetics, treatment effectiveness and adult outcomes. These findings demonstrate the importance of genetic testing to provide accurate diagnosis and classification, researching and promoting the use of standardized functional measures in AMC, and the provision of care within a multidisciplinary context. Acknowledgements: The authors have no conflict of interest to disclose.


  PP 104: Fractures Around The Knee Treated With Ilizarov, Internal Fixation And Arthroscopic Surgery. Technical Note Top


Bernard Prakash Devadasan

Mawar Medical Centre, Seremban, Malaysia

Background: Fractures around the knee are difficult to treat because of the problems arising from anatomical reconstruction of the articular surfaces, metaphyseal to the diaphysis stabilization. Objective. Compare the results of different fixation techniques in distal femur fractures (AO/OTA 33) and proximal tibial fractures (AO/OTA 41) and arthroscopically aided surgery. Methods: 2010 to 2016, 98 patients with distal femur N42 and proximal tibial fractures N56 were analysed. CT is essential. MRI for concurrent soft tissue injuries. Arthroscopy assisted fixation N6 and second stage soft tissue reconstruction N15 for tibial plateau fractures. AO/OTA 41-C3, proximal tibial periarticular fractures with shaft dissociation was treated with Ilizarov fixation N35. AO/OTA 33-B3-1, Osteochondral fractures > 2 cm2 with full-thickness femoral articular cartilage defects require fixation with bioabsorbable pins, compression screws or osteochondral grafts and headless screw compression across the defect if < 2 cm2. AO/OTA 41, mainly lateral plateau or bicondylar. Lateral meniscus incarcerated in joint and step-off exceeding 3 mm in the articular surface, condylar widening 5 mm, or lateral tilt exceeding 5° require arthroscopy-assisted surgery (ASIF) or second stage with ACL rupture in open fracture. Results: Follow-up period 10 mths-1yr using modified Rasmussen clinical and radiologic criteria treated by open reduction and internal fixation or stabilization and reduction of fractures with Ilizarov fixation and arthroscopically assisted surgery. meniscus71%, anterior cruciate ligament (ACL) 25%, posterior cruciate ligament (PCL) 3%, LCL3%, MCL4%. Cruciate ligament disruption frequently occurs in Type IV /VI fractures. Conclusions: Ilizarov fixation indicated in comminuted open fractures with extensive soft tissue injury. Fractures around the knee should be treated by open reduction for anatomical reduction. ASIF enables precise, anatomic reduction of the articular knee surface with menisci and cartilage repair. Proximal tibia Schatzker or AO/OTA classification and three-column concept in treatment strategy. Type 33C3 should be sub classified as 33-C3-1 lateral condyle articular, 33-C3-2 medial condyle articular 33-C3-3 articular multi-fragmentary as it relates to techniques/implants that require interfragmentary compression. Acknowledgements: Professor Maurizio Catagni


  PP 105: A new “Classification of Ilizarov Procedures” - for young Ilizarov surgeons to learn, understand and use Top


Basir Towil1, Rohaman Tasarib2

1. Hospital Shah Alam, Shah Alam, Malaysia

2. Hospital Serdang, Kajang, Malaysia

Background: Introduction. Ilizarov Procedures are operation or procedures that using Ilizarov External Fixator (IEF). The indications and application of IEF has been expended over the past few decades and Ilizarov procedures is becoming more in variety. Some of them are more complex than the other. It is important to classify these procedures so that easier for the young surgeons to learn, understand and use them in their practice. Methods: Methods. The classification is based on relative complexity of the procedures, relative frequency and a simple arrangement alphabet. Results: Results. We classify Ilizarov Procedures into 6 categories. Acute Fracture Fixation (AFF). In this category, the IEF is used for fixation of fractures such as articular fractures, peri-articular fractures, segmental fractures and severe long comminution fractures. Bone Lengthening (BL). This category referring to lengthening of bone that is relatively short due to congenital or acquired causes. This category also includes lengthening of bone that is relatively normal (e.g. for cosmetic reasons). Bone Transport (BT). This category referring to moving a segment of bone in order to close a bone gap due to trauma, infection, pseudoarthrosis or tumor resection. This category includes bone transport single level, double levels (tandem or convergence), or bidirectional from a single level corticotomy in case of bone gap at levels (proximal and distal). Correction of Angulation (COA). This category referring to correction of malunion of bone especially the long bone. Correction of Deformity (COD). This category referring to correction of deformity at or around a joint or joints. e.g. CTEV, Equinus of the foot, chronic subluxation or dislocation of a joint. Others. This category includes the less procedures such as bone translation, rotational correction, joint fusion and vascular related condition (e.g. Buerger's Disease). Conclusions: Conclusions. This NEW “CLASSIFICATION OF ILIZAROV PROCEDURES” hopefully will simplify the various type of Ilizarov Procedures so that the young surgeons can learn, understand better and use them as a new “language of communication” in their practice. Acknowledgements: Acknowledgements. 1. The Ilizarov fixator in trauma. a 10-year experience. Pavolini B1, Maritato M, Turelli L, D'Arienzo M. J Orthop Sci. 2000;5(2):108-13. 2. R Rose. Acute Trauma Applications of the Ilizarov Method. The Internet Journal of Orthopedic Surgery. 2009 Volume 16 Number 1. 3. R Rose. Tibial Lengthening using the classic Ilizarov Technique. The Internet Journal of Orthopedic Surgery. 2009 Volume 16 Number 1. DOI. 10.5580/a7368. 4. Aktuglu K1, Günay H2, Alakbarov J3. Monofocal bone transport technique for bone defects greater than 5 cm in tibia. our experience in a case series of 24 patients. Injury. 2016 Dec;47 Suppl 6. S40-S46. doi. 10.1016/S0020-1383(16)30838-5. 5. Marsh DR1, Shah S, Elliott J, Kurdy N. The Ilizarov method in nonunion, malunion and infection of fractures. J Bone Joint Surg Br. 1997 Mar;79(2):273-9. 6. GRANT, ALFRED D. M.D.; ATAR, DAN M.D.; LEHMAN, WALLACE B. M.D. The Ilizarov Technique in Correction of Complex Foot Deformities. Clinical Orthopaedics & Related Research. July 1992. 7. Bruno AA1, Kirienko A2, Peccati A3, Dupplicato P4, De Donato M4, Arnaldi E4, Portinaro N3. Knee arthrodesis by the Ilizarov method in the treatment of total knee arthroplasty failure. Knee. 2017 Jan;24(1):91-99. doi. 10.1016/j.knee.2016.11.002. Epub 2016 Nov 18. 8. Patwa JJ, Krishnan A. Buerger's Disease (Thromboangiitis Obliterans)- Management by Ilizarov's Technique of Horizontal Distraction. A Retrospective Study of 60 Cases. Indian J Surg. 2011 Jan;73(1):40-7. doi. 10.1007/s12262-010-0186-1. Epub 2010 Dec 14.


  PP 106: Lengthening over nail in bone dysplasias Top


Julio De Pablos, Lucas Arbeloa, Antonio Arenas Miquelez

Hospital San Juan de Dios, Pamplona, Spain

Background: Massive Bone Lengthening in Bone Dysplasia is usually achieved with Conventional Legthening Systems using External Fixation only. We show our results in a series of patients with Bone Dysplasias (BD), in whom lengthening over Nail (LON) was used to improve their stature. Methods: LON was used in 7 patients (14 segments) with Pathological Short Stature due lo Achondroplasia (5), Hypochondroplasia and Lery-Weill Syndrome. Mean age at surgery was 14,1 years and mean follow-up was 26 months. Results: The total lengthening achieved ranged from 4 to 12 cm depending on the segment and the goals previously agreed with the patient, which were achieved in every case. As a major complication, we identified a case of knee subluxation, after femoral LON, which was partially solved with physiotherapy. The mean ExFix Index (EFI. months of ExFix per lengthened centimeter) was of 0.37. This is 30% of the EFI observed in conventional lengthenings. Conclusions: The main advantages of LON in BD include. 2/3 reduction of EFI as compared with the conventional techniques and, as a consequence, less risk of infection and joint stiffness and less discomfort for the patient. Moreover, it minimizes the risk of deformities and re-fractures as the IM nail acts as a tutor during and after distraction. Drawbacks are. higher technical complexity, the necessity of one more surgery, the risk of articular damage in some cases, and less versatility in managing angular deformities. We think, LON should be taken into consideration in BD as it has important advantages over other more conventional techniques, the main one being the drastic reduction of the EFI with the former. Acknowledgements: No acknowledgements included


  PP 107: Specifics Of Work Organization Of An Orthopaedic Center Specialized In Limb Lengthening And Reconstruction Surgery Top


Alexander Vadimovich Gubin, Elena Anatolievna Voronovich, Dmitry Yurievich Borzunov, Yury Alekseevich Gorokhov

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: 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. Methods: 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. Conclusions: 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. Acknowledgements: there is no conflict of interests


  PP 108: Preliminary Results In The Application Of A Standardized Protocol For Patients Undergoing Limb Lengthening Top


Monica Paschoal Nogueira, Alessandro Monterroso Felix

HSPE - State Hospital of São Paulo, São Paulo, Brazil

Background: Introduction/Background. Limb lengthening is a complex procedure that requires accurate surgical techniques, but also a careful follow up. Quality of regenerate, rate of correction, alignment, and presence of infection, or contractures are all important and sometimes not all always evaluated in every visit. Patient status concerning quality of sleep, appetite, pain and irritability are most often left behind or forgotten as less important variables, but this management is essential to provide a good result and comfort of patients undergoing lengthening. Like a flight checkup, this proposed protocol is an instrument to provide best follow up and management of any lengthening procedure, and also is able to provide tools for research in limb lengthening. Methods: Methods. A cohort of patients undergoing limb lengthening is followed with application of a protocol with the following variables. identification and contact of patients, aim of lengthening or deformity correction, type of fixator used, evaluation of sleep, appetite and irritability, evaluation of pain, presence of infection and use of antibiotics, alignment, rate of lengthening/deformity correction, quality of regenerate, lengthening obtained, changes in the fixator, physical therapy status, presence of contractures, and other problems. At each clinical visit, the physician fills in each component of protocol. Results: Results. Seventeen limb lengthening procedures in 12 patients had application of this standardized protocol since 2014, and those were analysed, concerning the described variables. Some constant behavior is observed in the patient related variables (sleep, irritability and appetite) at the first 3 weeks, and then those variables improve. Pin tract infection is more often seen after 6 weeks of treatment and correlated with pain and more movement in physical therapy. Quality of regenerate can be related and better controlled with this detailed observation at each visit, and can modulate rate of lengthening for each specific condition, and age. It has been easier to avoid and prevent contractures, and is a good instrument to share with the rehabilitation team. Conclusions: Conclusions. This standardized protocol is an efficient tool to improve the follow up and quality of limb lengthening. It can better describe the limb lengthening procedure in every aspect, and can help to improve quality, optimize timing and avoid usual complications and problems of limb lengthening. Acknowledgements: No disclosures


  PP 109: Ankle Distraction Arthroplasty For End-Stage Ankle Arthritis: A Survival Analysis Of Various Clinical Factors Top


S Robert Rozbruch, Stephen Greenfield, Austin T Fragomen

Hospital for Special Surgery, New York, United States

Background: The treatment algorithm for end-stage ankle arthritis is not clear. Young or active patients present great challenges as they are at risk for revision after ankle replacement or progressive midfoot arthritis after fusion. We wished to determine the effectiveness of ankle distraction as a joint preserving approach. We define effectiveness by its ability to postpone the need for fusion, replacement, or repeat distraction. Additionally, we wished to determine factors contributing to ankle distraction survival including adjunct surgical procedures, patient demographics, and medical comorbidities. Methods: Billing logs of two senior surgeons were queried to identify 144 patients with greater than one year follow up, treated with ankle distraction alone or ankle distraction with simultaneous supramalleolar osteotomy (SMO) for deformity correction. Patients were then contacted through phone calls to determine the status of the ankle (natural vs failed). Survival analysis was performed for the primary outcome of need for fusion, replacement, or repeat distraction. Results: Of the 144 patients, only 21 have required fusion, replacement or repeat distraction. For patients with neutral alignment, treated with ankle distraction alone, the average survival was 11.4 years and patients who also had SMO had an average survival of 8.8 years. Of the 21 patients that failed distraction, nine were patients that had distraction and SMO. No significant differences in success were found for variables of gastrocnemius recession (p=.71), bone marrow aspirate injection (p=.60), microfracture (p=.99), arthrotomy vs arthroscopy (p=.99), age (p=.88), laterality (p=.46), or gender (p=.27), smoking (p=.35), diabetes (p=.35), rheumatoid arthritis (p=.42), and gout (p=.19). Post-traumatic avascular necrosis of the talus trended towards a significant risk for failure (p=.11). Conclusions: Ankle distraction is a valid and effective operation for the treatment of end-stage ankle arthritis. Patients with neutral alignment demonstrated excellent survival in our cohort. Distraction for patients with deformity that underwent simultaneous SMO had shorter survival (8.8 years vs 11.4 years). We still feel this is still a clinically significant time to be able to postpone a fusion and in some cases, make replacement an option as a result of deformity correction. Small number of failures limited the ability to analyze factors that may affect outcome. Acknowledgements: I am a consultant for Smith and Nephew, Stryker, and Nuvasive


  PP 110: Long-Term Follow-Up Leg Length Discrepancy After Osteosynthesis Of Femoral Neck Fractures In Non-Geriatric Patients. Top


Thomas Haider, Jakob Schnabel, Julian Hochpöchler, Cathrin Arthold, Gerald E. Wozasek

Medical University of Vienna, Vienna, Austria

Background: Bone healing in general is associated with resorption at the fracture site and concomitant shortening of the affected bone. Femoral neck fractures occur mainly in geriatric patients due to increased fall tendency and osteoporosis. Due to lower functional demands, leg length discrepancies in these patients are usually neglected. However, in young patients, acquired leg length discrepancy leads to significant morbidity. Data regarding femoral shortening after femoral neck fractures in non-geriatric patients remain scarce. Therefore, the aim of this study was to evaluate the long-term extent of leg length discrepancy in young patients after osteosynthesis in femoral neck fractures. Methods: We performed a retrospective search in our trauma registry identifying non-geriatric patients (age 18-65 years) who received internal fixation of femoral neck fractures between 2007 and 2015 at our department. These patients were subsequently invited to a follow-up examination including whole leg standing x-ray, clinical examination and completion of Harris hip score questionnaire. Results: A total number of 185 patients were contacted of which 55 patients returned for follow-up examination. Patients' mean age was 53 years (min.-max. 29-65 years) and the mean follow-up period was 67 months (min.-max. 12-113 months). Cancellous screw osteosynthesis was performed in 8 patients (15%) while 47 patients (85%) were treated with a dynamic hip screw. Leg length discrepancy of more than 1 cm was observed in 36 patients (65%), of more than 2 cm in 1 patient, with an overall mean shortening of the ipsilateral side of 7.35 mm (min.-max. 0-24mm). Comparison between both operation techniques did not reveal differences in extent of ipsilateral shortening or functional outcome. Conclusions: According to our presented data leg length discrepancies are common in non-geriatric patients after osteosynthesis of femoral neck fractures. Acknowledgements: The authors have no conflict of interest to declare.


  PP 111: Arthrodesis and osteotomy of the foot: Tactics of the treatment and sequence of the surgeries in Ilizarov method Top


Alexander Kirienko, Emiliano Malagoli

Istituto Clinico Humanitas, Rozzano, Italy

Background: The aim of the study was to report Ilizarov treatment indications and results in severe foot malfunction. In one group of cases was performed open arthrodesis and then progressive correction of deformity; in second group of patients we started with the correction of rigid deformity and than open surgery through arthrodesis was performed, in third group was done arthrodesis and osteotomy of adjacent bones. Methods: The study included 65 patients. The average age was 43.5 years. These patients had complex foot deformity with pain or instability that required foot joint arthrodesis to restore plantigrade foot. Aetiology of deformity were. trauma in 27 patients, polio in 6 patients, neurologic Charcot-Marie Touth disease in 7 patients, idiopathic flat foot in 3 patients, mielomeningocele in 7 patients, spastic hemiplegia in 4 patients, idiopatic cavus-varus foot in 3 patients, emimelia in 3 patients, syringomielia in 1 patient, Charcot foot in 4 patient. Application included correction of equinus foot; vertical calcaneus with varus or valgus of the hindfoot; abduction and supination or adduction and pronation of forefoot; anterior or mixed cavus; equino-cavo-varus deformity. Types of arthrodesis included tibio-talar joint fusion, subtalar arthrodesis associated with osteotomy of the calcaneus, corrective triple arthrodesis, Lisfranc joint fusion with distraction, corrective pantalar arthrodesis. Results: The follow up period was from 14 months to 20 years. Functional evaluation, obtained by Ankle-Hindfoot Scale of AOFAS, gave excellent result in 48 patients; good in 13 and fair in 4 (mean 73 point). Mean treatment time was 4.9 months. There were 43 complications in 35 patients, all treated successfully. No nerve or vascular damage was seen. In 93% of cases arthrodesis and a plantigrade position of the foot was obtained. Conclusions: Ilizarov method improves callus formation between bony surfaces when good bone contact is achieved after initial compression and cartilage removal. It is also possible to correct axial deviation. In cases of rigid deformity progressive correction and successive arthrodesis guarantied stable result. Acknowledgements: .


  PP 112: An international network of centers of excellence in limb lengthening and limb deformity corrections Top


Reggie C. Hamdy, Mina Mekhail

Shriners Hospital for Children-Canada, Montreal, Canada

Background: There is a paradigm shift taking place in the field of limb lengthening and deformity corrections (LLDC). The old model of working in silos to provide patient care is no longer effective, but there is a need for a global multidisciplinary and multisectoral approach to develop the next generation of orthopedic solutions. These solutions include. tissue-engineered bone graft substitutes, nanoparticulate delivery systems, medical devices to accelerate bone regeneration, patient-specific 3D-printed orthoses and prostheses, and point-of-care devices for rapid diagnosis and tracking healing. The federal government of Canada recognizes the importance of collaborative initiatives, and therefore provides multi-million-dollar grants to develop networks of centers of excellence (NCEs) around specific strategic priorities. We are applying for the federal grant to establish an international NCE in pediatric musculoskeletal health with emphasis on LLDC. The NCE will focus on excellence in research/innovation, training highly qualified personnel, promoting knowledge transfer, and increasing national and international partnerships. Methods: Our strategy was to first establish a local center of excellence and then expand it globally through applying for the federal NCE grant. We identified key stakeholders including surgeons, scientists, companies, NGOs, and government institutes that can become part of this NCE. We have also consulted with scientific directors of existing NCEs to learn from their experience and prepare our application. Results: We successfully established a center of excellence in limb lengthening, limb deformity corrections and bone regeneration (CoRect) at the Shriners Hospital for Children-Canada. We got the approval of the board of directors mid-2016 and already have several ongoing projects with national and international universities, hospitals, companies and institutes. We are currently preparing the proposal for the federal NCE grant and invite attendants of this congress to inform us if they are interested in becoming future members. Some of member benefits include. access to funding opportunities for collaborative research, international exchange programs, and training scholarships for graduate students and residents. Conclusions: We are proposing the establishment of a global NCE focused on LLDC to develop the next generation of orthopedic care. We invite you to show your support for such an initiative by contacting us. Acknowledgements: We would like to thank the International SHC for supporting this initiative.


  PP 113: Living With Achondroplasia: Quality Of Life After Limb Lengthening. : Reviewing Over Thirty Years Of Work Top


Pilar Rovira Martí, Anna Isart Torruella, Jordi Tapiolas Badiella, Ignacio Ginebreda Martí

Hospital Universitario Dexeus, Barcelona, Spain

Background: The objective of this study is to evaluate the quality of life and functionality of achondroplasic patients once the lengthening process of the three segments (tibias, femurs and humerus) has been completed. In this study the quality of life and functionality were evaluated using the questionnaire SF.36 version 2, a specific questionnaire for patients of low stature and the measurement of joint balance. We present a preliminary study of a more extensive work in which it is being carried out, an exercise test, a study of the gait, radiological evaluations and complications. Methods: We examined 31 achondroplasic patients (18 men and 13 women) who had completed the process of tibia, femur and humerus lengthening in our center, with a minimum follow-up of 3 years and a maximum of 22 years. The mean age of the patients was 27 years and 9 months (17 years and 6 months to 44 years and 11 months). The mean initial height was 112.29 cm (95-128cm). The age at which tibia lengthening began was 12.48 years (6.8-23.5), femurs 15.25 years (9.91-26.20), humerus 16.10 years (11.86 -25'12). They lengthen 15'22 (12'6-22'1) cm in tibia, 14 (11'4-18'4) in femurs, 9'7 (6'7-13'3) cm in humerus. The mean final height was 151 (140-169) cm. Results: The results obtained in SF.36 show similar results to those of the reference population, the joint balance is slightly decreased, 90.3% were labor-intensive, 96.7% were single, 80.6% lived in unadapted households 61'29% did housework without help, 93'54% could perform their hygiene without help, none required the use of crutches, 80'64% did not have difficulty being seen in counters, 41'9% worked in non-adapted jobs 74'19% lived with their parents, 90'3% did not require or punctually psychological help and all would be lengthen again. Conclusions: The achondroplasic patients after the elongation present a quality of life similar to the average of the population, are integrated in the society and all would return to operate. Acknowledgements: Thanks to all participants and the psychologist Miriam Pérez.


  PP 114: Limb Lengthening And Reconstruction In Patients Over The Age Of 50 Top


Minoo Keki Patel

Centre for Limb Reconstruction, Melbourne, Australia

Background: Not much has been discussed in limb reconstruction literature about limb lengthening and reconstruction in patients over the age of 50. We present our results for LLR surgery in patients over 50 and analyse how they differ from adult patients under the age of 50. Methods: We analysed our series of 23 consecutive patients over the age of 50 who had had deformity correction or limb lengthening or both in the lower extremity. Outcome measures were patient satisfaction, lengthening index, hip, knee and ankle range of movement, and Baltimore criteria (problems, obstacles and complications). Results: All 23 cases successfully completed their treatment. All were satisfied with the outcome, though 3 cases with external fixation considered the treatment to be cumbersome. 14 patients needed lengthening as a part of their treatment. Of these 5 had idiopathic leg length discrepancy and 9 had post-traumatic leg length discrepancy. All 14 either chose to stop short of their pre-op distraction calculations or preferred to reverse their distraction due to inability to cope with leg length equalisation. The lengthening index was comparable to that of a younger cohort. The number of problems, obstacles and complications were again comparable to that of a younger cohort. Conclusions: Patients over the age of 50 remain good candidates for limb reconstruction surgery with no greater risk than a younger cohort. Older patients are less likely to tolerate leg length equalisation. Acknowledgements: nil


  PP 115: Ilizarov Technique For The Treatment Of Knee Flextion-Contracture Deformity Caused By Lower Limb Hemangioma Top


Guo Baofeng

Beijing Chuiyangliu hospital, Beijing, China

Background: To investigate the clinical effects of the Ilizarov technique for the treatment of knee flexion-contracture deformity caused by lower limb hemangioma. Methods: The information of 14 patients with knee flexion-contracture deformity caused by lower limb hemangioma who were treated during the period between July 2008 and May 2014 was retrospectively analyzed. There were 6 males and 8 females in this group with an age range of 12 to 27 years (median age 22 years). 4 cases were companied with equinus deformity.5 cases were left knee flextion deformity while others were right knee flexion deformity with lower limb deformity history for 1 to 7 years. The knee flexion-contracture deformity was 20 degree to 55 degree(average 37.4 degree) and the Visual Analogue Scale (VAS) Pain Score after passive stretch the knee was 4 to 10(average 7.8).All of the patients installed Ilizarov Knee joint external fixation. The Foot and ankle joint distraction device will be installed at the same time if with equinus deformity. Distraction for correction begin at the 5 to 7 days after operation. During the treatment period, the patients can do light weight walking. Results: 14 patients were followed up for 6-47 months (average follow up of 21 months). All patients' knee flexion deformity was correction with stretching the diseased knee to 2.2 degree (ranged from 0 degree to 5 degree), all the cases restore a normal lower limb weight line. The final follow-up VAS score was 3.4(ranged from 0 to 5). The deformity correction time was 12 to 37 days with an average of 17 days. There were no distraction area and pin track continuing bleeding while 5 cases with bleeding around pinhole of the distraction area were treated with Sterile gauze compression, Yunnan Baiyao and Slowing down the drawing speed. Conclusions: Ilizarov knee joint distraction technique for the slowly correcting knee flexion-contracure deformity caused by lower limb hemangioma can achieve satisfactory therapeutic effect without opening operation for abnormal vascular resection which avoiding the risk of bleeding and restoring the lower limb weight line and rang of motion of the knee joint and relieving the knee pain. Acknowledgements: Key words: hemangioma knee flexion-contracture deformity Ilizarov technique


  PP 116: Treatment Of Foot And Ankle Deformities Secondary To Lower Limb Hemangioma With Ilizarov Technique A Top


JIAO Shaofeng

National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: To investigate clinical effects of Ilizarov technique for treatment of foot and ankle deformities caused by lower limb hemangioma. Methods: 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 months, 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%. Conclusions: 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 this kind deformities. Acknowledgements: Key words: Hemangioma foot and ankle deformity Ilizarov technique


  PP 117: Joint-Preserving Reconstruction Of The Knee Using Tumor-Bearing Bone Treated By Liquid Nitrogen In Patients With Osteosarcoma Top


Takashi Higuchi, Norio Yamamoto, Toshiharu Shirai, Katsuhiro Hayashi, Akihiko Takeuchi, Hiroyuki Tsuchiya

Kanazawa university, Kanazawa, Japan

Background: Surgeons have multiple alternatives for reconstructing large bone defects following malignant bone tumor resection, including massive endoprosthesis, composite arthroplasty, allograft, and distraction osteogenesis, the first two of which are the preferred choices for tumors involving the metaphysis of long bones. However, these procedures severely limit joint function compared with that in normal joints. To preserve the joint structure in an effort to preserve good limb function in patients with metaphyseal malignant bone tumors, we have been performing epiphyseal or metaphyseal osteotomy and reconstruction using frozen autografts treated with liquid nitrogen. The purpose is to evaluate the results of intentional joint-preserving reconstruction using frozen autografts containing tumor treated with liquid nitrogen in patients with osteosarcoma involving the metaphysis. Methods: Between 2006 and 2014, we have treated with this surgical technique for 18 cases of osteosarcoma patients who had achieved good response for neoadjuvant chemotherapy. In all cases, tumors involved the metaphysis with or without diaphysis of long bones (12 distal femurs, 6 proximal tibias). After neoadjuvant chemotherapy, they underwent intentional marginal excision with epiphyseal osteotomy to preserve their knee joint. The bony lesions containing tumor were frozen in liquid nitrogen and utilized for reconstruction with intramedullary nailing or plates. Functional evaluations were performed using MSTS score. Results: In eighteen patients (9 males, 9 females) with a mean age of 11.6 years, 13 patients were continuous disease-free (CDF), two were no evidence of disease (NED), one was alive with disease (AWD) and one was died of disease (DOD). Functional outcomes were assessed as excellent in 15 patients and poor in three with a mean follow-up of 46.1 months. The mean functional score was 90.2%. Nine patients regained normal range of motion of knee joint and can walk and eleven patients can run almost normally. Seven patients needed additional surgery because of postoperative infection, tumor recurrence originating from surrounding soft tissues, or postoperative fracture. No intraoperative complications, such as surrounding soft-tissue damage or neurovascular injury, were observed. Conclusions: Joint-preserving reconstruction using frozen autografts yielded excellent function for patients with osteosarcoma. Acknowledgements: None


  PP 118: Ilizarov Technique With Minimal Invasive Osteotomy Of Tibia And Fibula For Varus Knee Osteoarthritis Top


Jiancheng Zang, Sihe Qin

Department of Orthopaedics, Affiliated Hospital of National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: Osteoarthritis with varus knee is the very common disease in the world, the knee joint preservation method becoming more and more popular than TKA or UKA. This abstract to observe the clinical effect of Ilizarov technique combined with minimally invasive osteotomy in the proximal tibia and fibula for the treatment of knee osteoarthritis, and to explore the effective method for the knee osteoarthritis. Methods: January 2010 to December 2014, 36 patients in our hospital were retrospectively analyzed. There were 25 males, 11 females, average age 58.5 years old, including 39 knees of 36 cases, left 19 cases, right 14 cases and 3 cases of double knee. Based Osteoarthritis Grade, 15 knees were Grade 3, 24 knees were Grade 2. The average VAS is 7 preoperatively. The average medial angle of the proximal tibia was 62.5 degrees, and the average angle of the tibial-femoral angle was 167.3 degrees. According to HSS evaluation, average 58.4 points. 39 knees were accepted by the proximal tibia and fibula minimally invasive osteotomy combined with Ilizarov external fixation and then corrected gradually. Results: The operation time was 40~95minutes, average 55.0minutes. There was no serious complication of neural or vascular injury which external fixation related. 35 cases 38 knees had been follow-up, average 34.5 months, VAS score at the last follow-up was average 2 points. The proximal tibia medial angle average was 96 degrees and tibia-femoral angle average 7.5degrees at weight-bearing position on AP view. The HSS was 88.7 points average. Based Qin Sihe standard of deformity correction evaluation, excellent in 30 cases, good in 6 knees, 2 knees, the excellent rate was 94.7%. Conclusions: The Ilizarov technique combined with tibia and fibula proximal minimally invasive osteotomy for knee osteoarthritis have some advantages as follows. stable, minimally invasive, and can be adjusted on the coronal and sagittal plane, it is suitable for the patients with different extent of varus knee osteoarthritis. Acknowledgements: The authors declare that they have no conflict of interest.


  PP 119: Distraction Histogenesis For The Rigid Equinovarus After Spina Bifida With Denervative Pressure Ulcers Top


YongHong Zhang1, Dong Wang1, Sihe Qin2

1. the 2nd hospital of Shanxi medical University, Taiyuan, China

2. Rehabilitation Hospital of the National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: The rigid equinovarus based on spina bifida always related denervative pressue ulcers, often deep to bone, sometimes with infection. it is very difficult to handle with traditional methods. In this study, Ilizarov distraction histogenesis technique were explored for the treatment of the rigid equinovarus with denervative pressure ulcers. Methods: 2 spina bifida patients with denervative pressure ulcers on the rigid euinovarus feet were freed of walking and washed with hydrogen peroxide and saline four times a day, and operated with triple arthodesis and modified Ilizarov technique 6 days later. The patients were encouraged to walk 7 days after operation with the help of walking aids. Results: All the patients were recovered from the rigid equinovarus without infection, and had plantigrade and painless walking gaits. The sensation of the operated feet was improved a lot. There was no recurrence after more than one year follow up. Conclusions: DH technique could be a practical method for the treatment of rigid equinovarus. and probably helpful for the recovery of foot sensation. Acknowledgements: All our team, especially Dr. Liu laiyou, Dr. WangDong, Liuhong, you always work hard, Thank you!


  PP 120: Ilizarov Transosseous Osteosynthesis Method In The Management Of The Patients With Chronic Osteomyelitis Top


Alexander Gubin, Nikolay Klyushin, Yurii Ababkov, Sergey Burnashov

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: The management of the patients with chronic osteomyelitis of the long bones is still a complicated clinical task. Common treatment techniques of this pathology don't guarantee assured cure regardless the variety of the most current antibacterial means and surgical technologies. Methods: We present the analysis of Russian Ilizarov Center experience in the management of over nine thousand (9730) patients with chronic osteomyelitis of various etiology, location and duration of the disease. In 93.3% of the cases the osteomyelitis combined with different orthopaedic and traumatic pathology< mainly with bones defects (43.1%), pseudarthrosis (17.5%), osteomyelitic cavities (5.9%) and others. Ilizarov technique was applied in 87.3% of treated patients. Results: The techniques elaborated by Ilizarov for restorative treatment of patients with chronic osteomyelitis including combinations with different orthopaedic and traumatic pathology allow us to provide successful stable arrest of chronic purulent necrotic process, at the same time correcting completely or partially the orthopaedic pathology. Moreover, they give the possibility to obtain stable positive outcomes of treatment in 97.6 % of the cases. Conclusions: When the method of Ilizarov controlled transosseous osteosynthesis is applied in chronic osteomyelitis management, the mechanism of suppressing the purulent infection is based on the factor of activating and supporting the condition of tension stress in the tissues of affected segment during the process of orthopaedic reconstruction and appearing effect of their increasing bacterial activity. The complex of these techniques of controlled compression-distraction transosseous osteosynthesis provides the possibility to individualize the treatment process, whereby the specific ways of orthopaedic pathology correction are secondary to the task of infection arrest in the tissues of involved segment. Acknowledgements: There is no conflict of interest.


  PP 121: Reconstruction Of The Post-Traumatic Soft Tissue Defects Using Ilizarov Transosseous Osteosynthesis Technique Top


Natalia Gennadievna Shikhaleva

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: Purpose is to improve the results of medical rehabilitation of the patients with extensive limb wounds using combination of Ilizarov transosseous osteosynthesis and vascularized tissues complexes. Methods: We have treated 42 patients with the soft tissue defects of the upper and lower limbs using tissue complexes with axial type of circulation. The first group included 22 cases with soft tissue defects of hand and forearm. The second group included 20 cases with soft tissue defects of the lower limbs. In the first group, we applied non-free radial pedicle flap, non-free posterior forearm flap, free radial flap, foot tissue complex transfer for finger formation and non-free hand flap. In 15 cases, the segments were fixed with Ilizarov fixator. In the second group, non-free sural flaps were used in 7 cases, prefabricated medial plantar flap was applied in one patient, muscular transposition was done in 2 cases, free fibular flap was in one case and non-free medial planta flaps were applied in four patients. In all cases of this group Ilizarov fixator was attached for fixation of the limb in the position favorable for wound healing. Results: Complications in the immediate post-operative period included partial necrosis of the free flap in one case and development of venous insufficiency in 3 cases. Arrest of complications required additional conservative treatment. Good and satisfactory results were obtained in all cases. Conclusions: Application of vascularized tissue complexes combined with Ilizarov transosseous osteosynthesis has certain advantages over the plaster cast fixation. Prevention of vascular pedicle compression by circular bandages and possibility of temporary forced position creation to avoid vascular pedicle tension make the combination of these treatment techniques optimal in some cases. Acknowledgements: There is no conflict of interest


  PP 122: Pediatric Surgical Treatment Of Residual Hip Dysplasia Complicated With Avascular Necrosis Of The Femoral Head Top


Mikhail Pavlovich Teplenky

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: Avascular necrosis of the femoral head makes reconstructive procedure difficult in residual hip dysplasia and aggravates prognosis. Purpose. review short- and mid-term results of pediatric surgical treatment of residual hip dysplasia complicated with avascular necrosis of the femoral head. Methods: Results of treatment of 18 children (20 joints) with avascular necrosis of the femoral head developed after closed reduction of DDH were studied. Mean age was 4 years (2,5-6). Distribution of AVN by Tonnis grading. III -12, IV - 8. Distribution of decentered joints. I – 3, II – 13, III –4. Ilizarov extraarticular reconstruction of articular components and drilling of the femoral head and the neck was performed in 16 cases. The above intervention was combined with open reduction of dislocation in four observations. Results: Results were followed from 2 to 6 years. Clinical outcomes were evaluated by Mc Key. class I– 6, class II– 11, class III– 2, class IV– 1. Radiological results according to Severin. IIB type – 14, IIB type – 4, type III - 2. Degree of head restoration was evaluated according to Meyer. I – 3, II – 13, III - 4 joints. Distribution of joints according to Coleman. I – 3, II – 3, III – 12, IV – 2. Positive results were achieved in 85.7% of the cases. Conclusions: Reconstructive procedures combined with drilling of articular components and decompression with external fixation provide positive influence on reparative processes in ischemic necrosis of the femoral head. Acknowledgements: There is no conflict of interest.


  PP 123: Management Of Adolescents With Dysplastic Coxarthrosis: Russian Ilizarov Scientific Center, Kurgan, Russia Top


Mikhail Pavlovich Teplenky

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: The significance of pelvic and femoral osteotomies in the condition of developed arthrosis is still disputable. Early osteoarthritis and dis-congruency of the articular surfaces are evaluated by many specialists as contra-indication for the joint preserving operation. Purpose. Review middle term results of reconstructive treatment in adolescents and young adults with dysplastic coxarthrosis. Methods: Treatment outcomes of 20 patients with dysplastic coxarthrosis were analyzed. Mean age at intervention was 15 years (12-20). The grade of arthrosis was assessed according to Tonnis. grade I – 10, grade II - 7, grade III - 3. The type of congruence of articular surfaces were assessed according to Coleman. III -8, IV – 12. All subjects underwent extraarticular hip reconstruction with the Ilizarov apparatus included pelvic and femoral osteotomies. Results: Outcomes were followed from 5 to 12 years. Functional outcomes according to Merle d'Aubigne-Postel were. Pain 4,7±0,1 points. Range of motion – 4,1±0,2 points. Walking ability – 4,6±0,1 points. Radiographic findings according to Severin were. IIa - 9, IIb - 7, III – 4. The grade of arthritis was unchahged in 14 cases, progressed in 2 joints, reduced in 4 cases. Considering clinical and radiological picture the positive outcomes made up 82%. Conclusions: application of reconstructive operations with Ilizarov frame allows to extend fairly the indications for extra-articular reconstructive invasions in dysplastic coxarthrosis. Improved congruence of the articular surfaces in conditions of osteoarthritis in most cases leads to a slowing of progression. Acknowledgements: There is no conflict of interest.


  Reconstruction after articular lesions Top



  PP 124: What are the true chances for reconstruction in sequelar destroyed acetabulo femoral joints in young patients Top


Dalia Arriagada Sepulveda

COTI, Santiago, Chile

Background: Abstract Text. after necrosis of the hip joint for several etiologies, during childhood and adolescence, there is yet not a universal accepted good procedure to reconstruct the hip. Almost everybody today will live the sequelae to its natural history evolution, a few surgeons will offer total hip arthroplasty and even less clinicians will perform arthrodesis. This talk presents the follow up of 17 patients and 19 hips operated during last 15 years with a PELVIC SUPPORT OSTEOTOMY with very good functional results graded by Merle scale. A fully detailed of actual surgical technique is also shown. Methods: Results: Conclusions: Acknowledgements: .


  PP 125: Short Term Clinical And Radiological Evaluation Of Ankle Arthrodesis With Monolateral External Fixators Top


André Perin Shecaira1, Maurilio Darcy Mendes2, Rodrigo Mota Pacheco Fernandes3

1. UFRJ, Rio De Janeiro, Brazil

2. INTO, Rio De Janeiro, Brazil

3. HPMRJ, Rio De Janeiro, Brazil

Background: Ankle arthrodesis is the gold standard treatment of symptomatic ankle arthritis that does not respond to non-operative therapy. In the present study, we want to show complications and the efficiency of ankle arthrodesis done with monolateral external fixations. Methods: we revised eleven patients that realized ankle arthrodesis with monolateral external fixator and a ankle clamp between 2013 e 2015. With every one followed clinically and serial radiographs to evaluate bone consolidation, residual alignment and possible complications. . Results: every patient obtained full ankle fusion and plantigrade foot at final treatment. The most community complication was pin tract infection - always solved at treatment's final stage. Conclusion. the use of monolateral external fixation in ankle arthrodesis is an efficient way to treat degenerative alterations of tibio-talar articular surface. Conclusions: The monolateral external fixators in ankle arthrodesis is an efficient method and a good alternative in treatment of ankle arthrosis. Acknowledgements: nos disclaimers


  PP 126: Ankle arthrodesis with circular external fixation, proposal of a surgical technique and case studies Top


Carlo Salomone1, ENZO Privitera2

1. MIOS-MIOA, Albenga, Italy

2. MIOS-MIOA - clinica Gretter, Albenga - Catania, Italy

Background: Arthrodesis of the ankle with EF (external fixation) in accordance with the criteria set out by Charnley in 1953 provide a stable system dynamic over time leading to fusion of the tibiotarsal joint. The indications for ankle arthrodesis with EF are primarily secondary arthrosis from trauma and/or infections. This paper offers a new technique with circular EF aimed at managing and handling the cases above, who may have a need for bone recovery, alignment or soft tissue management. Methods: The surgical technique of circular EF requires a double tibial clamp and a double clamp at the foot, respectively talus and calcaneal-medial tarsal. K wires and screws are used. With this technique, 30 ankle fusion patients (20 males and 10 females) of 44 years average age (range 24-66 aa), with a mean follow up of 36 months (range 6-90 months) who were treated between January 2008 and January 2016. Results: Of the 30 patients treated, 23 consolidated, 1 case of refracture, 1 amputation due to soft tissue issues and 4 residual deformities and 1 non-union which evolved into sub ankylosis. In the case of the 23 patients considered healed, the end of treatment considers the primary area as stable, freely loading without pain and free of any septic issues. Conclusions: This method proved to be duplicable, reliable, and allowing for simultaneous multidisciplinary treatment of complications pre-and intraoperatively such as infection, shortening, deformity and soft tissue healing. Based on the percentage described, the percentages are similar to those described in the literature, with a good tolerability of the system. The technique proposed with a free grasping of the talus allows for a valid compression in the primary area and management of the effects in the subtalar joint area. This possibility predominantly demonstrated in young subjects a preservation of the subtalar joint, decreasing the limitations described and observed with previous methods. Acknowledgements: Coester L M et al., Long term results following ankle arthrodesis for post traumatic arthritis. JBJS vol.83a no.2 2001. Barr JS, Record EE. Arthrodesis of the ankle joint. Indications, operative technic and clinical experience. N Engl J Med 1953; 248:53-56. Wang GJ, Shen WJ, McLaughlin RE, Stamp WG. Transfibular compression arthrodesis of the ankle joint. Clin Orthop 1993; 289:223-227. Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951; 33:180-191. Mann RA, Van Manen JW, Wapner K, Martin J. Ankle fusion. Clin Orthop 1991; 268:49-55. Malarkey RF, Binski JC. Ankle arthrodesis with the Calandruccio frame and bimalleolar onlay grafting. Clin Orthop 1991; 268:44-48. Tahir Ogut, Glisson RR et al., External fixation versus screw fixation for ankle arthrodesis. a biomechanical comparison. Foot and ankle international, vol.30 no.4 2009. Edward V. Craig. Ortopedia Clinica. Antonio Delfino Editore 2007. Marti RK, Raaymakers EL, Nolte PA. Malunited ankle fractures. The late results of reconstruction. J Bone Joint Surg Br 1990; 72:709-713. Morgan CD, Henke JA, Bailey RW, Kaufer H. Longterm results of tibiotalar arthrodesis. J Bone Joint Surg Am 1985; 67:546-550. Scranton PE Jr. An overview of ankle arthrodesis. Clin Orthop 1991; 268:96-101. Holt ES, Hansen ST, Mayo KA, Sangeorzan BJ. Ankle arthrodesis using internal screw fixation. Clin Orthop 1991; 268:21-28. Buck P, Morrey BF, Chao EYS. The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle. J Bone Joint Surg Am 1987; 69:1052- 1062. Mann RA. Biomechanical approach to the treatment of foot problems. Foot Ankle 1982; 2:205-212. Thordarson DB, Markolf KL, Cracchiolo A III. External. fixation in arthrodesis of the ankle. A biomechanical study comparing a unilateral frame with a modified transfixion frame. J Bone Joint Surg Am 1994; 76:1541-1544. Mears DC, Gordon RG, Kann SE, Kann JN. Ankle arthrodesis with an anterior tension plate. Clin Orthop 1991; 268:70-77. Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop 1991; 268:84-95. Newman A. Ankle fusion with the Hoffmann external fixation device. Foot Ankle 1980; 1:102-109. Paremain GD, Miller SD, Myerson MS. Ankle arthrodesis. Results after the miniarthrotomy technique. Foot Ankle Int 1996; 17:247-252. Richter M. et al., A new foot and ankle outcome score. questionnaire based, subjective, Visual-Analogue-Scale, validated and computerized. Foot and Ankle Surgery 12 (2006) 191-199. Wu WL, SU F-C et al., Gait analysis after ankle arthrodesis. Gait and Posture 11 (2000) 54-61. Mann RA, Rongstad KM. Arthrodesis of the ankle. A critical analysis. Foot Ankle Int 1998; 19:3-9. Rosen H. Reconstructive procedures about the ankle joint, in Jahss MH (ed). Disorders of the Foot and Ankle. Medical and Surgical Management, 2nd ed. Philadelphia. WB Saunders, 1991, vol 3, pp 2593- 2613. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 1976; 58:356-357.


  PP 127: Diferences Between Resection And Reconstruction Vs Curettage In Pelvic Ring Tumors - Our Experience. Top


Francisco Xará Leite, João Esteves, Vânia Oliveira, Pedro Cardoso

Centro Hospitalar do Porto, Porto, Portugal

Background: This study intended to evaluate our department's 15-year practice in the treatment of pelvic ring tumors. Methods: Twenty-five patients underwent pelvic/sacral surgery in our department from 2000 to 2015. Most common diagnoses included condrosarcoma (n=8), cordoma (n=5), giant cell tumor (n=4), osteosarcoma (n=2) and metastases (n=2). We also had one case (n=1) of Ewing sarcoma, peripheral nerve sheath sarcoma, condroblastoma and schwannoma. Of all type I tumors (n=6), 3 needed reconstruction with allo or autograft. All type II tumors (n=3) were treated with aggressive curettage plus adjuvants (drilling, fenolization, cement). We also needed no reconstructions for type III lesions. The sacrum (type IV) was the most involved area (n=7), with 3 undergoing total sacrectomy and illiolumbar reconstruction. Plus, 1 osteosarcoma involving zones I+II underwent radical resection and reconstruction with iliofemoral arthrodesis; of 5 lesions involving both zones II+III, 2 had total hip replacement anchored on the remaining ilium; and 1 giant cell tumor of zones I+IV, treated with aggressive curettage. Results: From a total of 7 curettages and 18 resections (13 with wide margins, 3 marginal and 2 intralesional) 4 became infected, all in patients subject to sacrectomy, of which 2 resolved and 2 became chronic. In all 3 total sacrectomies, patients presented subsequent neurologic deficits. One of the pelvic reconstructions failed, demanding revision. Recurrence occurred in 4 condrosarcomas – 3 with disease progression to lung metastases and death, and 1 local recurrence requiring pelvic amputation. Also, there were recurrences of 3 cordomas, all eventually leading to death, and of both osteosarcomas, with metastases and death. The average functional score (American Musculoskeletal Tumor Society) of the 9 surviving patients who underwent some form of resection is 79% vs 94% in the 8 subject to aggressive curettage. Conclusions: Pelvic reconstructions after tumor resections are technically demanding and require extended surgical time, carrying high complication rates. However, the challenge for limb preservation is worth taking if we account for the good functional outcome of the surviving patients. Developments on reconstructive techniques including custom-made implants, although expensive, allow better post-operative function. However, if the approach is surgically reasonable, histology permits and adjuvants are predictably effective, a less invasive option should be chosen so morbidity is minimized. Acknowledgements: None.


  PP 128: Acetabular Defects And Pelvic Reconstructions At Total Hip Replacement Revision: Report Of Three Cases Top


Cláudia Sofia Rodrigues, Luis Lopes Coutinho, Daniel Soares, Joaquim Ramos, Rafaela Coelho

Centro Hospitalar do Porto, Porto, Portugal

Background: The management of severe acetabular deficiency at revision arthroplasty remains a complex problem and bone deficiency in revision total hip arthroplasty is one of the most challenging ones. We describe 3 patients who required revision total hip arthroplasty. Methods: Case 1 A 74-year-old woman was admitted to our hospital with a left hip joint pain. She had undergone uncemented THA 20 years earlier for hip osteoarthritis. Clinic and imagiologic studies suggested chronic prosthetic infection, and the patient was advised to pursue a 2-times revision THA. At the time of reimplantation, an acetabular fracture was detected intraoperatively. An open reduction and osteosynthesis with reconstructive plates and revision with a highly porous metal acetabulum component was performed. Case 2 A 70-year-old woman was admitted to our institution with right hip joint pain after a neglected trauma which had occurred 3 months earlier. Radiographic study showed a slightly deviated acetabular fracture and associated hip osteoarthrosis. The patient was advised to pursue an uncemented total hip arthroplasty which underwent without any complications. 4-months after surgery the patient reported pain in the right hip and radiographic study showed acetabular protrusion. We proposed an acetabular revision, with acetabular reconstruction with allograft and Bursh-Schneider ring. 2 years later the patient reported right hip pain. Radiographically we could see aseptic loosening of the ring. A 2nd intervention was performed with reconstruction of the acetabulum with allograft and a tantalum cupcage system. Case 3 An 81-year-old woman was admitted to our emergency department after a fall with trauma of the right hip, causing pain and functional incapacity. She had undergone uncemented THA 15 years earlier. Imagiologically she presented a periprothesic acetabular fracture with minimal displacement. We decided for conservative treatment, but at the 2-week control radiograph, the fracture had displaced, so we proposed surgical treatment. We performed an open reduction and osteosynthesis with reconstructive pelvic plates and reconstruction of the acetabulum with tantalum shell and cemented polyethylene. Results: All 3 patients are now without pain and performing full-weight bearing. No complications were reported. Conclusions: Reconstruction of the acetabulum with considerable pelvic bone defects, due to acetabular fractures or pelvic discontinuity, in revision hip arthroplasty requires complex surgical techniques. Acknowledgements: The authors declare that there is no potential conflict of interest relevant to this article.


  PP 129: Use Of The Circular Aluminum Fixator For Correction Of Atraumatic Deformities At Knee Level: A Multicenter Study. Top


Diego Sant'anna Faria1, Marcelo Utsunomiya Fumio2, Robinson Toshimitsu Kiyohara2, Saulo Bueno Brescancin3, Ricardo Ezidio Bandeira3, Marcio Tsuguio Utsunomiya4

1. Hospital das Clinicas Luzia de Pinho Melo, Mogi Das Cruzes, Brazil

2. Hospital São Paulo, São Paulo, Brazil

3. Hospital Mario Gatti, Campinas, Brazil

4. Faculdade Ceres, São Jose Do Rio Preto, Brazil

Background: Untreated arthrosis leads to the disruption of the subchondral bone and a decrease in the thickness of the articular cartilage and consequently a deviation of the axial axis. In the literature the classic indication for osteotomy at the knee level and the limit for correction is 15 degrees of varus and 10 degrees of valgus. The concept of high osteotomy for the treatment of unicompartmental knee arthrosis is credited to JACSON AND WAUGH (1961). The use of external fixator is an alternative for the fixation of the high osteotomy with fewer complications. Although the plaque provides better stabilization of the osteotomy, it is not able to perform correction of residual deformities as the fixative. Methods: . The work was carried out from January 2008 to January 2015; Of multicentric character; Where 35 knees with high tibial osteotomy were treated; Of this 5 were female and 30 were male; The age ranged from 38 to 60 years; Of these, 32 deformities were varus and 3 valgus; With varus deformities of 4 to 13 degrees with an average of 8 degrees. Results: The high osteotomies fixed with external aluminum fixator had 100% consolidation, presenting as advantages. correction of residual deformities without the need of bone graft, even in corrections above 10 degrees, perfect alignment of the lower limbs and with low Complications index. Conclusions: It is a percutaneous and minimally invasive surgery, without the appearance of additional deformities after performing the osteotomy, allowing the early loading. On the other hand, the fixer has as its disadvantage the aesthetic part and the need for a long learning curve. Therefore, we concluded that the external fixator of aluminum is a good alternative for the fixation of osteotomies at the level of the knee and with very low index of complications. Acknowledgements: Especially Dr Bongiovanni, Dr Hilario Boatto. Hospital São Paulo, Hospital Mario Gatti and Hospital Luzia de Pinho Melo


  PP 130: Osteophyte Removal Technique Combined With Ilizarov Ankle Distraction In The Treatment Of Middle-Late Ankle Osteoarthritis Top


Guo Baofeng

Beijing Chuiyangliu hospital, Beijing, China

Background: To explore the effect of Osteophyte removal technique combined with Ilizarov ankle distraction in the treatment of middle-late ankle osteoarthritis. Methods: The information of 9 patients with middle-late ankle arthritis who were treated during the period between October 2009 and December 2014 was retrospectively analyzed. There were 6 females and 3 males in this group with an age range of 20 to 45 years (median age 34.2 years). All patients are unilateral ill.5 cases had ankle traumatic history 3 cases had Post operation history of foot deformity caused by Poliomyelitis sequelae 1 case was natural incidence, equinus cavus deformity. After open operation of Osteophyte removal to ankle part surgery, all of the patients install Ilizarov foot and ankle external fixation. Draft ankle joint to keep joint clearance at 5mm to 8mm and walk. During the treatment period, the patients can do light weight walking.AOFAS ankle-hind score was used to evaluated the clinical effect. Results: 9 patients were followed up for 12-60 months (average follow up of 29.4 months).The time with external fixator was 12 to 24 weeks with an average of 16 weeks.At the time of the latest follow-up,AOFAS ankle-hind score was 76 to 89 with an average of 81,which compared with pre-operation number of 29 to 48(average was 34.6),the difference has statistically significant.There were no serious complication after the operation.5 cases had mild pin tract infection who were treated by local alcohol treatment and oral antibiotics. 1 case had heel pin broken, we removed the pin at the same time of external fixator removing time. Conclusions: Osteophyte removal technique combined with Ilizarov ankle distraction in the treatment of middle-late ankle arthritis is an simple and mini-invasive method which can achieve satisfactory therapeutic effect and delay joint replacement or ankle fusion. Acknowledgements: Key words: Osteophyte removal, Ilizarov technique,joint distraction,ankle osteoarthritis


  PP 131: Clinical Results With Short-Stem Arthroplasty Do Not Correlate With Imaging Results And Patient Specific Factors Top


Pedro Neves1, Pedro Barreira1, Pedro Serrano1, Joaquim Ramos1, Rafaela Coelho1, Rui Lemos2

1. Centro Hospitalar do Porto, Porto, Portugal

2. Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova De Gaia, Portugal

Background: Total hip arthroplasty is one of the most reliable procedures in orthopedic practice. Short-stem implants emerged as an alternative with some potential advantages in relation to common implants. The aim of this paper is to evaluate the clinical results of a population who underwent total hip arthroplasty with a short stem implant (Proxima®) and correlate them with imaging results and patient factors. Methods: Were included all the operated patients between January 2007 and September 2011, with a minimum of 5 years of follow-up. It included patients with both metal-on-metal and metal-on-polyethylene implants. Imaging results included subsidence and angulation of the stem and stress shielding (acetabulum and femur). We considered relevant subsidence when ≥5mm and relevant angulation when >3°.Patient factors, other orthopedic morbidities, relevant medical morbidities and medication were registered. The Oxford Hip Score (OHS) and Harris Hip Score (HHS) measured the clinical results. Both scores were divided accordingly to the results in Excellent (E)/Not Excellent (NE). Results: We obtained a total of 30 patients (19male, 11female), with an average age of 43.5 years-old. Twenty-two patients had unilateral and 8 had bilateral arthroplasty. There was relevant subsidence on 11 hips (2 NE in OHS;1 in HHS). Relevant angulation was found in 10 hips (2 NE in OHS). A total of 15 cases with acetabular stress shielding were identified (2 NE in OHS). There was a total of 20 hips with femoral stress shielding (2 NE in OHS;2 in HHS).Sixteen patients were obese (3 NE in OHS;4 in HHS).Twenty-four patients had severe medical conditions (4 NE in OHS;3 in HHS).Only 7 patients had chronic relevant medication (4 NE in OHS;1 in HHS).There were 23 patients with orthopedic morbidities (5 NE in OHS;2 in HHS).Relatively to the imaging results, there was an average subsidence of 3.7mm and angulation 2.2°. Acetabular stress shielding was present in 15 hips and femoral stress shielding in 20. Conclusions: Results demonstrate this short stem implant has extremely good results with only 6 cases in OHS and 4 in HHS showing NE results (all of them with Very Good clinical results). The only factor with a trend to worst results is the chronic medication (only small differences iun OHS). We may say that short stem prostheses are a great alternative to classic implants and even in the presence of subsidence, angulation or stress shielding the results are excellent. Acknowledgements: Dr. Sérgio Figueiredo


  Reconstruction after lower limb trauma Top



  PP 132: The short-term results of Grade III open tibia fractures treated with definitive circular fixators Top


Gerhard Pienaar1, Nando Ferreira1, Luan Nieuwoudt2, Leonard Charles Marais2

1. University of Stellenbosch, Cape Town, South Africa

2. University of KwaZulu-Natal, Pietermaritzburg, South Africa

Background: Grade III open tibia fractures have previously been shown to have high infection and non-union rates, and the optimal treatment remains controversial. Methods: We present the short-term results of 94 consecutive Gustilo-Anderson. grade III open tibia fractures, definitively treated with circular external fixators in this retrospective study. Results: A total of 94 patients (80 males and 14 females), with a mean age of 36.5 years (range 8–73) were followed up for a mean period of 12 months (range 6–52). Deep infection occurred in four patients (4.3%) and non-union in three patients (3.2%). The mean time to union was 23 weeks (range 11–79). The prevalence of HIV infection was 32.9% and no statistically significant association between HIV infection and an increased risk of deep infection (p = 0.601) or nonunion (p = 0.577) could be demonstrated. Pin-site infection occurred in 16% with the majority being low-grade infections. Conclusions: The management of grade III open tibia fractures with definitive circular external fixation delivered promising short-term results with low complication rates in terms of infection and non-union. Acknowledgements: I would like to thank Dr R Rodseth PhD for his contribution to this study. There are no conflicts of interest


  PP 133: Is Distraction Arthroplasty Using Multi Axial External Fixator Work For Young Patient With Severe Ankle Arthritis? Top


Yeok Pin Chua

sunway university/ sunway medical centre, Selangor, Malaysia

Background: Abstract Text. Ankle arthritis is not as common as in knee and hip arthritis. The standard operative treatment for severe ankle arthritis is ankle fusion or ankle arthroplasty when failed non-surgical treatment. However, for young patient with ankle arthritis, joint preservative procedure like ankle distraction arthroplasty may be an option. This paper is to determine the outcome for patient undergone ankle distraction arthroplasty with Taylor Spatial Frame. Ankle distraction arthroplasty is a joint sparing procedure offer in young patient with severe ankle arthritis. It allows maintenance of intermittent intra-articular fluid pressure and the damage to the cartilage is diminished by offloading contact between the joint surface. At the same time, it promotes cartilage reparative processes. We will describe the surgical procedure and outcome of the procedure. Methods: .Results: Conclusions: Acknowledgements: .


  PP 134: The Use Of Taylor Spatial Frame For Treatment Of Complex Foot And Ankle Deformities, Disorder And Infection Top


Yeokpin Chua

sunway university/ sunway medical centre, Selangor, Malaysia

Background: Abstract Text: Difficult ankle problem like infection, severe ankle trauma, charcot arthropathy with deformity are commonly seen especially in developing country. Surgical treatment of this difficult ankle problem is challenging to surgeons with several possible complications commonly wound infection and nonunion. This presentation is to describe management of this difficult problem with multi-axial ring fixator. Methods: We used minimally invasive technique with multiaxial external fixator to treat this problem like hindfoot fusion, fixation of severe pilon fracture, infection ankle fracture and correct the severe ankle equinus. Results and Conclusions: We use multi-axial external fixator to mange these difficult problems with various success rate.


  PP 135: Treatment Of High Risk Long Bones Non Union Using Home Based Low Intensity Pulsed Ultrasound (LIPUS) Top


Yeok Pin Chua

Sunway University/ Sunway Medical Centre, Selangor, Malaysia

Background: Long bone fracture following high energy trauma is common, and 4 to 10% may eventually develop nonunion despite repeated surgical interventions. LIPUS has been reported to accelerate bone repair in fractures. We conducted this study to evaluate the outcome of treatment with LIPUS in resistant nonunion of the long bone . Methods: We treated 6 patients (4 males and 2 females) with LIPUS following established nonunion. Five had high-energy limb injuries while one had a pathological fracture at the allograft site used for reconstruction of osteosarcoma. There were 5 tibial and one femur fractures. All the fractured limbs had been stabilized with external fixators and bone grafting had been performed done. After a period, nonunion, LIPUS was started after counseling of patients. After completed 150 times/days of LIPUS treatment, the patients were assessed for clinical and radiographic evidence of union. Results: Mean age of the patients was 37.5 years (range, 19 – 60 years). LIPUS was applied over the skin for 20 minutes daily over a period of 120 days. Four out of the 6 patients developed bone union (healing rate of 66.7%). Two patients failed to unite and both of them were over 50 years of age. Considering all the patients had failed conventional modes of treatment including iliac bone grafting, this noninvasive technique may provide a new treatment option for resistant nonunion. Conclusions: We suggest that LIPUS may be considered for the treatment of nonunion, especially for patients younger than 50 years old. Acknowledgements: no conflict of interest


  PP 136: Factors associated with treatment failure of aseptic tibial nonunions managed by circular fixation Top


Gerhard Pienaar1, Nando Ferreira1, Leonard Charles Marais2, Tonya Esterhuizen1

1. University of Stellenbosch, Cape Town, South Africa

2. University of KwaZulu-Natal, Pietermaritzburg, South Africa

Background: Tibial nonunions pose significant treatment challenges despite the regularity with which they are encountered. While several studies have reported the outcome of treating different nonunion subtypes with various strategies, few have investigated the factors that influence treatment and outcome. This study aims to identify factors that complicate the management of uninfected tibial. nonunions and are associated with failure of treatment. Methods: We retrospectively reviewed all patients with uninfected tibial nonunions who were treated according to a standardized treatment algorithm over a 5-year period. Results: The final cohort consisted of 84 patients with a mean age of 36.5 years (range 5–68 years). Bony union was achieved in 79 out of 84 (94%) tibias. Malalignment (P < 0.001), smoking (P = 0.008), alcohol use (P = 0.039), and time from injury to nonunion management (P = 0.003) were found to be associated with treatment failure. The factors found to be associated with increased treatment complexity were smoking (P = 0.035), alcohol use (P = 0.011), and time from injury to nonunion management (P < 0.001). Conclusions: General orthopedic surgeons should, therefore, refer these patients to reconstructive surgeons as soon as the diagnosis of a tibial nonunion is made while reconstructive surgeons should note the importance of host optimization and mechanical alignment during the management of these conditions. Acknowledgements: There are no conflicts of interest


  PP 137: Total Diaphyseal Defects Of The Tibia Treated By Transversal Medialward Transport Of Fibular Split. Top


Fernando De La Huerta MD: Asami Mexico, Fernando De La Huerta

Instituto Mexicano del Seguro Social, Guadalajara, Mexico

Background: Large diaphyseal defects usually result from high energy trauma to extremities or from wide dèbridements in cases of chronic osteomyelitis, and they represent a significant challenge for orthopaedic doctors. The principle of osteogenesis by traction described by Ilizarov is an excellent biological method for filling bone gaps on long bones but the time required to fill the gap is so long. The objective of this study is to present the Fibular transversal medialward split to decrease the time to filling the gap in Tibial bone defects. Two areas of research were developed that could be able to perform medialward bone translation to fill the gap. Methods: Experimental Research. This medialward bone transport system was experimentally tested on five adult dogs, with average weight of 15 kg. The animals were submitted to 12-hour fasting previously to surgery. Two wires were fixed in the lateral side of the tibia. These wires had been attached to the bone transport devices which was fixed to a circular frame in the dog's leg. Once the system was complete stable, a corticotomy of one half of the tibia was performed. 7 days later the medialward traction was started until four cms of transversal distraction was achieved. The complete new bone formation was done with an average of 1 month and a half for each 1 cm. Clinical Application. Six patients with tibial bone defects were treated by the medialward Fibular translation bone method. The mean bone defect was ten centimeters. Results: The mean external fixation time was 5 months, Union was achieved in all cases. An external circular frame with transversal transport devices were attached to the half part of the fibula, followed by an axial medial shaft corticotomy was performed . The length of the transversal bone transport was an average of 4 centimeters. Conclusions: Summary. The main disadvantage of the Ilizarov method in the axial bone transport is the lengthy external fixation time with the transversal medial ward. In the management of Fibular bone transport, the lengthy time is shorter, especially considering the large defect size of these large Tibial defects, the transversal bone transport is favourably to reduce the treatment time. Acknowledgements: Orthopaedics Division. Instituto Mexicano del Seguro Social . Guadalajara Mexico


  PP 138: Soft Tissue Reconstruction In Grade 3 Tibial Fractures And Osteomyelitis With Ilizarov Fixation. Technical Note. Top


Bernard Prakash Devadasan

Mawar Medical Centre, Seremban, Malaysia

Background: Objective. To determine the outcome of soft tissue and osseous reconstruction with Ilizarov fixation. Treatment of open fractures is challenging. Muscle flaps are the preferred method of wound coverage in lower extremities. The lower extremity has been divided into the rule of thirds with the gastrocnemius muscle flap- proximal third, soleus muscle flap- middle third and free tissue transfer-distal third. Thorough debridement, stable anatomical fixation with Ilizarov frame in fractures, excision of infected bone in osteomyelitis, early flap coverage has improved the clinical outcome. The pivot point is most crucial to the success of the soleus flap and the zone of injury determines its viability. Methods: Design. A retrospective review. From 2000 to 2016 we treated 34 patients with an open tibial fractures and osteomyelitis with a local and free flap. We reviewed databases for type of trauma, time to tissue cover, infection, and union of fracture. Bone defect ~7-14 cm. A clinical data with infectious non-union of tibia with accompanying soft tissue defects was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria of scoring system. All cases presented with different degrees of skin and soft tissue defects, wound with exposed bones, discharging sinuses and adhesive scar around bones underwent bone transport and lengthening aided by plate or intramedullary nailing. Flap area ranged from ~ 15 cm by 5 cm. Vaccum Assisted Closure (VAC) aided in the wound healing. Various flaps were used to resolve the soft tissue problem with delayed split thickness skin graft 5 days later. Results: When soft tissue cover was delayed beyond 7 days, infection rate increased from 27% to 60% (p < 0.04). According to the ASAMI score, there were 32 excellent results, 1 good result, and 1 poor result. The organism commonly was methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. Conclusions: Soft tissue takes precedence from bone. Flap transfer increases the blood supply to compromised areas and provides coverage of exposed vital tissues in1stage with adequate debridement, bone stabilization, proper flap selection, and meticulous microsurgical technique avoiding microvascular anastomosis within the zone of injury. Staged soft tissue flap reconstruction surgery delayed healing and was at risk of compromising the bone union. The surgical debridement is the main aspect in the treatment of tibial osteomyelitis and local antibiotics. Acknowledgements: Prof Maurizio Catagni


  PP 139: Treatment Of Periprothetic Fracture Nonunion And Bone Defect Of Femur After THA With Ring Fixator And Distraction Osteogenesis Top


ShengSong Yang, Lei Huang

Beijing Jishuitan Hospital, Beijing, China

Background: Bone defect of femur shaft after debridement of Vancouver Type C periprothetic fracture is challenging problem. The patient is female, 30 years old. She was injured in a motorcycle accident 6 years ago; diagnosis was femoral neck fracture (Lt). A THA was performed 4years ago because of femoral head necrosis. She falls down from bicycle and hurt her left thigh 2years ago, diagnosis is periprosthetic fracture of femur. An ORIF was perform with shape memory alloy plate. Infection and sinus occur after operation. Plate removal and irrigation operation was performed 8 months ago. Now diagnosis is of periprosthetic fracture nonunion and bone defect of left femur. Methods: From the PE and result of examination the author believed that the femoral stem is stable, and the infection has been eradicated. So, we perform distraction osteogenesis operation with ring fixator and femoral supercondyle osteotomy. After the bone segment was transport to the proximal femur, a clamp with 2 pins mounted above the acetabulum was connected to the ring fixator, partial weight bearing is permitted. It took 12 months for the 15cm new bone to consolidated. Then A cable plate was used to fix the docking site, accompany with autograft of iliac crest of both side and right fibula. Results: the patient was followed up for 4 years, the new bone had been consolidated, and docking site united very well. Now she can stand on both leg without support, and walk with a cane. the patient is very satisfied with the result of treatment. Conclusions: Distraction osteogenesis with ring fixator and femoral supercondyle osteotomy is an effective way that can produce enough new bone for the bone defect of femur shaft after debridement of Vancouver Type C periprothetic fracture. It is very helpful to the new bone consolidate that to start partial weight bearing as early as possible. Open reduction with A cable plate and sufficient autograft is necessary for the union of the docking site. Acknowledgements: The author has not received any benefit from any company or organization.


  PP 140: The Analysis Of Current Situation In The Orthopedic Treatment Of Disabled People In China Top


Qin Sihe

national research center of rehabilitation technique aids, Beijing, China

Background: What are the actual situations for incidence, etiology, characteristics,. medical requirement of disabled people in China? How about the orthopedic staff training and academic research? Are the orthopedic surgeries for the massive patients with limb disabilities right?. Methods: There is a lack of such analysis in orthopedic field.The author has performed orthopedic surgeries on more than twenty thousand cases with varied limb disabilities in which statistic analysis was carried out in 16678 cases.The results showed that the orthopedic surgeries in the treatment of lower limb deformities and disabilities had been ignored because of the complicated treatment course and a lack of powerful motivation of market after the development of the large hospitals in the direction of market economy in the recent decade.There is a severe shortage of orthopedic surgeons,and even a loss of staff to do some orthopedic surgeries for certain lower limb disabilities ,leading to the situation that thousands of patients with limb disabilities did not get right orthopedic surgeries due to a lack of financial support and orthopedic surgeons. Results: The author analyses the incidence, aetiology, characteristics of age distribution ,economic condition and medical requirements,as well as put forward the suggestion and resolution to this problem. Conclusions: The author analyses the incidence, aetiology, characteristics of age distribution ,economic condition and medical requirements,as well as put forward the suggestion and resolution to this problem. Acknowledgements: Key Words. patients with limb disabilities,analysis of current situation,orthopedic surgery,resolution


  PP 141: New Technologies And New Concepts In Surgical Treatment Of Lower Limb Deformities And Impairment Top


Qin Sihe

national research center of rehabilitation technique aids, Beijing, China

Background: To summarize the “surgical treatment technology systems for correction of lower limb deformities, repair and functional reconstruction of incomplete limbs “, which were gradually formed by author during 31 years' experience of orthopedic surgery, in order to give positive references for orthopedic surgeons. Methods: More than 20,000 patients with various deformities and disabilities of lower limbs who were treated with surgery by author were reviewed. The complete cases from May 1978 to December 2009 were statistically analysed. According to the patient characteristics andactual condition of China ,the principles of lower limb deformity correction for polio sequelae and cerebral palsy ,Ilizarov external fixation system, center of rotation of angulation developed by Dror.paley ,and Orthotic technology were put together ,and all the above knowledge were constantly absorbed and optimized.Under the influence of Darwin's theory of evolution and philosophy idea” Daofa Ziran”, the idea of “natural bone reconstruction” was proposed.and this idea was summed up in 24 words.”Surgical treatment system with Chinese characteristics for correction, repair and functional reconstruction of lower limb deformity “ was primarily formed at last. Results: A total of 5911 patients with various lower limb deformities and disabilities who received operations between June 1999 and December 2009 were retrospectively analyzed age range 1.5 to 76 years.All these cases had not bone infection 4 patients were ill with incomplete peroneal nerve palsy . 9 patients with deformities of lower limb on the verge of amputation were saved.The rates of treatment satisfaction were above 95 percen. Conclusions: “ Surgical treatment technology systems for correction of lower limb deformity, repair and functional reconstruction of incomplete limbs “ proposed by author has many advantages.It includs extensive indication, less invasion and good curative effects, low medical risks.This system thatis in line with national conditions and the patient's realitycan effectively treat complex lower limb deformities whichcould not be treated by common orthopedic surgery .It deserves further research and has broad prospect. Acknowledgements: Keywords. Lower limb deformities, Incomplete limb, Surgical treatment ,Reconstruction, New technology system


  PP 142: The Design And Application Of Synchronized Springy Lengthening Apparatus For The Tibia And Tendo Calcaneus/ Top


Qin Sihe

National research center of rehabilitation technique aids, Beijing, China

Background: To study the role of writer's synchronized springy lengthening apparatus for the tibia and calcaneal tendon in preventing the clubfoot of secondary to the Ilizarov tibia lengthening. Methods: Based on the Ilizarov tibia lengthening apparatus, a special synchronized springy lengthening apparatus for the tibia and calcaneal tendon was designed. The tibial was made of distal and proximal two rings respectively and 4 threaded rods, and the calcaneal was made of a half ring, 2 hinges, and a threaded rod with spring. The half ring was fixed to the calcaneus by 2 crossed wires. The fracture tibia and fibula, ankle joint, calcaneoastragaloid joint were attached to the apparatus. At the same time of tibia lengthening, the soft tissue was simultaneously stretched andthe ankle joint could move and the leg could bear weight. If the clubfoot angle was larger the percutaneous fasciotomy of calcaneal tendon was performed; if the angle was less than 200, the pes deformities were corrected only by the stretch of calcaneal tendon. Results: 77patients'tibia were lengthen average 4.6cm, with an average speed of 0.7mm/d. The healing indices of the lengthened tibia was 1.35 months/cm. There are not the secondary varus and valgus deformities and clubfoot in all the patients. The clubfoot with 100-400angle of the 16 patients were corrected after tibia lengthening. Conclusions: The new apparatus coincide with the biomechanical principle and can effectively prevent the secondary deformities of foot such as chubfoot, talipes varus and valgus after tibia lengthing procedure. Acknowledgements: Key words. tibia lengthening, clubfoot, tendon calcaneus, Synchronized Springy Lengthening Apparatus


  PP 143: How much annoyance with pin-site infections during tibial fracture treatment? A prospective serie rapport of 100 patients Top


Telmo Ramos

Department of Orthopaedics, Skaraborg Hospital, Lidköping, Sweden

Background: When the fracture is fixed externally, many of the infections that affect the patient should be less difficult to treat than those treated by being fixed with plates and screws implanted. The aim of the present study was to evaluate pin-site infections in fractures of the tibia treated with the Ilizarov extern fixator. Methods: We analyzed prospectively 100 consecutive patients with an isolated unstable tibial fracture (30 were proximal metaphyseal, 31 diaphyseal, and 39 distal metaphyseal) that were treated at our institution using the Ilizarov external fixation. The median age of the patients was 49 years old (range 18—74). All the patients received cloxacilin (2 grams i.v.) preoperatively, which was repeated twice during the first 24 hours. The pin-site dressing protocol was based on chlorhexidine (Kurgan protocol). Pin-site infection was defined as discharge from the pin site with pain and/or tenderness in the soft tissues in accordance with the Checketts-Otterburn classification. Bacteriologic cultures were done if necessary. If a pin-site infection was diagnosed an empiric short-course antibiotic therapy was initiated with flucloxacillin. All the antibiotic prescriptions were registered and as well the performed clinical investigations if infection appears. In the follow-up done 2, 4, 8, 12 weeks and one-year was evaluated the self-appraisals (VAS Pain, VAS Satisfaction, NHP, EuroQol 5-D, KOOS and FAOS). Results: The time of extern fixation in weeks was a median of 15 weeks (6—30). The total number of potential pin-site infections was 2.548. One-hundred and two pin-site minor infections were observed in 66 patients. 72 Checketts-Otterburn II in 44 patients who were treated with short-term antibiotics and 30 Checketts-Otterburn III in 22 patients, all treated with the removal of the offending wire. Three patients had infection Checketts-Otterburn IV that healed after soft-tissue debridement and long-term antibiotic (clindamycin) for 12 weeks. The incidence of pin-site infection in the study was 4 %. The self-appraisal scores showed that the external fixation was well tolerated and the overall restoration was good. Conclusions: Even though the IL is burdened with a high frequency of superficial pin infections, the problem is limited, apparently without a negative impact in terms of the patients' self-appraisal and clinical outcome. Acknowledgements: The Research Fund at Skaraborg Hospital, Sweden supported this study. The funding agency was not involved in the design or the performance of the study.


  PP 144: Role of external fixation in complex post-traumatic non-union in the inferior limb: Reconstruction versus amputation Top


Nicola Tartaglia1, Chiara Noviello1, Gianfranco Corina2

1. , Acquaviva Delle Fonti, Italy

2. , Brindisi, Italy

Background: Complex non-unions (aseptic and infected) 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 Ilizarov method of bone transport helps to resect nonunion and to operate bone transport with a stable implant (circular, hybrid or monolateral). Methods: From 2005 to 2015 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. Results: 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. Conclusions: Authors believe that Ilizarov method lies is based on radical resection of non-union and the need of a very stable construct for bone transport (circular but also hybrid and monolateral rail). A good evaluation of patient psychology needs to be assessed 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 a team of dedicated plastic surgeons (not always necessary plastic graft in infected soft tissue defect), 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. Acknowledgements: We are grateful to the Hospital Committee for the scientific support realizing this study. Authors declare no affiliations or involvement in any organization or entity with financial and non-financial interests in the subject matters or materials discussed in the manuscript.


  PP 145: Comparative Study Of Open Fractures Of The Tibia With A Nail With A Core Release Of Antibiotics (SAFE DualCore Universal). Top


Nuno Craveiro-Lopes

Orthopedic Department, Portuguese Red Cross Hospital, Lisbon, Portugal

Background: The aim of this study is to compare the clinical and radiographic results of an interlocking nail with a releasing antibiotic core of PMMA, named SAFE Dualcore Universal nail, with a standard interlocking nail for the treatment of open fractures of the tibia. Methods: Prospective, controlled cohort 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 significative 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 (from 5 months to 4 years) for the STD group and 2.1 years (from 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 significative difference (p=0.02). The mean time to union was 7.5 months (from 3 months to 1.5 years) for the STD group and 4.5 months (from 2 months to 8.5 months) for the SAFE group, a statistically significative difference (p=0.02). The complication rate was 64% (9/14) in the STD group and 25% (4/16) for the SAFE, including the infection rate, a statistically significative 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 and 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 ½ months later. Conclusions: We observed that the open fractures of the tibia treated with the SAFE nail presented a statistically significative lower rate of infection, faster consolidation and fewer complications. Acknowledgements: Nill


  PP 146: Original method and device of dynamic external fixation for joints in complex intraarticular fractures Top


Milorad Borivoje Mitkovic1, Sasa Milenkovic1, Ivan Micic1, Milan Milorad Mitkovic2

1. Medical faculty University of Nis, Nis, Serbia

2. Orthopaedic and traumatology clinic, Clinical center Nis, Nis, Serbia

Background: Dynamic joints fixations provides natural stability of joints with complex fractures (as flexion - extension) while prevents undesirable movements (as varus - valgus). We present results of method and device we have developed. Methods: As a clinical material we have used 93 patients with rigid or dynamic external fixation of following joints. ankle and knee. We have used new external fixation device which consists of only 3 components. bar, carrier and clamp. The same system is suitable for bridging or dynamic fixation of joints. It provides flexion-extension bat prevents varus-valgus. Rigid bridging frame can be performed in out patient clinic 2-3 weeks after the operation. We also used original device for joint axis rotation finder. Minimal internal fixation has been used in 72 fractures. Results: Average time of healing was 2-6.5 months. End functional results in intraarticular fractures were. very good 22%, good 57%, fair 17%, and poor 4%. Conclusions: Transforming from rigid bridging fixation to dynamic joints fixation is relatively simple. It can be concluded that dynamic external fixation of joints gives promising results in intraarticular fractures treatment. Acknowledgements: Author has licence agreement with external fixation producer as owner of patent.


  PP 147: Original extarnal fixation system in treatment of war wounds with fractures caused by cluster bombs Top


Milorad Borivoje Mitkovic1, Sasa Milenkovic1, Ivan Micic1, Predrag Stojiljkovic1, Milan Milorad Mitkovic2

1. Medical faculty University of Nis, Nis, Serbia

2. University orthopaedic and traumatology clinic, Nis, Serbia

Background: Locomotor system is the most often affected part of human body, during the war. The aim of this study is to describe the nature of war wounds with fractures caused by cluster bombs and success rate of the use of original external fixation system. Methods: As a clinical material it is presented series of 81 patient sustained war wounds with fractures (99 injuries). Average age of the patients was 32,7. The youngest patient was 20 and the oldest 77. According to the grade of the injury (ICRC classification) it was. grade I-14 patients, grade II-48 patients and grade III-29 patients. As material for fracture fixation it was used external fixation system known as “War Fixator”. We used one protocol, which is combination of the protocol of the International Committee of Read Cross (ICRC) for treatment of complicated open fractures, adapted to our conditions. For solving of soft tissue defects rotator fasciocutan flap was used. For solving of bone defect the same, above mentioned external fixator was used. The nature of the wounds caused by cluster bombs is different in comparison to war wounds caused by conventional arms. The sides of wound were represented by conquasated soft tissues (fat, muscles) with big thickness of dead tissues, ordinary 0.5-4.5 cm. The main characteristic is higher percentage of amputation due to high rate of neurovascular damage. Results: Amputation rate was high due to high speed of shrapnels and severe damage of neurovascular elements. We have three chronic infections, one aseptic nonunion and one mall union. there were no thromboembolic complications. Conclusions: Using of external fixation during primary surgical intervention leads to good results. Using of very simple but versatile external fixator provides shortening of the surgical procedure. Acknowledgements: First author has licence agreement with external fixators producer as the owner of internationally recognized patents.


  PP 148: Impaired Joint Motion And Contractures In Callus Distraction And Segment Transport - A Retrospective Study Top


Lukas Zak, Gerald E. Wozasek

Department of Trauma Surgery, Medical University of Vienna, Austria, Vienna, Austria

Background: Temporary movement restriction of the adjacent joints are common complications during distraction osteogenesis at the lower limb. The aim of this study was to investigate the incidence of tendon contracture and impaired joint motion of the knee or ankle joint during and after callus distraction with ring fixation. Methods: 20 patients were surgically treated for callus distraction and segment transport with an external ring fixator after traumatic bone loss in 21 lower extremities. The impaired joint motion of the adjacent joints during and after treatment were evaluated retrospectively. Results: During treatment we observed free movement of the ankle joint in 4 patients (19%), restricted movement in 11 patients (52%), and no movement in 6 patients (33%). After an improvement in 8 cases (38%) and an impairment in 2 (10%), the joint movement resulted, after treatment, in a free range of motion in 12 cases (57%), impaired motion in 3 cases (14 %) and a fixed joint position in 6 cases (29%, 2 arthrodesis). In the knee joint, during treatment 6 times restriction in extension (24%) and 5 times restriction in flexion occurred, which resulted in one restriction (5%) in extension and 3 (14%) in flexion after frame removal. Conclusions: Impairment of joint motion during bone lengthening with an external ring fixator in the lower extremity occurs in most cases in the ankle joint. Various treatment options exist to deal with tendon contracture as soon as it has been noticed, but physiotherapy may prevent or mitigate its onset. Acknowledgements: No


  PP 149: The Algorithm Of The Use Of Ilizarov Technique And Microsurgical Flap For Complex Posttraumatic Defects Of Lower Extremity Top


Shengdi Lu

Shanghai Jiaotong University affiliated Sixth People's Hospital', Shanghai, China

Background: Currently, there are three methods for the reconstruction of the posttraumatic complex defects of lower extremity. 1) the use of composite flap transfer, 2) the combined use of the Ilizarov technique and the flap transfer, and 3) the used of the Ilizarov technique for simultaneous transfer of bone and soft tissue. However, the indications and contraindications of these three methods remain unclear. The purpose of our study is to retrospectively review the application of these three methods in patients with complex posttraumatic defects, and build an algorithm for their indications. Methods: We retrospectively review the patients with complex posttraumatic defects from January 2006 to January 2016, patients were divided into three groups according to the methods they took. Data including the rates of complications, hospitalization stays, entire treatment periods, and times of surgeries were extracted from hospital database, while other data including the limb functions and patients' self-satisfactory were recorded during follow-up studies. Results: There were totally 32 patients included, with 21 males and 11 females. Their ages ranged from 16 to 52 years old, with a mean age of 34.4 years old. The group of patients who treated with composite flap transfer holds the least treatment periods (5.5 weeks), and the least times of surgeries (1.4 times). The group of patients who treated with the combined use of the Ilizarov technique and the flap transfer holds the best limb functions and patients' self-satisfactory. Patients who treated with the used of the Ilizarov technique for simultaneous transfer of bone and soft tissue have the least rates of complications (2 complications for the entire group). The rates of complications rises, while the limb functions and patients' self-satisfactory decreased with the increase of entire treatment periods. Conclusions: The length of bone defects is a main factor for the decision of treating methods, when length of bone defects in the composite tissue defects less than 5 cm, we recommend the method of Ilizarov technique, and if width of soft tissue defects is less than 6cm, we also recommend the used of the Ilizarov technique for simultaneous transfer of bone and soft tissue. If the bone defects are larger than 5cm, the use of composite flap transfer is recommended. Acknowledgements: None


  PP 150: Custom 3D printed titanium truss cages combined with the Masquelet technique to reconstruct segmental bone loss: Preliminary results of treatment Top


Kevin Tetsworth1, Vaida Glatt2

1. Royal Brisbane Hospital, Herston, Australia

2. University of Texas Health Science Center, Queensland, United States

Background: Traumatic bone loss is a complex clinical problem that often requires extreme solutions. We introduce a novel strategy for treating bone loss, using patient specific 3D printed titanium truss cages in conjunction with the Masquelet membrane technique. Methods: Prospective series of eight cases. complications and rate of union were recorded. Samples of membranes and controls from normal fascia were preserved in RNA Later (Qiagen; Hilden, Germany), and stored at -80 C. Biological activity was investigated using RNA-Seq (Illumina; San Diego, CA, USA) to analyze gene expression for up/down regulation of growth factors relevant to fracture healing. Samples were also collected for histology. Patients underwent two procedures. (a) resection of avascular bone fragments and insertion of an antibiotic PMMA spacer, stabilised with a plate or IM nail; (b) 10-12 weeks later, custom 3D printed titanium truss cages (4Web Medical; Frisco, TX, USA) were implanted into the segmental defect within the Masquelet membrane; cages were filled with cancellous auto/allograft immediately prior to implantation. Results: The series includes 8 patients; 6 male and 2 female; mean age 53.1 years (26-73); 5 femurs, one tibia, one proximal humerus, and one mid-foot. The mean interval between stages 12.7 weeks (11 to 15); mean segmental defect 9.7 cm (2.2 to 18.4); mean bone defect volume 108 cc (8 to 239); mean length of follow-up 19 months (8 to 28). There were no infections, no fractures, no nerve injuries, no loss of alignment, and no non-unions identified. Preliminary analysis revealed up regulation of growth factors associated with initiation of fracture healing. VEGF (angiogenesis) was highly up regulated relative to the controls. Genes responsible for the membranous ossification pathway (TGFβ, BMP-2, BMP-6, Rankl, Osterix, IL-6, and IL-17) demonstrated a three-fold increase relative to the controls. Histology showed bone-like tissue was present with evenly distributed cell nuclei throughout the membranes, having the appearance of osteocyte or chondrocyte-like cells. Conclusions: Preliminary results suggest the use of custom 3D printed titanium truss cages, in conjunction with a Masquelet induced membrane, consistently resulted in successful reconstruction of these complex bone defects. This approach was most advantageous for massive juxta-articular bone loss, when other biological techniques were not possible. This technique compares favourably to other available methods of limb salvage and reconstruction. Acknowledgements: The authors have no conflicts of interest to declare relevant to the current study.


  PP 151: Reconstruction of complex and open intercondylar and supracondylar fractures of femur with Ilizarov ring fixator Top


NAVEEN Chandra J

manipal hospitals, Vijayawada, India

Background: Abstract Text. This study was done to determine the clinical effectiveness and safety of Ilizarov external fixation for the acute treatment of severely comminuted extra-articular and intercondylar fractures of the distal femur. A total of 10 patients with complex fractures was treated. There were two type-A3, three type-C2 and five type-C3 fractures according to the AO/ASIF system. The mean follow-up was 24 months. Most fractures (8) united primarily at a mean of 16 weeks. One patient with a type-IIIA open fracture had infection and nonunion. The mean range of flexion of the knee at the final follow-up was 105° (35 to 130). We conclude that, in the treatment of comminuted fractures of the distal femur, the Ilizarov fixator is safe and effective in providing stability and allowing early rehabilitation. Methods: Results: Conclusions: Acknowledgements: .


  PP 152: Ipsilateral Fibular Transport With An Ilizarov Frame For Treatment Of Massive Tibial Bone Defect (China) Top


Zhang Qun

Orthopedic department, General Hospital of PLA, Beijing, China

Background: n/a. Methods: A retrospective analysis was conducted in 21 patients with long bone aseptic non-unions of the lower extremities without bone defects who were treated with the accordion technique combined with MIPD between January 2010 and December 2015. The limb-length discrepancy(LLD) was less than 2cm in all patients. None of the patients received autogenous bone grafts during follow-up. All surgeries were performed by the same surgeon, and the modified Application of Methods of Ilizarov (ASAMI) criteria were used to evaluate the operative effectiveness. Results: A total of 21 patients were included in this study, and 1 patient was lost during follow-up. Fifteen of these patients presented with oligotrophic non-unions, and 5 patients presented with atrophic non-unions. The average follow-up period in these patients was 12.5 months (range. 8-42 months). The alternative compression and distraction procedure was repeated 1 to 3 times. Blood loss was 30 to 250ml during surgery. Ultimately, bone union was achieved in 19 patients and failed in 1 patient. The fractures healed within 4 to 8 months (average time. 5.8 months), and fracture healing was considered excellent in 19 patients and poor in 1 patient. Postoperative function was evaluated as excellent in 9 patients, good in 6 patients, fair in 4 patients, and poor in 1 patient. Conclusions: The accordion technique combined with MIPD, which is a simple, minimally invasive procedure that does not require autologous bone grafting, resulted in a high bone union rate and good postoperative function. Acknowledgements: Keywords. Ilizarov technique; Decortication; Chipping; oligotrophic non-union; atrophic non-union; minimally invasive.


  PP 153: Accordion Technique Combined With Minimally Invasive Percutaneous Decortication For The Treatment Of Bone Non-Union Top


Zhang Qun

Orthopedic department, General Hospital of PLA, Beijing, China

Background: A variety of approaches have been used to treat oligotrophic or atrophic non-union. Conventional methods are often associated with great operative trauma, increased blood loss, a risk of re-infection, higher medical costs, and complications at the donor site. This study aimed to assess the clinical efficacy of the accordion technique combined with Minimally Invasive Percutaneous Decortication (MIPD) for. these types of bone non-union. Methods: A retrospective analysis was conducted in 21 patients with long bone aseptic non-unions of the lower extremities without bone defects who were treated with the accordion technique combined with MIPD between January 2010 and December 2015. The limb-length discrepancy(LLD) was less than 2cm in all patients. None of the patients received autogenous bone grafts during follow-up. All surgeries were performed by the same surgeon, and the modified Application of Methods of Ilizarov (ASAMI) criteria were used to evaluate the operative effectiveness. Results: A total of 21 patients were included in this study, and 1 patient was lost during follow-up. Fifteen of these patients presented with oligotrophic non-unions, and 5 patients presented with atrophic non-unions. The average follow-up period in these patients was 12.5 months (range. 8-42 months). The alternative compression and distraction procedure was repeated 1 to 3 times. Blood loss was 30 to 250ml during surgery. Ultimately, bone union was achieved in 19 patients and failed in 1 patient. The fractures healed within 4 to 8 months (average time. 5.8 months), and fracture healing was considered excellent in 19 patients and poor in 1 patient. Postoperative function was evaluated as excellent in 9 patients, good in 6 patients, fair in 4 patients, and poor in 1 patient. Conclusions: The accordion technique combined with MIPD, which is a simple, minimally invasive procedure that does not require autologous bone grafting, resulted in a high bone union rate and good postoperative function. Acknowledgements: Keywords. Ilizarov technique; Decortication; Chipping; oligotrophic non-union; atrophic non-union; minimally invasive


  PP 154: Computer Tomography In Limb Salvage And Deformity Correction - Indications, Radiation Exposure And Safety Considerations Top


Lukas Zak, Thomas Tiefenboeck, Gerald E. Wozasek

Department of Trauma Surgery, Medical University of Vienna, Austria, Vienna, Austria

Background: CT scans are an essential tool in bone reconstruction. It is necessary for various questions and helps the surgeon for crucial decisions. However, CT is known as a method with high radiation exposure and shouldn't be underestimated. The aim of this study was to present the usual indications for CT-scans in deformity correction, to estimate the effective radiation dose and to further avoid unnecessary radiation exposure by narrowing the field of examination and explicit scanning methods. Methods: We performed a retrospective data analysis including 19 out of 25 patients treated by bone reconstruction after severe bone defects. CT scans were performed preoperative, postoperative or during treatment for planning, further decisions or follow-up. Radiation exposure and risk of fatal cancer were evaluated for each patient, indication and region of examination. Results: The quality was high despite metal frames or cast. Mean effective dose was 3.27 mSv for each patient with a mean cancer risk of 1:117.014. This depends on location and indication of measurement as a mean ankle measurement starts at 0.04 to 0.12 mSv, up to 6.8 or more mSv for vascular depiction. Conclusions: We conclude that CT evaluation with or without 3D reconstruction is an important tool in complex bone reconstruction and deformity treatment. However, strict indications are necessary to reduce radiation exposure and alternative methods should be considered. Acknowledgements: no


  PP 155: A Study Of Reconstruction Of Lower Limb Trauma By Limb Reconstruction System (LRS) Using 50 Cases Top


Hariram Ramniwas Jhunjhunwala

Post Graduate Insitute of Medical Sciences of Bombay Hospital, Mumbai, Mumbai, India

Background: LRS is a Versatile Unique external fixation with various indications. It can be used as a Uni-Lateral Fixator but Very Sturdy. It can be used for Limb Lengthening, Transportation, in Compound Communicated Fractures, Infected Non-Unions, Arthrodesis of Joints and Fixations of Various Osteotomies. It is a Rail System with the Compartments move. Methods: We have used LRS in various indications in . 50 Cases. We have used on 22 Femurs, 26 Tibias, 2 Humerus. In Non-Infected = 14 Cases, . In Infected = 36 Cases,. In Arthrodesis of Joint = 3 Cases. Results: Results = Good to Excellent . Conclusions: LRS as a external fixator has multiple indications . and easy to apply. It is patient's friendly and gives a excellent results. Acknowledgements: Principles Deformity Correction by Dror Paley


  PP 156: Management Of Traumatic Bone Defects Using Ilizarov External Fixator - Different Treatment Strategies Top


Prasad Nvsv Pavuluri

Srujan ortho and accident care, Khammam, India

Background: Abstract Text. Increased number of high velocity compound comminuted trauma and increased number of internal fixations for the early mobility of the patient have contributed to more number of infected gap non-unions. The strategies for the repair of different types of bone loss maybe it is acute or maybe it is post fixation infected nonunion are different. It could be a minimal bone loss or it could be a massive bone loss of up to more than half of the segment, the strategies differ accordingly. Bone transport has a high rate of ultimate success with many series reporting upwards of 90% eventual healing with arrest of infection. There is no donor site morbidity associated with transport, as all the new bone comes from the injured leg. In addition, the leg can be functional and weight bearing during treatment. However, the treatment does require prolonged time in the external fixator, in some series up to 2 months per cm of gap filled. A large part of the frame time is due to delayed healing of the docking site, and this problem frequently requires bone grafting. The prolonged time in the frame contributes to a high rate of complications, such as pin site infections, cellulitis, contracture, edema. My experience with these situations with good clinical examples will be covered. Methods: Results: Conclusions: Acknowledgements: .


  PP 157: The Deformity Correction And Fixator-Assisted Treatment Using Illizarov Versus Taylor Spatial Frame In The Foot And Ankle Top


Yudha Manggala1, Andri Primadhi2, Chayanin Angthong3

1. Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin Hospital, Bandung, Indonesia

2. Foot and Ankle Surgery, Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin Hospital, Bandung, Indonesia

3. Foot and Ankle Surgery, Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand

Background: Ring fixation techniques have been reported to obtain the correction of challenging deformities. Recently, a new type of external fixator called Taylor Spatial Frame® (Smith & Nephew, Memphis, Tenn.) has been increasing in popularity as an alternative to the Illizarov external fixator. However, there has been none of reports published regarding the comparison of outcomes between classical Illizarov ring and TSF for corrections of ankle and foot deformities. This study was to report the comparison of outcomes between these circular external fixations to assess the effectiveness of ankle and foot deformities correction, follow-up results, and complications. Methods: We report 12 patients in whom ankle and foot deformity was corrected using circular external fixation and following procedure. The parameters were assessed. age, gender, affected sides, causes of deformity (equinus, Charcot, fracture-related), surgical procedure, pre-postoperative deformity, and complications (soft tissue-related, implant-related issues). Of the 12 patients, 7 patients was applied Illizarov ring fixator and 5 patients were carried out with TSF. Outcomes were evaluated according to motion improvement or healing rate of fusion or fracture in x-rays, healing of ulcers, and infection clearance. Final outcome was categorized as success, partial success, and revision-needed. Results: With the ratio of male compared to female is 2:1. The patients' mean age was 44.8 years (range 18-63 years). There were 7 and 5 patients who had the deformities on right and left sides, respectively. Mean follow-up time was 7 months. Of 12 patients, the success rate was 75 %, partial success was 16,7 % and 8,3% revision-needed. The patient with partial success had a soft tissue problem and delayed consolidation. We did soft tissue flap to cover the wound and giving calcium medication. And one patient got revision due to delayed consolidation following the operation. Even though the average amount of parameters was higher in the TSF-group, there was no significant difference (P>0.05) when comparing the two groups. (Initial dorsoflexion differences with p-value 0,378; Last follow up dorsoflexion differences with p-value 0,297;Succes results differences with p-value 0,470;Complications differences with p-value 0,293). Conclusions: TSF is a potential treatment to provide more effectiveness and lesser complications than Illizarov fixation in the correction of ankle and foot deformities. Acknowledgements: None. No financial interests or potential conflicts of interest


  PP 158: Acute Shortening In Posttraumatic Bone Defects Or Sequelae Of Chronic Osteomyelitis Top


León Gonzalo Mora H. Md.

CORA Group - Clínica El Rosario, Medellín, Colombia

Background: It is a technique in reconstructive surgery that allows to cover acute or chronic post-traumatic skin defects and to resect deteriorated fibrous tissue in chronic osteomyelitis with soft tissue damage. Apply the external Fixator, align the segments and shorten the limb up to 6 cms. To close the cutaneous defect, it offers significant advantages in coverage with reduction of the time of external fixators or plastic surgeries with vascularized flaps. It is a safe method and allows to cover structures at risk of infection when exposed to the external environment such as bone and tendons. Methods: Soft tissue management techniques are mixed in bone compression and elongation with osteotomy at a site different from that of the exposed tissue or trauma. The external fixator is placed monolateral or circular according to the decision of the surgeon, a complete debridement of the devitalized tissue is performed, the bone edges and soft tissues are regularized, an attempt is made to leave a horizontal defect that allows shortening of the limb, The distal circulation, capillary filling and pulse should be checked to avoid vessel closure and limb loss. Results: The technique is applied to 46 patients with bone defects with an average of 5 cm (3 to 14 cm). It decreases the use of external fixator until in a third of the time, from 1.5 month to centimeter to 0.8 month by centimeter and if combined with techniques of Internal fixation decreases until 0.5 month of tutor by centimeter of lengthening. It allows for early bone coverage, avoiding infection, bone drying and need for other skin coverage techniques such as regional or vascular flaps. Conclusions: The technique can be applied with external fixation Monolateral or circular, allows better and safe handling of soft tissues. It reduces the time of external fixation, allows an immediate skin cover, favoring the consolidation and avoiding infections. It can be applied as part of the control of damage in trauma centers. Acute limb shortening and re-elongation is another excellent technique for the reduction of soft tissue and bone defects by restoring limb function in a single procedure without the need for further reconstruction procedures in most cases. Although based on the Ilizarov techniques, problems frequently encountered with bone transport are achieved by converting a reconstruction of the complicated limb into a linear limb elongation. It is recommended to be used as definitive treatment immediately after trauma. Acknowledgements: CORA Group. Medellín- Colombia.


  PP 159: Masqueleth Technique Or Distraction Osteogenesis In Bone Defects, What Is The Best.: By. León Mora H. MD Top


León Gonzalo Mora H. Md

CORA Group - Clínica El Rosario, Medellín, Colombia

Background: Abstract Text. A critical analysis of each of the techniques is performed as an alternative of reconstruction in segmental defects secondary to trauma, infection, pseudoarthrosis, serious comparisons of the two alternatives, their application principles, results and possible complications, biological principles are analyzed Of the bone consolidation and recommendations are made for the application in reconstructive surgery, it is determined according to the scientific evidence which technique is safer and more versatile in certain cases. It is concluded that the technique of Masqueleth or induced membrane is useful in certain cases, a demanding technique and that can have a greater number of complications if the application protocol is not rigorous. Comparatively the Osteogenesis by Distraction in a more biological technique, more predictable in time and its results and a bone of better quality is obtained, applicable in segmental osseous defects of the extremities . Methods: Results: Conclusions: Acknowledgements: .


  PP 160: The Chinese Successful Experience Of Limb Salvage For The Treatment Of Lower Limb Deformities On The Verge Of Amputation Top


Qin Sihe

National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: Analyzed the clinical efficacy of Ilizarov technique combined with orthopedic surgery in the treatment of lower limb deformities on the verge of amputation and discuss the Chinese successful experience. Methods: Between May 2010 to December 2015,we use sinicization Ilizarov technology combined with Qin Si he orthopaedic surgery technique for the treatment of severe lower limb deformities on the verge of amputation on 56 patients, which 39 cases male and 17 female(mean age 32 years, range 5~62 years old).Including 4 cases of the Congenital Absence of Fibula, 1 case of Congenital Absence of Tibia,1 case of Congenital distal tibia and fibula agenesia with ankle deformity; 33 cases of traumatic lower limbs; lumbar spinal bifida due to ankle malformation in 12 cases with weight-bearing area of ulcer; 2 cases of nerve injury of spinal cord tumor; 3 cases of vascular obliterans. Results: 56 patients were followed up for 6-54 months (mean, 32 months) .56 patients were successful achieve limb salvage, the patients with lower limb deformities were corrected at final follow-up time, the limb alignment were mostly restored, realized the plantar foot.Of which 44 cases of the patients with lower limb length completely corrected,12 cases with the length difference less than 3cm.48 patients can walk freely, 6 patients wearing with braces, 2 cases need crutches to walk.All cases achieved the goal of orthopedic and functional reconstruction through surgery, and no serious complications.The surgical method and procedure was optimized and achieved a series of innovative on subversive theory, history of science of bone surgery, clinical medical model and achieved very satisfactory results. Conclusions: [Key words] Ilizarov technique,Qin Sihe surgical,verge of limb amputation,lower limb deformity,limb salvage. Acknowledgements: [Key words] Ilizarov technique,Qin Sihe surgical,verge of limb amputation,lower limb deformity, limb salvage


  PP 161: How To Reconstruct Crawl Squatting Patients' Standing And Walking Function-----Analysis Of Surgical Treatment Of 603 Cases Top


Qin Sihe

National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: Paralysis of the lower limbs, hip and knee flexion contracture deformity lead to the loss of the limb alignment which is the chief reason for crawl squatting gait.The patients can crawl and squat instead of walking on the ground, while far distance required to move by the wheelchair. The urgent appeal of the patients is the ability of standing and walking. Methods: From February 1981 to December 2014, 603 cases with crawl squatting gait were treated. 406 cases were male and 257 female. The age from 3 to 56 years old including 534 cases less than 20 years old, (6-10 years old in 247 cases, 11-15 years old 116,16-20 years old), accounting for more than 90%. 498 cases were poliomyelitis sequelae, 70 cases cerebral palsy , 13 cases congenital joint contracture syndrom , and 22 cases the other reason.Crawling-squat ting type:grasping hands and feet squatting 492 cases;crawling 64 cases;Kneeling on both knees 26 cases;moving by bench 17 cases;Shakeing and moving by butt 3 cases. Results: The patients did not occur limb necrosis, osteomyelitis and other complications.More than 50% of patients due to financial difficulties and other reasons can not complete the planned surgical treatment .All patients were followed up for more than 3 years after operation. All patients achieved upright walking by or not crutch. Conclusions: In this group, the 603 cases of crawling squatting patients are the largest group in the world which reflecte that there are more severe patients with lower extremity disability in China. The combination of Ilizarov technology and Qin Si he orthopedic technology, expand the surgical indications for crawl squatting patients, basically can avoid the risk of surgery, guarantee the curative ef. Acknowledgements: [Key words] Severe physical disability, Crawling squatting, Operation principle, Systematic rehabilitation


  PP 162: Massive Bone Lengthening Beyond Twenty Percent Of The Initial Bone Length: Mansoura University, Egypt Top


Tamer A. Mawla A. Gawad, Nabil Ahmed Elmoghazi

mansoura university, Mansoura, Egypt

Background: Historic guidelines suggesting limits to the amount of limb lengthening, we report the results and complications of those patients in whom the initial goal of lengthening or transport exceeded 20% of the initial segment length. Methods: Our study represents 25 patient with28 bone segments managed by Ilizarov External fixator in Orthopedic Department, Mansoura University mean follow-up of 42.5 months. Limb-length discrepancy was the primary indication in 10 segments, bone defect in 12 segments and mixed Limb-length discrepancy and bone defect in 6 segments, out of these cases there were 5 cases with composite soft tissue and bone defects. Lengthening ranged from 8-22 cm with a mean lengthening goal of 32% (ranged. 25-50%) of the original bone length was achieved; additional procedures were needed in 9 segments to augment regenerative and treat associated soft tissue problems, mean treatment times was 9.25 months with a healing index of 32 days/cm. Results: By Paley's classification scheme, all had problems, in addition to an average of 1.2 obstacles and 0.8 complications per segment lengthened. Good to excellent results were achieved in 84%. Conclusions: The uses Ilizarov external fixator for massive Limb Lengthening and bone transport Beyond Twenty Percent of the Initial Bone Length provides good option but with prolonged period of frame application. Acknowledgements: Thanks to Mansoura University hospital and faculty for supporting us to accomplish this work


  PP 163: Treatment Of Post Traumatic Chronic Osteomyellitis With Antibiotic Loaded Intramedullary Nail (SAFE DualCore) Top


Luis Barbosa, João Vide, Ana Marta Coelho, Daniel Mendes, Manuel Resende Sousa

Hospital Beatriz Ângelo, Lisboa, Portugal

Background: Treatment of posttraumatic chronic osteomyelitis is a challenging problem. Basic principles are aggressive surgical debridement, fracture stability, dead space management and appropriate delivery of antibiotics.The self-releasing antibiotic fixation endomedular nail (SAFE) DualCore is a locked intramedullary nail with a core of antibiotic-impregnated cement, which may address all the previously mentioned requisites of treatment. The authors present two cases of posttraumatic osteomyelitis treated with SAFE nail. Methods: Case 1 is a 35-year-old female with a fracture of the left tibia 2 years ago, which was fixed with plate and screws. She developed posttraumatic chronic osteomyelitis (Cierny IIIa) with acute septic drainge (3 fistula) at presentation in our institution. CT showed intramedullary infection in 15cm of the diaphysis and 3 cm of the cortical bone. The patient underwent surgery with removal of the plate and screws, surgical debridement and anterograde intramedullary nailing using the SAFE nail. Case 2 is a 78-year-old male with an open fracture of the tibial diaphysis. Initially treated with external fixation. Skin graft was needed due to necrosis in the posterior leg. At four months, external fixation was converted to intramedullary nailing which had to be removed one month later due to acute osteomyelitis. Management of post traumatic osteomyelitis was done with two months of external fixation followed by intramedullary nailing with SAFE nail. Results: In Case 1 wound coverage was not possible in the initial setting due to thorough debridement. Wound healing by second intention was completed by the 6th post-operative week. There were no other soft tissue healing delays. Case 1 presents with a pain free resolution of her symptoms. Is able to walk with full loading and no pain in the leg. Radiographically good bone apposition is present and no signs of infection are seen. Case 2 walk with can, but reports no pain. At one and a half years later, the patients had no other episodes of infection. Radiographically, with strong evidence of consolidation. Conclusions: SAFE nail is a valid solution in the treatment of post traumatic osteomyelitis, in particular, in the presence of non-union. This device allows the selection of the antibiotic according to sensibility test and a high concentration of these antibiotics locally, suppressing the infection during the period of tissue healing and bone consolidation. It also enables a quicker start of weight bearing. Acknowledgements: The authors received no financial support


  PP 164: A Simple Case With A Complicated Final: A Displaced, Closed, Tibial Fracture Becomes An Emergency.. Top


Marco Camagni, Haris Tsibidakis, Francesco Guerreschi, Piero Poli, Andrea Biffi, Alessandro Pelis

Ospedale A. Manzoni, Lecco, Italy

Background: Pedestrian hit by a car female 11-year-old, height 160 cm and weight over 50 kg with fracture of the distal third of the tibia, displaced, without signs of skin problems. Absence of associated neurovascular injury. Methods: Treated surgically, previous antibiotic prophylaxis, with a plate and screws after 3 hours of admission and regular course. After 2 months, infection with wound dehiscence and exposes of implants, delayed union, broken plate and bone infection. In emergency wide bone resection and applied Ilizarov frame with proximal osteotomy for segment transport for bifocal treatment. Results: Excellent clinical and radiological outcome, with no signs of local infection. Conclusions: Where did we go wrong? . - Surgical time?. - Surgical treatment? Is better ESIN or simple Cast?. - Clinical follow up is too simple?. - Antibiotic therapy is too short?. Let's discuss .. Acknowledgements: Karladani AH, Granhed H, Edshage B, Jerre R, Styf J (2000) Displaced tibial shaft fractures. a prospective randomized study. Kubiak EN, Egol KA, Scher D, Wasserman B, Feldman D, Kovac KJ (2005) Operative treatment of tibial fractures in children. are elastic stable intramedullary nails an improvement over external fixation? J Bone Joint Surg Am 87:1761–1768 . Silva M, Eagan MJ, Wong MA, Dichter DH, Ebramzadeh E, Zionts LE. A comparison of two approaches for the closed treatment of low-energy tibial fractures in children. J Bone Joint Surg Am 2012; 94:1853–1860. Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Orthop Surg 2005; 13:345–352.


  PP 165: Management Of Septic Complications With External Fixation In Leg Fractures. Our Experience In A Dedicated Centre Top


Carlo Salomone1, Giovanni Riccio1, Giorgio Burastero1, Antonio Biasibetti2

1. MIOS - MIOA, Albenga, Italy

2. MIOS-MIOA / CTO, Albenga / Torino, Italy

Background: In fractures of the lower extremity there are a series of outcomes and complications due especially to high energy trauma and the bone exposure that comes with it. This leads to the onset of septic pseudarthrosis, osteomyelitis and intolerance of internal fixation systems. At the MIOS (Infectious Diseases and Septic Orthopedics), a regional referral center for the treatment of bone infections, we often encounter this type of pathology using external fixation. Methods: From 2008 to today, we have encountered four different clinical cases. exposed trauma, where we proceed to a temporary stabilization with an external fixator in emergency and then proceed to a definitive treatment where indicated with an external fixator; acute septic complication, in which the treatment is to remove the means of synthesis and conversion with external fixation; chronic complications (such as chronic osteomyelitis and pseudarthrosis), where we proceed to clean the primary area of disease and removal of the internal synthesis (where present) and then proceed to the application of an external fixator where bone recovery is required, or where required arthrodesis. Except for emergency treatment, where unilateral fixators or multiplanar were used, the method we favor is the use of circular external fixators. Results: In our case series, of the 6 exposed trauma treated as described above all healed, of the 5 acute complications 4 healed and one case proceeded to an arthrodesis, of the 15 chronic osteomyelitis treated 10 healed while 5 cases were amputees, of the 85 septic pseudarthrosis cases 67 healed, 15 cases proceeded to arthrodesis, and finally 3 cases were amputated. Conclusions: In our case series, of the 6 exposed trauma treated as described above all healed, of the 5 acute complications 4 healed and one case proceeded to an arthrodesis, of the 15 chronic osteomyelitis treated 10 healed while 5 cases were amputees, of the 85 septic pseudarthrosis cases 67 healed, 15 cases proceeded to arthrodesis, and finally 3 cases were amputated. Acknowledgements: Ilizarov GA. Tha Tension Stress Effect on the Genesis and Groth of Tissue. Part II the Influence of the Rate and Frequency of Distraction. CORR. 1989. 260-266.41. Gustillo RB. The Influence of Induced Micromovement Upon the Healing of Experimental Tibia Fractures. Journal of Bone Joint Surgery. 1985, 67B. 650-655. Panjabi MM, White III AA, Wolf Jr JW. A biomechanical comparison of the effects of constant and cyclic compression on fracture healing in rabbit long bones. Acta Orthop Scand 1979;50(6 Pt 1):653—61. Bianchi A, Maiocchi C. Introduzione alla conoscenza delle metodiche di Ilizarov in ortopedia e traumatologia. Edizione Medi Surgical Video1983. Morandi M, Landi S, Kilaghbian V et al. Schatzker type VI tibial plateau fractures and the Ilizarov circular external fixator. Bull Hosp Jt Dis. 1997; 56(1):46-8.


  PP 166: Bone Transport of Tibia: Top


OMER Ali Rafiq, SNOOR Jalal Mustafa

College of Medicine-University of Sulaimani, Slemani, Iraq

Background: This is a comparative study to evaluate the outcome of forty patients with bone loss in tibia using conventional external fixation device for group A while for group B using Ilizarov external fixator device each group consists of 20 patients , based on principles of distractive osteogenesis. Methods: Forty patients with bone loss of 4.0 to 10.0 centimeters in tibia were treated in a period from April 2011 to April 2016, their ages ranges from 15-65 years, and female to male ratio was 6:34. The causes of the defects in tibia were; fracture due to road traffic accident (20 cases), bullet injury to leg (8 cases), gap nonunion (8 cases) and infected non unions (4 cases). They were divided into two groups each consisted 20 patients, conventional external fixator used for group A, while for group B Ilizarov external fixator device was applied with performing transverse Corticotomy proximal or distal to the gap. Results: Evaluation of results was done according to Association for Study and Application of Ilizarov Method (A.S.A.M.I.) scoring system and it revealed that both functional and bony results were better in Group B than Group A, but the results were not statistically significant. Conclusions: Fixation of the bone by Ilizarov frame gives more rapid union of the bone, less chance of pin tract infection and cosmetically more preferable because of smaller scar tissue of entry of K wires than Schanz pins. Acknowledgements: I would like to thank all the staff in college of medicine and in Orthopaedic Department of the hospital in contacting of the patients for proper follow up of the cases.


  PP 167: Treatment Of Fractures Of The Tibial Plateau (Schatzker VI) With External Fixators Vs Plate Osteosynthes: What Is My Choice? Top


Francesco Sala1, Paolo Capitani1, Valentina Scita1, Federico Bove1, Rosario Spagnolo2, Ahmed M Thabet3

1. Ospedale Niguarda, Milano, Italy

2. Ospedale di Romano di Lombardia, Romano Di Lombardia, Italy

3. Department of Orthopaedic Surgery School of Medicine, El Paso, Texas, United States

Background: To determine the effectiveness of the circular external fixation (CEF) for patients with complex fractures of the tibial plateau (Schatzker VI) compared to the outcomes with a fixed angle locking plates group. Methods: Level III evidence. Retrospective, comparative study. Level I trauma center. Fourteen patients treated with CEF (Group A) were compared to fourteen patients treated with minimal invasive angle locking plates (Group B). The mean time from the fractures to the surgery was 20 days. The main outcome measures were clinical and radiographic. Results: Complete union was obtained in all fractures of the Group A without additional surgery at an average of 22 weeks. No nonunions or delayed union occurred. Results based on Association for the Study and Application of the Method of Ilizarov criteria. 71% excellent, and 19% good for bone outcomes and 64% excellent, 29% good, and 7% poor for functional outcomes in Group A. Normal alignment was observed in both groups. Conclusions: Definitive fixation with the CEF is effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of correct axial alignment, accurate application, versatility, and improved union rate and range of motion for complex fractures of the tibial plateau (Schatzker VI) in patients with multiple traumatic injuries, infection, and soft tissue injury. Acknowledgements: The authors declare that they have no conflict of interest.


  PP 168: Staged Management For Fifteen Patients With Missed Lisfranc Injuries: A Report Of Short-Term Results Top


Hui Zhang

Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China

Background: Lisfranc joint injury is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is very difficult and needs extensive dissection. Surgical outcome is not as good as that of an early reduction. The aim of this cohort study was to analyze the midterm clinical and radiographic outcomes of staged reduction and fixation in a consecutive series of patients with the old Lisfranc injuries. Methods: Fifteen patients (16 feet) with missed Lisfranc injuries were treated with staged reduction. Mean duration between injury and surgery was 4.8 month (3–8 month). In first stage, an external fixator was applied across the Lisfranc joint or/and Chopart joint and distraction was done at 1–2 mm/day. In the second staged, the open reduction and internal fixation (ORIF) was done and we were able to reduce all the fractures and dislocations. Results: The mean duration between two surgeries was 3.2 weeks (range, 2.5–4.5 weeks). Anatomic reduction was obtained in all 15 patients. At the last follow-up point, according to the grade of score, seven feet had good functional results, five feet fair, and four feet poor. In the four patients achieved poor functional results, two patients were due to severe injuries to the articular surface and tissue scaring, two patients were due to loss of reduction. In the four poor functional feet, two of them were scheduled to secondary arthrodesis during the follow-up. The average American Orthopaedic Foot and Ankle Society Midfoot Scale (AOFAS) scores for these patients were 75.8 points (range, 43 to 98 points). The pain visual analog scale (VAS) was 3.1 points at the final follow-up. Conclusions: Our study has displayed that staged reduction and extra-articular fixation should be considered for old Lisfranc injuries with a good reduction, the firm stability, low risk of intraoperative fracture and complication of soft tissue. Acknowledgements: No conflict of any interest


  PP 169: Treatment Of Post-Traumatic Equines Deformity Accompanying Unstable Scar Of The Heel And Around Ankle Top


Hengsheng - Shu

Dept.of Trauma, Tianjin Hospital, Tianjin, China

Background: To research the operative method and its comment on the posttraumatic equines deformity accompanying unstable scar of the heel. Methods: between June 2006 and May 2010, seven cases of posttraumatic equines deformity accompanying unstable scar or ulcer of the heel were treated with retrograde sural neurocutaneous island flap transfer combined the hinged Ilizarov apparatus application. All the patients were male and with a mean age of 37 years (range, 21-48 years). The average duration of followup was 18 months (range, 8-40months). The average preoperative dorsiflexion of equines deformity was ―45°and ankle motion was 10°. The areas of flaps were from 7 cm × 6cm to 11 cm ×9cm. The hinged Ilizarov apparatus was applied for gradual correction of equines deformity in all patients. Achilles tendon lengthening, sural neurocutaneous island flap transfer, and hinged Ilizarov application were dong simultaneously in 5 patients as a one-stage operation. In the remaining 2 patients, the delayed sural neurocutaneous island flap was done first and two weeks later the hinged Ilizarov apparatus was applied and the delayed flap was transferred as a second surgery. 2-3 weeks after the flap transfer, the strut of the Ilizarov fixator was adjusted to gradual correct the drop foot. Results: The duration of correction of equines deformity ranged from 2 to 4 weeks. All the flaps survived. The results were evaluated by the degree of active dorsiflexion of the ankle, the range of active movement of the ankle, activities, and walking ability. The results were good in six patients and fair in one patient. Conclusions: The posttraumatic equines deformity accompanying unstable scar or ulcer of the heel can be effectively treated by the Ilizarov technique combined the sural neurocutaneous island flap transfer. Acknowledgements: The authors want to thank all of the patients involved in this clinical research because of their courage and believe in


  PP 170: Open reduction and internal fixation combined with joint distraction for treatment of crush talar body fractures Top


Hui Zhang

Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China

Background: Crush talar body fractures are rare and usually have a very poor prognosis with a high incidence of avascular necrosis (AVN) and post-traumatic arthritis (PTA). The treatment for these injuries still remains challenge. The aim of this study was to evaluate the outcomes of crush talar body fractures treated by open reduction and internal fixation (ORIF) combined with joint distraction. Methods: From July 2013 to November 2015, eight crush talar body fractures were underwent surgical treatment in our department. When soft-tissue had recovered, ORIF combined with joint distraction was performed. Radiological analysis was obtained by plain radiographs and computed tomography (CT). Clinical outcomes were evaluated according to the Ankle-Hindfoot Scale of the American Orthopaedic Foot and Ankle Society (AOFAS), Visual Analogue Scale (VAS), SF-36 and patient satisfaction. Results: Six patients were followed up for an average duration of 22.3 months (range 13-28 months). All fractures obtained union. Superficial wound infection occurred in one case. Two patients developed in PTA and one patient presented with AVN and PTA. The mean AOFAS score was 69.7 (range 37-97), and the mean VAS score was 2.5 (range 0-6.2). The mean score of physical component summary (PCS) in SF-36 was 57.6 (range 32.8-87.5), and the mean score of mental component summary (MCS) was 64.8 (range 53.9-77.5). About 16.7% (1/6) patients felt very statisfied, 33.3% (2/6) statisfied, 33.3% (2/6) fair, and 16.7% (1/6) dissatisfied. Conclusions: Due to the high rate of AVN and PTA, crush talar body fractures have poor results. ORIF combined with joint distraction may provide a new and effective treatment to minimize the complications and obtain satisfactory outcomes for these injuries. Acknowledgements: No conflict of any interest


  PP 171: Treatment Of Tibia Pathologic Fracture Secondary To Chronic Osteomyelitis Using Ilizarov Method: Case Report Top


Rafael Portela, Catarina Aleixo, Guido Duarte

Centro Hospitalar Vila Nova de Gaia / Espinho, Gaia, Portugal

Background: Osteomyelities of long bones can cause pathologic fracures. However, there is no consensus on the materials and the techniques to use in fixing these pathologic fractures. Methods: Case Report. Results: We present a case report of a diabetic 74 years old female. The time of infection was for several years. The location of the pathologic fracture was on the middle third of the diaphyses of the left tibia. First of all, it was tried conservative treatment for 3 months without success. Then It was performed osteosynthesis with Ilizarov technique. At 5 months with Ilizarov, it was made grafting and a distal cutaneous posterior tibial flap, due to non-consolidation. After 12 months, the initial procedure the Ilizarov external fixator was removed and the patient was able to walk without crutches. The time of follow up is 5 years. Conclusions: This case demonstrates that the Ilizarov Technique is a valid method to treat pathologic fractures of the tibia with unresolved chronic osteomyelitis. Acknowledgements: Dr. Guido Duarte


  PP 172: Killing two birds with one stone: Mechanical axis correction with bone transportation for tibial bone defect with concomitant mal-alignment Top


Xing Teng, Lei Huang, Shengsong Yang

Jishuitan Hospital, Beijing, China

Background: It is more challengeable to treat the patients with bone defect combined with previous mal-alignment. It will be more satisfied if we can re-align the mechanical axis while achieving the bony union in bone defect. Usually the bone defect and the deformity apex are in different level. Mal-alignment correction from the bone defect level will lead to significant translation, which will compromise the union secondary to poor apposition. Docking site mal-apposition can be improved during transportation period. Level for osteotomy in bone transportation is another alternative for re-alignment. Methods: We retrospectively studied three cases with tibial bone defect in combination with mal-alignment caused by various pathologies. Case one was about 11cm of distal tibial bone defect with ipsilateral distal femoral varus mal-union (mLDFA 93°, MPTA 89°). The mechanic axis was corrected through proximal tibial osteotomy while distally transported the bone. Case two was about 6cm of distal tibial bone defect with congenital proximal tibial genu varum (MPTA 83°), complaining about medial knee pain in walking before injury. The re-alignment was tried at proximal tibial osteotomy while transported the bone distally. Case three was 7cm of proximal tibial bone defect with pre-injured intolerable medial painful osteoarthritis as result of congenital genu varum (aLDFA 81°, MPTA 80°). Genu varum was overcorrected from bone defect. The secondary translation was diminished by moving the transported fragment grangually. Results: All the three patients had the tibial bone defect united with bone transportation. The EFI (external fixator index) were 1.4, 4, and 1.7months/cm. The MAD (mechanical axis deviation) was medial 5mm, lateral 7mm and 13mm respectively. MPTA at the last following-up were 96°, 90°and 96°. Bony results were all excellent, so was the functional results except that the case one was good according to Paley's criterion. Conclusions: On one hand, there is no doubt to manage the tibial bone defect with bone transportation. On the other hand, we succeeded in achieving the following two goals through bone transportation. re-aligning the mechanical axis through the osteotomy, and improving the mal-apposition in the docking site secondary to re-alignment through bone defect. Acknowledgements: No


  PP 173: Analysis of outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia Top


Ankur Sahu Ankur

PT BD SHARMA PGIMS ROHTAK, Rohtak, India

Background: Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6 cm) bone defects of tibia treated with distraction osteogenesis. Methods: The study included 35 patients (30 males and 5 females) who had minimum of 6 cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27 cm. Mean follow-up period was 25.4 months. Results: Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness. Conclusions: Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients. Acknowledgements: Conflict of interest nil


  PP 174: Problems and strategies to treat the tibial osteomyelitis after fractures using Ilizarov Technique. Top


Kai Zhang

Binzhou Medical University Hospital, BINZHOU, China

Background: Tibial fractures are the most common site of open fractures. Tibial osteomyelitis is one of the most common complications. Ilizarov technology is the gold standard for the treatment of chronic osteomyelitis. In the treatment of the problems encountered in the process and treatment strategy is worth further study. Methods: Applied bone transport technology treatment thirteen patients with post-traumatic osteomyelitis between April 2009 and December 2012.With 9 males and 4 females, aged 23 to 65 years old with an average of 39.5 years old. Early thorough debridement and amputated necrotic bone, Install the bone external fixator and minimally invasive osteotomy on metaphysic, the wound was closed lavage negative pressure drainage or transplanted thick skin after VSD biological materials cover up. Application of ilizarov bone transport technology to repair bone defect. According to X-ray film shown in bone healing mineralization condition gradually dismantled fixed components by regular follow-up. Results: All patients had 12 to 32 months (mean 18.4 months) follow-up. Different degrees of soft tissue defect after treatment with individualized were healing and no recurrence of infection. Bone defect after debridement was between 4.5cm and 12cm (mean 6.1cm), all limbs were restored to normal length. One case of axial deviation by means of adjustment regain to normal force. One case of tissue contracture collapse on the bone defect through an operation fixed to improve by silk suture. One case of mild stent-tract infection was cured after debridement dressing combination antibiotics. There was no effect on all knee and ankle joint of function. Conclusions: Post-traumatic osteomyelitis cure the key was to solve the contradiction between infection and bone defect. However, ilizarov bone transport technology can not only under the premise of simplified treatment program safe and effective control of infection, restore bone defect, but also fixed stiffness can be adjusted according to the bone healing time eliminate stress shelter, correct the deformity, avoid secondary operation and clinical curative effect is superior, worthy of clinical popularization and application. Acknowledgements: Thanks to my colleagues for their efforts in this work, thanks to the support and understanding of my patients.


  PP 175: Treatment By External Circular Fixation For The Resolution Of Complex Traumatic Cases In The Lower Limbs. Top


Javier Martínez Ros, Cesar Salcedo Canovas, Jose Molina González, Francisco Javier Carrillo Piñero, Miguel Martínez Ros, Manuel Medina Quirós

Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain

Background: High-energy injuries to the lower limbs are usually the result of traffic accidents, of work or sports origin. They are sometimes associated with more serious injuries to the body, in the context of a polytraumatized patient where such injuries have to be temporarily stabilized by damage control surgery. The objective of this communication is to contribute our experience in the resolution of these complex patients, where complex open fractures of difficult resolution are already present, together with bone loss and coverage, and this is where the external fixation is To play a key role in the treatment. Methods: There are 10 patients treated with Circular External Fixation, in the context of severe injuries to the lower limbs (open fractures, massive bone loss, coverage defects, associated vascular lesions ..). We collected items related to. epidemiology, configuration of external fixation, therapeutic times, associated reconstructive bone techniques, coverage techniques performed, local and systemic complications. Results: There are 8 males and 2 females. In 80% of cases the collaboration of the Plastic Surgery Service is required. The results referring to the previous items are collected. Conclusions: Reconstructive surgery based on external fixation solves these complex cases in which, given the contamination suffered at the first moment, it is essential to avoid the implantation of permanent material, it should not be forgotten that infection is one of the challenges to be solved in this context. On the other hand, through the osteogenesis to distraction we will be able to restore the leg length, with the capacity to resolve deformities at the same time, as well as to solve other problems that occur in the limb, making it a very versatile and customizable treatment In each case. It also allows skin coverage, as we can modify the mounts to help the surgical comfort and subsequent cures, despite the apparent apparatus of the assembly. Acknowledgements: I would like to thank the work done by all the Traumatology Service of the Virgen de la Arrixaca University Hospital for the preparation of this work, especially Dr. Salcedo, without which this would not have been possible.


  PP 176: Prospective randomized comparison of ring versus rail fixator in infected gap nonunion of tibia treated with distraction osteogenesis Top


RAJESH Kumar Rohilla

University of Health Sciences Rohtak India, Rohtak, India

Background: Defects of bone and soft tissue in the leg may be the result of high energy trauma or may follow surgical debridement. The present prospective randomized study aimed to compare radiological and functional outcomes of ring versus rail fixators in patients with infected gap (>3 cm) nonunion of tibia. Methods: The study included only those patients who had minimum of 3 cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 33.2years in ring fixator group I and 29.3years in rail fixator group II. Each group included 35 patients. Mean bone gap was 5.84cm in group I and 5.78cm in group II. Mean follow up was 33.8 months in group I and 32.6 months in group II. The results were assessed as bone results and functional results according to the classification of the Association for the Study and Application of the Method of Ilizarov. Results: The bone result was excellent, good, fair and poor in 21, 12, none and 2 in group I; and 14, 15, 3, and 3 in group II, respectively. The functional results were excellent, good, fair, poor and failure in 16, 17, 1, none and 1 in group I; and 22, 10, none, 3 and none in group II, respectively. Mean SMFA score at 6 months postoperatively was 38.2 (range, 30.4-48.4) in Group I and 34.8 (range, 28.2-44.5) in Group II. (P value 0.0014, SS). Mean Functional Index in Group I was 36.1 (range, 28.7-47) in Group I and 32.8 (range, 26.5-42.6) in Group II. (P value 0.003, SS). Mean Bothersome Index was 43.5 (range, 35.41-52.08) in Group I and 40.2 (range, 33.33-52) in Group II (P value 0.0048, SS). Conclusions: Both fixator systems achieved comparable rates of union and functional outcome in infected gap nonunion of tibia. Deep pin tract infection was significantly higher in rail fixator. Patients were more comfortable with rail fixator. We recommend ring fixator in patients with bone gap more than 6cm. Patients with bone gap up to 6 cm can be managed with either of ring or rail fixator. Acknowledgements: conflict of interest – nil


  PP 177: Ilizarov method for treating ankle varus deformity due to epiphyseal injuries: Preliminary results for 12 cases Top


Lei Shi, Sihe Qin, Xuejian Zheng

Rehabilitation Hospital of National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: Ankle varus deformity after ankle epiphyseal injury is a kind of special deformity, children epiphyseal fracture cause asymmetry of distal tibial growth, along with the growth and development gradually appear varus deformity and Walking dysfunction. This study is to discuss the clinical effects of Ilizarov method for treating ankle varus deformity due to epiphyseal injuries. Methods: Twelve patients with ankle varus deformity due to epiphyseal injuries were analysed retrospectively from July 2009 to October 2012. Of them, eight cases were male and four cases female. The average age was 17.4 years old (from 14 to 24 years old). In the preoperation, we analysed the ankle deformity, confirmed CORA, drew up a operating plan, and assembled external fixator. We used supramalleolar osteotomy and Ilizarov fixator to treat ankle varus deformity, of which calcaneus osteotomy were used in 2 cases. In the postoperation, we remedied ankle deformity by adjusting the Ilizarov fixator. The functions of the ankle were assessed by the American Orthopaedic Foot & Ankel Society (AOFAS) scoring system. Results: A mean follow-up of 48(38 to 73) months showed that all the patients were . satisfied to the outcome of ankle appearance and functions improving. The average fixating time was 13.2 weeks. Of them, eight patients had pin infection and cured by conservative treatment. One patient had strong limb pain and relieved by slower adjusting velocity. One patient had osteotylus delayed union and final union by prolonging the time of fixator. One patient had pain in the front of ankle after removing external fixator, and the pain can be relieved after rest. Two patients had continued stiff ankle. AOFAS scoring. The mean preoperative score was 40.2(22 to 65), and the postoperative score was 85.5(75 to 95). Conclusions: Ilizarov method for treating ankle varus deformity due to epiphyseal injuries can lead to a good outcome, which is a minimally invasive therapy and can be used to treat complex deformity because of the flexible and controllable fixator. Acknowledgements: There is no conflicts of interest in this study.


  PP 178: Bone transport as an ankle saving procedure in extreme para-articular non unions of the distal tibia Top


Giovanni No Midlle Name Lovisetti

Menaggio Hospital, Menaggio, Italy

Background: Non-unions of distal periarticular tibia constitute a challenge for orthopaedic surgeons. In these conditions bone transport techniques can be problematic, due to the limits in fixation of the short and osteopenic distal tibia epiphysis. Difficulties are encountered in resection of the pathologic bone in a thin soft tissue envelope with scar tissue close to neurovascular structures, different surface areas of the bone segments at the docking point. Aim of our study has been to present a short case series of bone transports in this peculiar anatomic situation. Methods: 7 tibial bone transports with distal resection less than three centimeters from the ankle joint are presented. They were in 7 pts, 5 m and 2 f, mean age 63.5 yrs. (r. 31 – 79). Tibial nonunion was consequent to fractures in 5 cases (3 treated with plates, one with nail and one with ex fix), and in 2 cases to late failure of a closed docking point. Three patients presented local sepsis. Bone resection has been 38 mm mean (range 30- 70 mm). Acute shortening (25 mm) has been performed in one patient, partial shortening of 10 and 15 mm in two. Tibial osteotomy was performed in all cases with Gigli saw. Bifocal treatment was 5, trifocal 2. Latency period has been of 15 days. The standard distal assembly has been performed with three wires in tibia and foot inclusion in the frame in all cases. After resection antibiotic, loaded bone cement was applied for 15 days in three cases. Ilizarov frame has been used in 2 patients, a combination of traditional bars and hexapod struts in one case, a multilevel (two levels in 3 patients, three levels in one) hexapod was utilized in 4 subjects. Isometric transport has been employed four times. Open docking was carried out in 3 cases, with iliac bone graft in two. Results: All patients healed uneventfully, with a mean time in frame of 32.8 wks. (r. 27-40). One 7° varus and two cases of proximal procurvatum of 5 and 12° were recorded. All other alignments were within 2°. Ankle functional results have been quoted as excellent in all cases except in one diabetic patient who developed Charcot foot requiring hind and mid foot arthrodesis. Conclusions: Transport procedures consent consolidation along with conservation of the ankle joint in a correct mechanical environment, restoring precisely the alignment of tibia in most cases. Acknowledgements: Maurizio Catagni, Francesco Sala


  PP 179: Complication Factors Investigation Of Tibia And Fibula Open Fractures Internal Fixation After Ex-Ternal Fixation Top


Rong Hai Tao, Shuai Xiu Shang, Xiang Wang, Hua Jian Gu

Department of Orthopedics Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China

Background: To investigate influence factors of complications occurrence after shifting external fixator to plate fixation on open tibia and fibula fracture. Methods: Clinical data of 54 cases experienced internal fixation after external fixation were retrospectively analyzed, collecting results of blood tests included WBC, N, hs-CRP, ESR, PCT, external fixation period. After internal fixation, postoperative skin necrosis defect, infection, fracture healing time were evaluated. Results: All 54 cases got 10~12 months follow-up. N, hs-CRP and PCT related risk factors were statistically significant. Multiple-Logistic regression analysis P values were 0. 029, 0. 046, 0. 011 respectively. Conclusions: When open tibia and fibula fracture fixation change from external fixation to inner, the N, hs-CRP, PCT inflammatory markers should return to normal range before operation, so that reducing the incidence of postopera-tive complications. Acknowledgements: The authors report no conflicts of interest in this work.


  PP 180: The role of Ilizarov surgery in infection following internal fixation for fractures of the lower limb Top


Thirumal Manickam

Hosp TAR Klang, Klang, Malaysia

Background: Treatment of fractures by internal fixation is on the rise. Risk of infection however remains resulting in an increased volume of patients presenting with this complication. There is no standard treatment protocol for acute osteomyelitis till today. Methods: Between July 2014 and December 2015, we treated 22 cases of acute osteomyelitis. Of these 6 cases had infection in the diaphysis of femur, 6 in supracondylar femur and one patient in both supracondylar femur and diaphysis of tibia. Three cases were infected in the tibial plateau, 3 in the diaphysis of tibia, and 3 in the ankle. Conventional treatment may be done using Intramedullary nail coated with cement impregnated with antibiotics, Macquet's technique or other local antibiotic delivery agents such as gentamicin beads. All these methods are associated with variable success and failure rates. In our hospital, we have introduced our own treatment classification depending on the extent and severity of the osteomyelitis into four types. Results: Of these 22 cases, infection was eradicated and union achieved in all except one (supracondylar fracture of femur). In one patient with refracture of docking site and who needed bone grafting and reapplication of fixator, passed away a day before surgery. Conclusions: The Ilizarov method has proven to be effective in the treatment of infection following internal fixation. Acknowledgements: There is no conflict of Interest


  PP 181: Combined bone and soft tissue defects of the leg treated by distraction histogenesis using external fixation techniques Top


Mahmoud Abdel-Monem El-Rosasy, Wael Abdel-Latif Azzam, Ashraf Atef Mahmoud, Osama Ali El-Gebaly, Mohamed Mostafa Hosney

Tanta University, Faculty of Medicine, Tanta, Egypt

Background: Combined bone and soft tissue loss of the leg presents a great challenge to Orthopaedic surgeons. Limb reconstruction for such injuries is lengthy and may not yield satisfactory functional results. Distraction histogenesis using Ilizarov techniques comprehensively addresses these injuries and minimizes the need for tissue grafts. Methods: This study presents the results of cases treated between 2000 and 2015 and included 254 patients with tibial fractures complicated by bone and soft tissue defects as a result of open fractures or surgical debridement of infected non-unions. The bone loss ranged from three to eleven Cm. (average 4.7 Cm.). Their ages ranged from 12 to 54 years (average 22 years). The follow up ranged from 24 to 140 months. The procedure included resection of all devitalized tissues, acute limb shortening to close the defect (no 150) or bone transport (no 104), application of Ilizarov fixator and metaphyseal osteotomy for re-lengthening or bone transport. Results: In all patients (100%) the fractures united with well aligned limbs. Acute limb shortening of up to six Cm. was done in the lower third of the leg. Limb lengthening was done in all cases and ranged from 3 to 9.5 Cm. (average 4 Cm.). Bone graft was needed in 72 cases (28%) and skin grafting was needed in 10 cases (4%). Satisfactory results were obtained in 93% of cases. Conclusions: Distraction histogenesis comprehensively addresses the problems of combined bone and soft tissue loss and minimizes the need for soft tissue flaps. It is better instituted early in the management of these cases to ensure better functional results and shorter treatment time. Acknowledgements: The authors have no conflict of interest


  PP 182: Simultaneous Acute Femoral Deformity Correction And Gradual Limb Lengthening Using A Retrograde Internal Lengthening Nail Top


S Robert Rozbruch1, Christopher Iobst2, Scott Nelson3, Austin T. Fragomen1

1. Hospital for Special Surgery, New York, United States

2. Nemours, Florida, United States

3. Loma Linda University, California, United States

Background: Patients with leg length discrepancies often have other concomitant deformity. We describe the outcomes of acute, fixator-assisted deformity correction with gradual lengthening using the retrograde femoral motorized internal lengthening nail (MILN). Methods: This is a multi-center retrospective series of 27 patients with a mean age of 28 years for whom an external fixator was combined with a MILN to correct angular or rotational deformity and leg length discrepancies in the same operation. The fixator was applied temporarily to restore normal alignment and blocking screws were used. The MILN was inserted and locked in place to hold the correction and then gradual restoration of limb length followed. Alignment, leg length discrepancy, Knee motion, and ASAMI scores were recorded. Results: There was a mean follow up of 13 months. Preoperative deformities were mainly valgus in 15 patients and varus in 10 patients. Postoperatively, 93% of patients corrected to within 3 mm of length discrepancy. The mean lengthening was 30 mm, and 81% had mechanical axis deviation corrected within 8 mm. Mechanical lateral distal femoral angle corrected to an average of 88 degrees postoperatively. Posterior distal femoral angle averaged 84 degrees postoperatively. Final ASAMI scores were excellent in 96% of the patients. Range of motion was unaffected. Conclusions: The retrograde MILN with intraoperative external fixation and blocking screws was effectively used to correct both limb length discrepancy and deformity, with excellent overall outcomes. This surgical technique. may help avoid complications observed with prolonged external fixator use. postoperatively. Acknowledgements: I am a consultant for Nuvasive and Smith and Nephew.


  PP 183: Management Of Valgus Or Varus Knee Deformity With Fixator Assist Nailing Technique And Distal Femur Osteotomy Top


ShengSong Yang

Beijing Jishuitan Hospital, Beijing, China

Background: Distal femur osteotomy (DFO) is an effective method to treat valgus or varus knee deformity caused by angular deformity of distal femur in young patients. Our question is can we get accurate correction of valgus or varus knee deformity with fixator assist nailing (FAN) technique and distal femur osteotomy. Can we use anatomical lateral distal femur angle (aLDFA) as a reliable intra-operative criteria for accurate correction. Methods: We retrospectively review 14 patients with 17 knees deformity (12 valgus knees ,5 varus knees) whom were treated with DFO and FAN. The average age of patients is 23(17-44) years old. We mounted the unilateral external fixator on lateral side of femur, performed minimal invasive DFO, adjust fixator to get a desired aLDFA (81±2 ○), then fixed the femur osteotomy with retro-grade IM nail. We measured and analysis the lateral distal femur angle(LDFA) and mechanical alignment deviation(MAD) and range of motion(ROM) before operation and after operation. Results: All 14 patients were followed for 12-72 months (average 34 months). The osteotomy site united in 3-5 months (average 3.5 months) post-operatively. We achieved the desired MAD with in 10 mm of the goal in 14 of 17 limbs. We achieved LDFA to normal range (85-89○) in 8 of 17 limbs. The ROM is not significantly changed before and after operation. There is no infection, nonunion or neuro-vascular injury occurred. Conclusions: The FAN technique an effective, accurate and minimal invasive method to treat valgus or varus knee deformity caused by angular deformity of distal femur in young patients with DFO. If the malalignment is caused by deformity of distal femur, the restoration of aLDFA to 81±2 ○ is suitable criteria of accurate correction. Acknowledgements: the author received no benefit from any company.


  PP 184: Distraction Histogenesis For The Critical Problems During Our Severe Lower Limb Injury Practices, A Series Of Case Report. Top


YongHong None Zhang1, Dong None Wang1, Sihe None Qin2

1. the 2nd hospital of Shanxi medical University, Taiyuan, China

2. Rehabilitation Hospital of the National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: There are still many severe trauma in China, especially in lower limbs, many cases are difficult to be treated with traditional methods. We tried to solve the difficult clinical problems with DH technique during our severe lower limb injury practices. Methods: There are so many critical conditions when we treat severe lower limb injury, for example, large amount of muscles and skin necrosis without bone defect, severe osteoporosis with osteomyelitis and chronic joint dislocation, very old lady with severe ankle deformity after ankle fracture, etc. we take the distraction histogenesis as our practicing law, and applied this technique into our clinical practice, especially for critical points. All the patients began their rehabilitation as earlier as possible. Results: All the critical points referred before were solved with DH technique and active rehabilitation. Conclusions: DH technique could be used to cope with some critical problems which is hard to be treated with our traditional methods. Acknowledgements: Prof. Qin, the Chairman of ASAMI China has given me so much supports! . My teams, Dr. WangDong, liu laiyong, Liuhong, often hard work with active attitude, Thank you!


  PP 185: A Case Report Of Lengthening Of Short Amputated Foot Stump Post-Traumatic Using Ilizarov External Fixator Top


Ibrahim Elsayed Abuomira1, Yasser Elbatrawy2

1. Al-azhar university, Assiut, Egypt

2. Al-azhar university, Cairo, Egypt

Background: Abstract Text. The trauma after vascular disease is the most common indication for amputation in patients under the age of fifty. Amputations due to traumatic lacerations have a number of unique characteristics not found in vascular disease. The remaining stump often has an excellent blood supply and the patient is usually young and in good general condition and is expected to regain a high level of function. The use of prothesis has many complications, irritation and skin Issues, general fatigue, reduced mobility, poor balance, instability, or a fear of falling, current prosthetic not meeting your needs, back pain and intact limb pain. The Ilizarov method is a reliable method for the lengthening foot stump. The technique of distraction osteogenesis can also be used to improve the quality of life of patients with short foot amputation stumps by giving them a better mechanical stump that is more effective than prosthetic use, and for the function of the adjacent joint. Methods: Female patient 17 years old was presented by short amputated foot stump. She was complaining from difficult fitting prosthetic uses that lead to ulcer and infection. In this case observed foot-length discrepancy 10 cm. In this case were treated with classic ring Ilizarov fixator. Results: The use of prothesis with short foot amputation stumps has many complications. The technique of distraction osteogenesis can also be used to improve the quality of life of patients with short amputated feet stumps by giving them a better mechanical stump that is more effective than prosthetic use, and for the function of the adjacent joint. The main area of concern in amputation stump lengthening is the soft tissue. To prevent these skin problems resulting in new debridement's and reamputation, skin and soft tissue should be in optimal condition prior to any lengthening. To this purpose tissue expanders may be used to produce a pocket for bone growth, or vascularized myocutaneous flaps. Lengthening of short amputated feet stumps is the long treatment time. Conclusions: The mean length gain was 8 cm but the consolidation time was very long (healing index 1.8 month/centimeter). The final outcome was excellent in this case. Acknowledgements: n/a


  PP 186: Correction Of Posttraumatic Shortening And Deformity Of Distal Part Of Lower Leg With Ilizarov Method Top


Piotr Morasiewicz, Wiktor Orzechowski, Leszek Morasiewicz, Miroslaw Kulej, Szymon Lukasz Dragan, Szymon Feliks Dragan

Wroclaw Medical University, Wroclaw, Poland

Background: Fractures of the distal part of the lower leg are the most common injury of the lower extremities. Due to the specific anatomy and fracture mechanism, in this location of fractures, often occur complications. nonunion, shortening and deformity. The Ilizarov method is effective in lengthening and axis correction. Purpose of the study was to evaluate the results of treatment with the Ilizarov method posttraumatic shortening and deformity of distal part of lower leg. Methods: In the years 2001 - 2013 in our clinic were treated 39 patients with posttraumatic shortening and deformity of distal part of lower leg. 22 patients were evaluated in control studies. We assessed the elongation index, Correction coefficients, alignment index, correction factor, complications and results in functional scale. Results: Alignment index was in averaged 98%, correction coefficients was in averaged 100%, elongation index was 166 days / cm, correction factor was 3.5 days / one sequence, the majority of patients achieved a very good result in the functional scale. Conclusions: Fractures of the distal part of the lower leg have a high risk of complications compared to other locations of fractures. Ilizarov apparatus allows for correction of post-traumatic shortening and precise correction of deformity in three planes. Evaluated patients achieved very good and good results in functional scals, with a relatively small number of complications. The Ilizarov method allows to obtain very good results in the treatment of post-traumatic shortening and deformity of distal part of lower leg. Acknowledgements: There was no Conflict of Interest for all authors. There was no sources of founding.


  PP 187: Radiological Evaluation Of Ankle Arthrodesis With Ilizarov Fixation Compared To Internal Fixation-Prospectively Radiological Study Of 67 Patients Top


Piotr Morasiewicz, Wiktor Orzechowski, Leszek Morasiewicz, Maciej Dejnek, Szymon Feliks Dragan, Szymon Lukasz Dragan

Wroclaw Medical University, Wroclaw, Poland

Background: We asked whether the type of ankle joint arthrodesis stabilization will affect:(1) rate of union, (2) rate of adjected-joint arthritis, (3) malalignment of the ankle joint. Methods: We prospectively radiological studied 67patients who underwent ankle arthrodesis with Ilizarov external fixator stabilization (group 1, n=29) or internal stabilization (group 2, n=38) from 2007 to 2014. Radiologic outcomes were mesure by:(1) rate of union, (2) rate of adjacent-joint arthritis, (3) malalignment of the ankle joint. The Levene's test, Mann–Whitney U-test and Students t-test were used to the statistical analyses. Results: Ankle fusion was achieved in 100% of patients treated with external fixation and in 90% with internal stabilization. Desired frontal plane alignment was achieved in 100% of patients with external fixation and 74% with internal stabilization. Desired sagittal plane alignment was achieved in 100% of external fixation and 84% of internal stabilization. A total of 14 (48.3%) patients from group 1 showed a radiographic evidence of pre-existing adjacent-joint OA. The radiographic evidence of pre-existing adjacent-joint OA was also found in 31(81.6%) subjects from group 2. Alterations of adjacent joints were also found on postoperative radiograms of 19 (65.5%) patients subjected to Ilizarov fixation and in all 38 patients from group 2. Conclusions: Ilizarov fixation of ankle arthrodesis is associated with lower prevalence of adjacent-joint OA and ankle joint misalignment,and with higher fusion rates than after internal fixation.Although achieving a complex ankle fusion is generally challenging,radiological outcomes after fixation with the Ilizarov apparatus are better than after internal stabilization. Acknowledgements: There was no Conflict of Interest for all authors. There was no sources of founding.


  PP 188: Clinical Evaluation Of Ankle Arthrodesis With Ilizarov Fixation And Internal Fixation-Retrospectively Clinical Study Of 47 Patients Top


Piotr Morasiewicz, Wiktor Orzechowski, Leszek Morasiewicz, Miroslaw Kulej, Szymon Lukasz Dragan, Szymon Feliks Dragan

Wroclaw Medical University, Wroclaw, Poland

Background: Ankle arthrodesis can be achieved with external fixators or internal fixation. We asked whether the type of ankle joint arthrodesis stabilization will affect. (1) rate of complications, (2) pain level, (3) period of hospitalization, (4) functional outcome in FAAM scale. Methods: We retrospectively clinical studied 47 patients who underwent ankle arthrodesis with Ilizarov external fixator stabilization (group 1, n =21)or internal stabilization with screws or Blount staple (group 2, n =26) at our institution from 2007 to 2014. Clinical outcomes were mesure by. (1) rate of complications, (2) pain level, (3) period of hospitalization, (4) functional outcome in FAAM scale. Results: Total number of complications in group1 was 55, which corresponded to 2.62 complications per patient on average. Total of 67 complications have been documented in group2, which corresponded to the mean number of 2.58 complications per patient. In group 1 the mean VAS pain level before treatment was 4,69 and after treatment was 3,5. In group with internal stabilization the mean VAS pain level before treatment was 4,71 and after treatment was 5,59.In group with Ilizarov stabilization the mean period of hospitalization was 8,29days , in group 2 was 7,71 days. In group 1 the mean functional outcome in FAAM scale was 59,38, in group 2 was 52,65. Conclusions: Ilizarov fixation of ankle arthrodesis is associated with lower prevalence of VAS pain level after surgery, as well as with higher FAAM functional score than after internal fixation. Rate of complications and period of hospitalization were not statistically significant between both groups. Clinical outcome was satisfactory in both groups, but outcomes after fixation with the Ilizarov apparatus are better than after internal stabilization. Acknowledgements: There was no Conflict of Interest for all authors. Sources of founding. internal university grant. ST.C080.16.073


  Reconstruction after malconsolidation Top



  PP 189: Nonunion with bone loss Top


Maurizio Angelo Catagni1, Francesco Guerreschi2, Luigi Lovisetti1, Daniele Pili1

1. G.B. Mangioni Hospital, Lecco, Italy

2. Ospedale Alessandro Manzoni, Lecco, Italy

Background: Abstract Text. Nonunion with bone loss is a gap greater than 3 cm. The etiology is diverse. Every case of nonunion with bone loss will require some variant of Bifocal treatment to reestablish bone continuity and length. Nonunions with bone loss can be divided in two groups. A- Bone gap w/o limb shortening. B- Bone loss w/ limb shortening. (B1) Shortening of segment w/ bone contact. (B2) Shortening w/ bone gap and no contact of bone ends. The difference between the groups is that we need to reconstruct the bone loss without any lengthening in group A. Group B requires also the restoration of the length. Bone Gap Without Shortening. A bone segment is transported at the level of an osteotomy to form new bone. This segment of new bone will be the same length as the initial gap. When the ends of the nonunion get in contact progressive compression starts until consolidation. Bone graft can be applied at nonunion site to improve healing. A variant of this technique is called Trifocal Treatment, in which there are two sites of osteotomy and one site of compression. This modality decreases treatment time. Group B2. Shortening With Bone In Contact. Similar to simple Bifocal or Trifocal treatment. Compression at nonunion site is made at the same time that lenghtening. Group B3. Shortening With Bone Gap. The Bifocal Technique can be applied to this group. First internal lengthening is perform and compression at the nonunion site following the standard method. The second step is restoring the limb length by external lengthening. Massive segmental tibial bone loss. Massive bone loss of any cause is a challenge. The decision whether to amputate or reconstruct is controversial. Several studies suggest hospitalization costs are considerably less for amputation than for reconstruction. Williams reported that long-term cost of amputation is considerably higher than for reconstruction. We perform the fibular transport when the extent of the bone loss makes impossible to obtain bone regenerate by conventional transport and leghtening. Gradual, medial ipsilateral fibular transport is performed by proximal and distal fibular osteotomies to allow medial translation of the fibula. Two techniques can be applied. (1) Transport of almost all fibula to replace the entire tibial defect. (2) Transport of a fibular segment. Applied to fill a partial thickness defect of the tibia or to improve mechanical strength of a lengthened tibia. Methods: Results: Conclusions: Acknowledgements: .


  PP 190: The Clamshell Osteotomy and lengthening over nail. Top


Maurílio Darcy Dos Santos Mendes, Rodrigo Mota Pacheco Fernandes, André Perin Shecaira

Centro de Alongamento Ósseo, Rio De Janeiro, Brazil

Background: The objective of the study is to describe the Clamshell Osteotomy an Lengthening over Nail technique and to evaluate the capacity of correcting complex diafisary deformities with inferior limb lengthining discrepancy. Methods: The Clamshell Osteotomy an Lengthening over Nail technique was used to treat post traumatic femoral and tibial deformities, limb functional defect, joint pain secondary to the deformity and expected post correction limb discrepancy. Four patients were submited to the Clamshell Osteotomy an Lengthening over Nail technique. The deformed segment was identificated and than submitted to proximal and distal transversal osteotomy. The transected segment was again osteotomized along its long axis and was wedged open, similar to opening a clamshell. An intramedular nail was used to the fragments alignement with only proximal locking screws. The last step was the Monolateral External Fixation to the Lengthening over nail. Results: The four pacients had left femoral deformities. The average preoperative angular deformity was 18,35° and average preoperative limb discrepancy was 5,85 cm. The average preoperative rotacional deformity was 8°. The average postoperative angular deformeis was 3°, average postoperative limb discrepancy was 0,35 cm and the average postperative rotacional deformity was 1,25°. The External Fixator Index was 20,89 days / cm. Conclusions: The Clamshell Osteotomy an Lengthening over Nail technique is efective for diafisary complex deformities with inferior limb lengthining discrepancy, requiring less time with external fixador when compared to literature. Acknowledgements: We declare that there was no conflict of interest.


  PP 191: Treatment of traumatic long bone nonunion in children with Orthofix external fixator or Ilizarov fixator Top


Hang Liu, Ming Li

Orthopedic Center of Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, China

Background: Long bone nonunion in children is difficult to treat and the cause is complex. How to prevent the occurrence of nonunion and how to treat those nonunion caused by inappropriate treatment are important. Methods: Clinical data of 36 cases of traumatic nonunion of long bones with the treatment of external fixation system was collected and analyzed retrospectively from June 2004 to January 2016. There were 24 cases of males and 12 cases of females. For the fracture sites, there were two cases of humerus, 6 cases of forearms, 12 cases of femurs, and 16 cases of tibias. 26 cases were treated with Orthofix unilateral external fixation and 10 cases were treated with Ilizarov circular external fixation. There were 10 cases accepted autologous iliac bone transplantation or bone transport in first or secondary-stage operation. Results: All patients were followed up at least 12 months after nonunion healed. Finally, 34 cases obtained bone healing and removing external fixation. The mean time of fixation period was 18 months (range 12-34 months). 5.4 cm (range 3-11 cm) of the mean length of bone were regenerated in the six patients being applied bone transport at last. Pin track infection occurred in four patients but well controlled by anti-infection, no patient got bone infection. Two in three patients with nerve injuries were obviously improved by functional exercise and using of neurotrophic drugs after surgery, while the other patient remained symptoms of nervus peroneus communis injury. Two cases were judged as treatment failure after follow-up of 18 to 38 months, whose X-ray showed little osteotylus, and occlusive cavum medullare ossium. According to the Paley fracture healing score for efficacy evaluation, excellent in 22 patients (61.11%), good in 10 patients (27.78%), moderate in two patients (5.56%), and poor in two patients (5.56%). The acceptance rate was 88.89%. Conclusions: External fixations were well used in treatment of long bone nonunion and gained satisfactory curative effects. External fixation is superior in pressurization and prolongation. It is easy to fix during operation and easy to adjust after surgery. Acknowledgements: We greatly thank the patients and their parents involved in this study.


  PP 192: Combined Transosseous And Locked Intramedullary Osteosynthesis In Management Of Pseudoarthrosis Of The Femoral Diaphysis Top


Sergey Nikolayevich Kolchin

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: Assess the efficiency of combined use of transosseous and locked intramedullary osteosynthesis in patients with pseudarthrosis of the femoral diaphysis. Methods: 28 patients with pseudarthrosis of femoral diaphysis were treated with use of combined techniques of TO and locked intramedullary nailing. Their outcomes were compared with 36 patients that also had pseudarthrosis of the femoral diaphysis that was managed with classical Ilizarov transosseous osteosynthesis techniques. Patients of both groups had posttraumatic pseudoarthrosis. Combined techniques were used in 3 variants:1) sequential use of distraction osteosynthesis with Ilizarov apparatus and locked intramedullary nailing in 11 patients with pseudarthrosis and stiff deformities of femur;2)simultaneous use of distraction osteosynthesis with the Ilizarov apparatus and intramedullary nailing in 14 patients with pseudarthrosis associated with limb length discrepancy and in 1patient with diaphyseal defect of femur; 3) simultaneous use of compression and intramedullary osteosynthesis in 3 patients with pseudoarthrosis of of the femoral diaphysis when it was impossible to use reosteosynthesis with intramedullar. Results: In the first group, correction of angulation with the apparatus averaged 14.0±1.7 days. Consolidation was achieved from 3 to 5 months after the removal of the apparatus. In the second group, mean lengthening of the femur was 3.9±0.2 cm and restored a mean of 85.4±4.0% of bone loss. Distraction period was 34.7±1.8 on average and the index of transosseous osteosynthesis was 12.8±0.9 days/cm. Distraction regenerates were formed in all the cases. Pseudarthrosis union was achieved in 12 patients (80%) in the period from 4 to 9 months. In the third group, fixation in the apparatus continued 90.0±15.6 days. Pseudarthrosis union was achieved in all the cases. Complications were classified according to D. Paley (1990). Rate of true complications made up 37.9 %. Deep infection happened in three patients (10.3%) in the period of the observation that was more than six months. Conclusions: Classical technologies of transosseous osteosynthesis require the use of external fixation during the entire period of treatment. Combined osteosynthesis enables to obtain good and satisfactory treatment outcomes at a long-term. Moreover, it provides a 3.5-fold reduction of the external fixation period when it is simultaneous and a 6.5-fold reduction when it is sequential. Acknowledgements: not available


  Reconstruction after pseudarthrosis and resection of lesion (infection, tumor) Top



  PP 193: Complex Treatment Of Pseudoartrhosis Of The Tibia With The Periosteal Grafting And Intramedullary Fixation. Top


Milud Ibrahim Shadi1, Bartosz - Musielak2, Pawel Koczewski2

1. Department of Spine Disorders and Pediatric Orthopaedics Poznan University of Medical Sciences- Poland, Poznan, Poland

2. Departament of Pediatric Orthopaedics and Traumatology. Poznan University of Medical Sciences- Poland, Poznan, Poland

Background: Background. In the last few years, to improve the outcomes of congenital pseudarthrosis of the tibia (CPT) treatment, new procedures were added to the standard protocol. periosteal grafting, bone morphogenic protein (BMP) and bisphosphonate administration. In this study we analyzed the results of CPT treatment with periosteal graft combined with intramedullary (IM) nailing with or without Ilizarov frame. Methods: Materials and methods. Retrospective study of medical records and the radiographs of 10 patients with CPT treated with the complex procedure containing. resection of the hamartomatous periosteum, splitting of proximal tibial end or pseudarthrosis site resection, IM fixation, periosteal and cancellous bone grafting from the iliac bone was made. Mean age at the surgery was 5.4 years. Nine patients had NF-1 and one patient - idiopathic CPT. LLD ranged 0 - 10 cm (average 3.7). The anteroposterior preoperative scan of all patients were studied for assessments of ankle joint mortise, where proximal migration of the fibula was evaluated according to Malrotha scale for fibular shortening. The patients were classified according to El-Rosasy-Paley as type I in 5 cases, and type II in 5 cases. All the cases were classified as type IIC according to Crowford classification. The average follow-up after the above-mentioned operation was 7.9 years (range 5- 9.9). Results: Results. Primary pseudarthrosis union of the tibia was achieved in 9 patients, at a mean time of four and the half months (range 4-6 months). Failure to obtain bone union after 13 months in the youngest patient needed reoperation with the same technique which achieved solid union. Only in one case out of ten the refracture of the tibia occurred, which was successfully managed by the repetition of the primary surgery. Conclusions: Conclusion. Primary union of CPT in most of the cases can be obtained and maintained with limited pseudarthrosis resection, periosteal and cancellous bone grafting and intramedullary rod fixation. Significance. The presented here method significantly increases the chance of achieving and maintaining the bone union in cases of congenital pseudoarthrosis of the tibia which is essential for good functional outcome. Application of this method of surgical treatment has become an important tool in the treatment of one of the most challenging orthopedic conditions, which CPT presents to be. Acknowledgements: Acknowledgements. The authors declare that they have no conflict of interest


  PP 194: Clinical Analysis Of Ilizarov Microcirculation Reconstruction Technology For Wagner Grade 4 Diabetic Foot Top


Ding Wei Zhang

The Dept of Orthopaedics, Central hospital of Mianyang ,MianyangSichuan, China., Mianyangsichuan, China

Background: To evaluate results of Ilizarov microcirculation reconstruction technology for Wagner grade 4 diabetic foot. Methods: Microcirculation reconstruction technique using the Ilizarov treatment of 10 cases of Wagner grade 4 diabetic foot from March 2015 to March 2016. 8 males and 2 females; 6 cases of left foot, right foot 4 cases; aged 45 to 82 years, mean 61.8±8.9 years. Both conservative treatment fails, there are indications for amputation. Preoperative risk of ischemic foot pain intensity based on a visual analogue scale, 7-10 in 6 cases, 4-6 in 4 cases. Preoperative CT angiography confirmed limb arteries are varying degrees of stenosis or occlusion. Diabetic foot duration 15-102 d, average 52±6.8 d. Results: 10 cases suffering from ischemic foot pain were significantly alleviated, gangrene of foot ulcers healed, the average healing time of 72.0 ± 20.5 d, no amputation. Postoperative tibial osteotomy did not occur secondary to fracture, wound infection and other complications. 10 cases were followed up for 3 months to 1 year, an average of 6.3 ±1.2months. Suffering from ischemic foot pain intensity at the end of follow-up, eight cases of 0, 1-3 in 2 cases, compared with the preoperative difference was statistically significant(P<0.001). All patients were satisfied with the results of surgery. Conclusions: Ilizarov reconstruction of microcirculation of the diabetic foot has a good clinical efficacy, postoperative condition improved significantly, can significantly reduce the amputation rate, reduce patient suffering, improve quality of life, it is a worthy technology. Acknowledgements: I would like to thank Professor Qin Sihe, he gave me a great help.


  PP 195: Management of Infective Subtrochanteric Nonunions of femur by Ilizarov method. How far is it effective. Top


Srinivas Reddy Nookala

Prathima Institute of medical sciences, Karimnagar, India

Background: Management of infective subtrochanteric nonunions of femur is often a technical challenge to the surgeon. The aim of the study is to treat the infective . nonunions of the subtrochanteric region of femur by Ilizarov method. Methods: Presented is a retrospective series of 12 consecutive patients (all males) treated between 2003-2016 by Ilizarov method. The age of the patients ranged from 20-64 years with a mean age of 41.61 years. All were post operative infections. Variable range of shortening was presented in 9 cases. Implant removal is done if it is present. Wound debridement was done in all the cases followed by Ilizarov fixation in the same sitting in all the cases except four, which was performed as a two-stage procedure. Temporary external fixator is planned for two stagew procedure. Special Schanz pins (cephalic pins) were designed for additional stability of the proximal fragment which were found to be very effective. Results: All the patients were followed for a mean period of 1.76 years (range 6 months to 6 years). Union was obtained in 11 patients out of the 12 patients. Conclusions: ilizarov fixation is definitely a reliable method in subtrochanteric nonunions of femur of all types, though it technically demanding. Acknowledgements: nil-


  PP 196: 20-Year Follow-Up Of 8 Patients Treated With Circular External Fixator For Ollier's Diseaser And Maffucci'S Syndrome Top


Walter Hamilton De Castro Targa1, José Henrique Peres Dos Santos1, Paulo Roberto Dos Reis1, Guilherme Pelosini Gaiarsa1, Márcio Batista De Carvalho1, José Carlos Bongiovanni2

1. Hospital das Clinicas de São Paulo - Faculdade de Medicina da USP, São Paulo, Brazil

2. CEBRAO, Jundiaí, Brazil

Background: Ollier's disease is nonhereditary type of multiple enchondroma, or dyschondroplasia, that results from a failure of endochondral ossification. It is usually evidenced in the metaphyseal region of the long bones leading to shortening of the limb and epiphyseal enlargement. Affecting tibia and femur, 30% of maligninization when it becomes chondrosarcoma. When the disease of Ollier is associated with the presence of multiple hemangiomas, the same happens to be denominated Maffucci Syndrome and its rate of malignization can reach more than 50% of the cases. The classic treatment aims at the resection of tumor tissue, with curettage and bone grafting, and correction of angular deformities becoming a challenge to orthopedists. This study aimed to evaluate the outpatient follow-up of patients treated for these diseases with bone ressection and limb lengthening in the State of São Paulo. Methods: Initially the patients were submitted to resection of the tumor follow-up, with shortening until bone contact. Then, they underwent corticotomy for bone lengthening. General information recorded in patients' records was collected from the beginning of the treatment to the current stage of evolution. Results: In total, 8 patients were diagnosed with this condition, being 4 women and 4 men. There was no prevalence among the affected limbs, 4 for each side. The mean age was 12 years (9-16). 3 patients needed to perform 3 more lengthening, 4 patients performed 2 bone lengthening, and 1 patient performed only 1 time. 3 patients needed to perform humeral lengthening and 2 patients lengthened forearm. After removal of the circular circular fixator, the discrepancy of the lower limbs ranged from 2 to 7 centimeters and total correction was obtained in 3 patients. The range of motion of 120 degrees of knee extension was evidenced in 3 patients. 3 presented amplitude greater than 90 degrees and 2 presented amplitude smaller than 90 degrees. Conclusions: Bone resection and shortening associated with distraction osteogenesis using the external circular fixator is shown as a good option for the treatment of this type of affection. Acknowledgements: The authors declare that there are no conflicts of interest in the production of this article.


  PP 197: Our twenty-three years of experience in the treatment of segmental bone defects of the leg with the Ilizarov's method Top


Sergio Antonio Iriarte

Clínica del Sur, La Paz, Bolivia

Background: A severe complication of the fractures of the tibia is the bone defect that associated to infection, makes worst the prognosis. The chronicle bone infection is because of a not well treated acute infection. The fragments of necrotic bone in an infected atmosphere become a chronic infection. We are in front of an atrophic nonunion. The general principles in the treatment of this pathology and the execution of the assemblies are similar to those described in the aseptic nonunion. Methods: A great part of our treated patients that presented segmental bone defects had as important antecedents. comminuted open fractures, open fractures with bone loss (some associated to infection), infected osteosynthesis, hematogenous osteomielitis, among others. The treatment of 69 patients was analysed, from April 1993 to April 2016 with bone loss defects of different length, different chronic forms of bone infection, corresponding to groups B1, B2 and B3. In all of them were carried out clinical and radiological exam, and in patients in those that there was infection was carried out bacteriologic indentification. We apply the Ilizarov's assembling according to the nonunion type, bone defect smaller than 5 cm a single osteotomy (bifocal treatment). In defects bigger than 5 cm, double osteotomy (trifocal treatment). The skin care is essential, in some cases we used antibiotic pearls like spacers, to prevent retraction of the skin and scars of the deeper layers of tissue obstructing the bone transport. Results: Healing of infection in 69 patients, 100% of effectiveness of the method; bone consolidation in 68 (98.6%), correction of the bone defect in 69 patients (100%). Angular deviations and restoration of function of the limbs were also corrected in a large percentage of patients. Conclusions: Discussion and conclusion:. Many of our patients had been treated with other methods, as internal fixation, external fixation (other systems) and other techniques. Some patients had as antecedent. multiple previous surgeries. The Ilizarov's 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. Acknowledgements: I wish to express my sincere gratitude to my patients and all my work team!


  PP 198: Bioactive Glass S53P4 On Septic Non-Unions Infection Cure And Bone Healing - Early Experience And Results Top


Guilherme Pelosini Gaiarsa, Paulo Roberto Dos Reis, Jose Henrique Peres Dos Santos, Walter Hamilton De Castro Targa, Marcio Batista De Carvalho, Franklin Leite Rodrigues

hospital das clinicas da faculdade de medicina da usp, Sao Paulo, Brazil

Background: Septic long bone non unions is always described as a challenge to orthopedic surgeons. we reviewed our experience on osteomyelitis and septic nonunion using bioactive glass as bone growth substitute and using the bacteriostatic component of this graft. the NUSS(nonunion scoring system) published by Callori et al. defines the necessary use of scaffold, growth factors and MSC (mesenchymal stem cells) to treat the over 50 points cases. we describe 11 cases with more than 50 points on nuss with complete healing and infection cure. Methods: We retrospectively reviewed 49 patients out 55 surgeries with bioactive glass. between august 2011 to December 2016. found 20 septic non-unions, 3 with less than 3 months of surgery, 1 lost for follow up and 5 with internal synthesis and other grafts. 11 patients treated with external frames and single stage resection and bioactive glass grafting were found for follow up. Results: we describe 11 cases with more than 50 points on nuss with complete healing and infection cure. one of those patients had a fistula with glass drainage two years after the frame removal with spontaneous solution. time on frames with a media of 4,7 months (3,2 to 22) depending on associated bone lengthening size. NUSS results with a media of 58, (52 to 74) . Conclusions: bioactive glass as a bone graft substitute on septic nonunion has a great potential as a bone healing enhancement. we were not able to find any research of the potential of bioactive glass on nonunion healing. as we do not have access to MSC and growth factors as proposed by the diamond concept, we believe bioactive glass may be an interesting and simple alternative. Acknowledgements: None of the authors have any kind of conflict of interest to declare.


  PP 199: Distraction-Compression Systems For Massive Segmental Bone Defects In Children. An Update Top


Julio De Pablos, Lucas Arbeloa, Antonio Arenas Miquelez

Hospital San Juan de Dios, Pamplona, Spain

Background: Distraction Compression Systems (DCS) with External Fixation are used for the management of Large Segmental Bone Defects (LSBD), mainly in adults. Our objective is to present an update on our series of cases of LSBD treated with DCS in immature patients. Methods: We present a retrospective study (1998-2011) in 18 cases of LSBD treated with DCS in immature patients (8-16 years). Tibia was involved in 14 cases and femur in 4 and the length of the defect ranged from 5 to 23 cm. The etiology was Trauma (with/without sepsis) in 12 cases and 10 of them presented with associated injuries. Minimum follow-up was 4 years after completion of treatment. The DCS employed was Classic Bone Transport (BT) in 9 cases and Acute Compression and Progressive Distraction (ACPD) in 9. Monolateral Frames were used in all cases. Results: The reconstruction of the Defect was consistently obtained an all cases but one (Congenital Pseudoarthrosis of the Tibia -CPT-). Except for CPT cases the Healing Index (HI) in the Distraction Area was 0.75 m/cm. Graft was needed at the compression site in 3 cases of BT. As an average 3 operations per case were needed. BT was technically easy to achieve. The most important morphologic feature of the reconstructed segment with these treatments was its quick and good remodeling (tubulization). Main complications included one case of non-union and a rather frequent pin tract infection (31%). Conclusions: The DCS with Monolateral Frames are extremely effective in the reconstruction of LSBD in children. Pin tract infection rate is not low but this complication in no case prevented from completion of treatment. We recommend to be cautious in cases of CPT because of its low osteogenic potential. Acknowledgements: No Acknowledgements


  PP 200: Management Of Congenital Pseudoarthrosis Of Tibia By Using Ilizarov Ring Fixator After Excision Of Haemarthomatous Tissue And Pseudoarthrotic Bone Top


Hariram Ramniwas Jhunjhunwala

Post Graduate Institute of Medical Sciences of Bombay Hospital, Mumbai, Mumbai, India

Background: Management of CPT is a challenge. The problems of managing CPT include difficulty in obtaining union, deformity correction and Limb length discrepancy. Many modalities were discussed in past but none provided a comprehensive constant better result. Today there is 2 main modalities of treatment. 1 By Ilizarov Technique and . 2 By vascularised fibular graft. Methods: Eleven cases were treated at our institute. Ten by Ilizarov technique and one by vascularised fibular graft. The age group was 4 To 14 years at the time of surgery. TECHNIQUE. - Excision of haemarthomatous tissue and pseudoarthrotic bone, end to end compression, by Ilizarov frame. A proximal corticotomy of tibia for lengthning of tibia. One case of CPT was treated by vascularised fibular graft which also healed well. But he needed lengthening of the tibia as a secondary procedure. Results: Good to Excellent. Conclusions: Treatment of CPT by Ilizarov technique is very . rewarding. Vasculaarised fibular graft needs excellent. micro vascular surgeon and needs lengthening as a secondary procedure. Ilizarov technique can manage whole treatment in one procedure. Acknowledgements: Principles of Deformity Correction - Dror Paley. Campbell's Operative Orthopaedics


  PP 201: A systematic review of the single-stage treatment of chronic osteomyelitis over the last 20 years Top


Bethan Pincher, Carl Fenton, Rathan Jeyapalan, Hemant Sharma, Gavin Barlow

Hull Royal Infirmary, Hull, United Kingdom

Background: Despite advances in surgical and antibiotic therapies the treatment of chronic osteomyelitis remains complex and is often associated with a significant financial burden to the National Health Service. The aim of this review was to identify the different types of single-stage procedures being performed for this condition as well as to evaluate their effectiveness. Methods: Ovid Medline and Embase databases were searched for articles on the treatment of chronic osteomyelitis over the last 20 years. A total of 3511 journal abstracts were screened by 3 independent reviewers. Following the exclusion of paediatric subjects, animal models, non-bacterial osteomyelitis and patients undergoing multiple surgical procedures we identified 13 studies reported in English with a minimum follow up of 12 months. Following quality assessment of each study, data extraction was performed and the results analysed. Success rates were evaluated for each surgical technique and subdivided by Cierny host classification. Results: 531 patients with chronic osteomyelitis underwent attempted single-stage procedures. Following debridement, a range of techniques are described to eliminate the remaining dead space. These include musculocutaneous flaps, insertion of S53P4 glass beads or packing with antibiotic loaded ceramic or calcium-sulphate pellets. The average follow-up ranged from 12 to 110 months. The most common organism isolated was Staphylococcus aureus. Success was defined as resolution of pain with no recurrence of sinuses and no need for a second procedure to treat infection. Debridement alone was shown to produce success rates ranging from 60%-100%. This improved to 92%-100% for surgeries where a musculocutaneous flap or antibiotic impregnated calcium hydroxyapatite ceramic were used to eliminate dead space. Conclusions: There are currently a wide range of single-stage procedures being performed for chronic osteomyelitis with varying success rates. Treating patients with these methods in specialist centres can result in resolution of infection and may lead to improved quality of life for the patient and a financial saving for the NHS. So far no one technique has been shown to be superior and further long term follow up data is required. Acknowledgements: No conflicts of interest.


  PP 202: Treatment of infected bone defects with Ilizarov external fixator using bone transport and acute compression with lengthening: Top


Hugo Daniel Sagarnaga

Hospital de Clinicas, La Paz, Bolivia

Background: I report the experience from the last 13 years done in my private practice and also in a Public Hospital of my city La Paz, the objective was the treatment of massive tibial and femoral infected bone defects performing bone transport and also compression and distraction using the Ilizarov external fixator. Methods: Thirty eight patients were treated since October /2003 until march/2016 using these techniques. The patients were 9 females and 29 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 7 and 5 in epiphysis/methaphysis. The external fixation time ranged from 5 months to 24 months (average. 9.5 months). All active cases (n=16) 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 (four patients). Four patients had superficial infection at less 1 of the wires or pines 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 with lengthening at the proximal or distal metaphysis. Results: 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). Conclusions: Discussion and Conclusion. Ilizarov methodology produced a good result in infected bone defects of long bones. The results were comparable being more satisfactory the treatment with 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. Acknowledgements: My acknowledgements to God, my family for their understanding and to my patients.


  PP 203: Spontaneous Healing Of A Large Cortical Defects In Long Bones After Fracture. There Are Other Therapeutic Agents? Top


Haridimos Tsibidakis, Marco Camagni, Francesco Guerreschi, Andrea Biffi, Alessandro Pelis, Piero Poli

Orthopeadics and Traumatology, A. Manzoni Hospital, Lecco, Italy, Lecco, Italy

Background: We present two cases in which a large gap in bone was filled and healed without any intervention. Methods: An eighteen years old male with multiple injuries, he sustained fracture of the femur. Initially he was treated with internal fixation in other hospital but it became massively infected. We removed the implants and did debridement in first step but infection was not controlled. Then we resected the necrotic end of the bone, created gap. of 11cm and just fixed it with external fixation to control infection. The other patient sixty years old male had open fracture of his tibia. He was treated initially in another hospital with K wire in fibula, screws and external fixator and skin flap for loss of skin at wound site but was failed due to infection. Then we removed the external fixation, did daily dressing and waited for infection to control but still the wound was not healed. Finally, we did resection of the infected segment of bone and created a gap of 9 cm, applied external fixator with proximal osteotomy for segment transport. Results: When we were waiting for his health to improve and to control infection, we saw new bone formation in the gap. We followed up that patient and about of gap was filled and healed without any intervention. Conclusions: We also tried the external fixator in both of cases but due to spontaneous healing of the gap bone transport was abandoned. There are other therapeutic agents that are sometime used to hasten the union but none of them has used in these two cases. Acknowledgements: 1. Hinsche AF, Giannoudis PV, Matthews SE, Smith RM. Spontaneous healing of large femoral cortical bone defects. does genetic predisposition play a role?. Acta Orthop Belg 2003;69(5):441–6. 2. Kiter E, Akkaya S, Oto M, Günal I. Spontaneous regeneration of the large. femoral defect in patient with diffuse osteomyelitis after intramedullary. nailing. Eklem Hastalik Cerrahisi 2010;21(3):178–81. 3. Pazzaglia UE, Finardi E, Pedrotti L, Zatti G. Fracture with loss of the proximal. femur in a child. A case report. Int Orthop 1991; 15:143–4


  PP 204: Treatment Of Septic Nonunion After Femoral Shaft Fracture With Bifocal Bone Transport Over An Intramedullary Nail Top


Haridimos Tsibidakis, Marco Camagni, Francesco Guerreschi, Biffi Andrea, Alessandro Pelis, Piero Poli

Orthopeadics and Traumatology Units A. Manzoni Hospital, Lecco, Italy

Background: An open femoral shaft fracture, after damaged control, was initially treated with an intramedullary nail and complicated by a septic nonunion. Treatment in this case was obtained by a bifocal bone transport over the intramedullary nail using a circular external fixator, according to the principles of Ilizarov. Methods: A 33-year-old man had an open comminuted fracture of the left femur (Type IIIA according to Gustilo) on February 2012, treated initially by an external fixator, changed to intramedullary nail 10 days after trauma, one year after trauma pseudoarthrosis was present and debridement of the fibrous tissue with iliac bone graft was performed. On January 2014 nail was removed, but due to a hypertrophic nonunion, a new bigger nail, after intramedullary reaming, was placed on January 2015 and its dynamization was performed after 4 months. On June 2015, patient presented an infection, resistant to any antibiotics. Resection of the infected bone segment (5cm), debridement and stabilization, using a circular external fixator according to Ilizarov's principles, was performed, maintaining the intramedullary nail in situ. Within 3 months, infection was eradicated and bone transport was concluded with the bone surfaces in contact each other. Then, nail was locked, iliac bone graft was applied after bone surfaces new debridement, and external fixator was removed. Follow up continued for another 3 months until complete bone healing. Results: At 1year follow up patient had full weight bearing without clinically leg length discrepancy, axis deviation or mal rotation, and with satisfactory knee's range of motion. Conclusions: In case of infected nonunion already treated with intramedullary nail, bifocal bone transport can be performed using the external fixator according the Ilizarov principles with good results. Acknowledgements: 1. RicciWM , Gallagher B , Hardukeury DJ .Intramedullary Nailling of femoral shaftfracture current concepts. J Am Acad Orthop Trauma 2009 May 17 (5). 2. Pihlajamaki HK, Salminen ST, Bostman OM. The Treatment of non-unions following IntraMedullary Nail of the Femoral fractures. J Orthop Trauma 2002 July 16(6) 394-402. 3. StruipsDA, Poolman PW, Bhandari M. Infected nonunion of the long bones. J Orthop Trauma 2007 Aug:21 (7):507-11.


  PP 205: Bone defects reconstruction: Results after Masquelet Technique using reamer-irrigator-aspirator system Top


Elisabete Magalhães Ribeiro1, Cecília Sá Barros1, Luis Filipe Rodrigues1, Nuno Vieira Ferreira2, Nuno Sevivas3, Manuel Vieira Da Silva3

1. Department of Orthopaedics, Hospital de Braga (HB), Braga, Portugal

2. Department of Orthopaedics, Hospital de Braga (HB); School of Medicine, University of Minho (SM-UM), Braga, Portugal

3. Department of Orthopaedics, Hospital de Braga (HB); School of Medicine, University of Minho (SM-UM); Life and Health Sciences Research Institute (ICVS); ICVS/3B's – Research Group, Braga, Portugal

Background: Limb preservation remains a significant challenge in orthopaedic trauma. Treatment is still controversial as it depends on size defect, graft availability, soft tissue involvement and patient's conditions. In 1986, Masquelet presented the induced-membrane technique for previous infected or irradiated tissue. Currently, Reamer-Irrigator-Aspirator (RIA) provides adequate volumes, equal union rates and less complications for segmental defects. Here, we present the results after tibial defects reconstruction in patients submitted to Masquelet's technique using RIA. Methods: We selected 4 patients presenting with tibial infected nonunion from January 2013 to December 2016. All patients were treated according to induced-membrane technique using femoral bone graft obtained by RIA. The following parameters were analysed. bone size defect, pre-and postoperative pain, time for bone consolidation, time for load bearing, quality of life and overall satisfaction. We used Visual Analogue Scale (VAS), 36-item Short Form Health Survey (SF-36v2) questionnaire and Radiographic Union Score for Tibial fractures (RUST). Results: We evaluated 3 male and 1 female patients with a mean age of 39,00±11,01 years old and a mean follow-up of 23,31±15,44 months. Postoperative pain was significantly less (5,75±1,50 versus 0,75±0,96; p<0,05). There were no donor-site related complications. All patients had total bone consolidation at 12 months with medium RUST of 11,00±1,00. Bone healing was not affected by initial size defect. Time to total load bearing was 8,88±3,50 months by mean. Postoperative SF-36v2 score was 69,63±6,75 and 85,63±8,63 for Physical and Mental Health components, respectively. Overall satisfaction was 90%. Conclusions: Our data overlap literature referring bone healing between 11 months (Stafford et al, 2010) and 14,40 months (Karger et al, 2012) and total load bearing at 17,40 months. As recently stated, bone consolidation was also not affected by initial size defect. The absence of donor-site morbidity was a remarkable feature of RIA, as described by Dimitriou et al, 2011. In conclusion, Masquelet procedure is a viable option for large lower limb reconstruction with satisfactory results. The use of RIA presented as a reasonable option for obtaining considerable ammounts of bone graft with good consolidation rates and to overcome donor-related complications. Acknowledgements: The authors state no conflicts of interest.


  PP 206: Two Stage Revision Of An Infected Total Knee Arthroplasty Tumor Prosthesis With A Custom-Made Mobile “tumor” Spacer – A Case Report Top


Luís Lopes Coutinho, Luís Henrique Barros, Cláudia Rodrigues, João Maia Rosa, Vânia Oliveira, Pedro Cardoso

Centro Hospitalar do Porto, Porto, Portugal

Background: Distal femur tumors resection and reconstruction with total knee arthroplasty is a major orthopaedic surgery challenge. Although the high risk for complications and the subsequent need of revision, the reconstruction can save life and give the patient a good quality of life with good functional outcome. Methods: We present a case about a 48 years old male, with no relevant medical background, diagnosed in 2007 with a Distal femur grade 2 fibrosarcoma (Eneking IIB), with no secondary lesions. Total knee arthroplasty with modular endoprosthesis was performed in April/2007 and the pathology confirmed the diagnosis and revealed wide margins. Results: Three years after primary surgery the patient started having knee pain and x-ray revealed femoral loosening of the prosthesis, which was confirmed during the surgery – revision of the femoral stem in 2010 – and there were no signs of infection at this stage. Persistent pain after the surgery was interpreted as patellar suffering, and we decided to perform a patellar resurfacing in 2011. Two weeks after the third surgery, clinical signs of infection were observed. Surgical debridement with polyethylene replacement was performed and prolonged antibiotic therapy was instituted. Two years after (2013) the patient started having knee pain and x-ray revealed femoral loosening of the prosthesis again – a new revision of the femoral stem was performed. In 2015, signs of infection were again observed and it was decided to perform a two-stage revision of the prosthesis - Custom made articulating cement spacer loaded with vancomycin and gentamicin and 3 months later Total femur arthroplasty with a silver-coated titanium megaprosthesis. At almost 2 years follow-up, the patient is pain free and there are no signs of infection. The functional outcome is good - 25/30(83.3%) in the MSTS score. Conclusions: Two-stage procedures are the mainstay of chronic prosthetic joint infection but reconstruction options are frequently difficult in these patients. In the case presented the proximal femur was no longer suitable for adequate fixation of a new femoral stem and we therefore chose to perform a total femur arthroplasty. In order to minimize the risk of re-infection we used a silver-coated titanium third-generation metal megaprosthesis. Acknowledgements: The authors declare no conflict of interest.


  PP 207: A Series Of Limb Salvage Procedure In Distal Femur Tumors: A New Life For The Patient. Top


Luís Lopes Coutinho, João Maia Rosa, Cláudia Rodrigues, Helder Fonte, Vânia Oliveira, Pedro Cardoso

Centro Hospitalar do Porto, Porto, Portugal

Background: Distal femur tumors resection and reconstruction with total knee arthroplasty is a major orthopaedic surgery challenge. It can save the limb and life of the patient with good functional outcomes. The aim of the authors is to present the experience of our department of the last five years distal femur resections and knee reconstruction. Methods: Ten knee arthroplasties were performed after total surgical resection of 1 chondrosarcoma, 1 Ewing's sarcoma, 1 fibrosarcoma and 7 osteosarcomas. Close follow-up was performed by a multidisciplinary team. Local relapse, secondary lesions, infection, prosthesis loosening and function were analysed. Results: Patients submitted to surgery between 2012 and 2016 were followed till the present, with a total of 3 deaths due to disease progression. 1 Ewing's sarcoma (2,5 years after surgery), 1 fibrosarcoma (10 months after) and 1 osteosarcoma (3 years after) - only one patient had local relapse (fibrosarcoma) and transfemoral amputation was performed. In our series, we have 1 case (10%) of prosthesis aseptic mechanical loosening (1 year after the surgery) and 2 cases (20%) of infection (1 month and 2 years after the surgery). Musculoskeletal Tumor Ranking Scale (MSTS) questionnaire was performed with overall good functional results. Conclusions: In our experience, despite the local and systemic aggressive behavior of distal femur tumors, the total resection and the limb salvage procedure with knee reconstruction is, most importantly, a curative treatment for the patient. Although the high risk for complications and the subsequent need of revision, the reconstruction gives the patient a good quality of life with good functional outcome. Acknowledgements: The author declares no conflict of interest.


  PP 208: Planning of the treatment of non-unions of tibia and femur, applying an algorithm designed in our center Top


Ignacio Ginebreda, Sergi Rodriguez, Anna Isart, Pilar Rovira, Jordi Tapiolas

Hospital Universitari Dexeus, Barcelona, Spain

Background: Pseudoarthrosis includes a heterogeneous group of pathologies caused by multiple factors, such as the patient's general condition, severity of trauma, bone quality, mechanical stability of the fracture site, vascular involvement, soft tissue involvement, infection, and The previous treatments. The objective is to review the treatment of pseudoarthrosis following an algorithm that includes mechanical and biological aspects. Methods: Retrospective study with 53 cases of pseudoarthrosis of tibia or femur, both septic and aseptic. We collected epidemiological data, risk factors, type of fracture (AO and Gustilo), initial treatment, septicity, bone callus type, biological contributions, consolidation time, axial deviations, length discrepancies and complications; With all the data the nounion type is defined and the treatment algorithm is applied in an individualized way. Results: It includes 46 men and 7 women, with a mean age of 41 years. Twenty-four with pseudoarthrosis of the femur, 27 of tibia. 34 septic and 18 aseptic. 53% of the fractures were closed and 47% were open. The initial treatment was with external fixator in 13 cases, plate and screws in 19 and nail endomedular in 20. An atrophic callus was formed in 48%, hypertrophic in 33% and normotrophic in 19% of the cases. No relationship was found between the treatment and the type of callus. The final treatment was conservative in 4%, with plate and screws in 25%, endomedular nail in 23%, external fixator in 46%. An average of 4 surgeries were required until healing. We found a statistical relationship between treatment and consolidation time, obtaining a longer time in external fixation. The mean dissymmetry after consolidation was 13mm. The complications observed were 1 infection, 2 refractures, failure of the osteosynthesis material and residual axial deviations. Conclusions: The pseudoarthrosis / nounion should be considered as a multifactorial problem and it is advisable to individualize each case with its special characteristics. Preoperative planning should assess general aspects, septicity, type of stablization and biological contribution, with the aim of prioritizing consolidation, then global limb functionality and finally isometry. Having treatment guidelines helps you get good consolidation results and reduce the number of interventions. Acknowledgements: To all our team, to the patients that have collaborated in the study and to the departments of statistics and diagnosis by image


  PP 209: Management Of Infected Fractures And Non-Unions – Stability Is The Key; Fixation Hardware Is Not The Enemy: A Paradigm Shift Top


Minoo Keki Patel

Centre for Limb Reconstruction, Melbourne, Australia

Background: Abstract Text. The traditional understanding of infected fractures and non-unions calls for removal of infected, even all, hardware, in order to remove the biofilm. New research, by our group and our colleagues, shows that stability is the key to union. Not all hardware needs to be removed. The most important finding is that eradication of infection is not necessary for union. As a corollary, stability and union are the key to infection control. We present salient findings that make for a paradigm shift in the management of infected fractures and non-unions. 1) In over a hundred fractures with infection, union was achieved in over 93% cases by preserving the hardware and improving the soft tissue conditions, appropriate antibiotics and improving stability where necessary. 2) Removal of hardware delays fracture union or leads to non-union. Hardware exchange may also delay fracture union. 3) Stable internal fixation, with or without additional external fixation, leads to union, even in chronic infected non-unions and neuropathic joints. 4) Quiescence of infection, if not cure, is achieved with union. 5) We present our technique of fixator assisted and associated nailing for infected non-unions. 6) We also present our published results with management of infected non-unions with fusion of neuropathic ankles and femoral fractures. We present our protocol for management of infected fractures and infected non-unions. Methods: Results: Conclusions: Acknowledgements: .


  PP 210: Fallback Solution In Complex Femoral Nonunion - Clinical Case Top


Diogo Pascoal, Armando Campos, Ângelo Encarnação, Daniel Soares, João Rosa

Centro Hospitalar do Porto, Porto, Portugal

Background: Subtrochanteric femoral fractures have demanded special consideration in orthopaedic traumatology, given the high rate of complications associated with their management. Nonunions with limb length discrepancy are often one of the most difficult complication to treat. Classical management options include internal fixation with or without bone grafting, using cephalomedullary nails or fixed angle plates. However, when nonunion is associated with limb length discrepancy, a specialized treatment is needed to ensure bone and limb functional integrity. Methods: We introduce a case of a 52-year-old woman who suffered a subtrochanteric femoral fracture of the right femur and underwent a cephalomedullary nailing in 2012. In follow-up developed severe hip pain and disability in daily living activities. Radiologically presented an hypertrophic nonunion, with a limb length discrepancy of 9 cm. The patient was proposed for surgical treatment with nail extraction and bifocal compression-distraction (distraction osteogenesis) with monorail fixator. Distally, a femoral corticotomy and bone transport was done, while proximally, compression in the nonunion site was achieved after surgical debridement. After consolidation phase, at 11 months postoperatively, the external fixator was extracted and the patient underwent internal fixation with plate and screw in order to support the regenerated bone. Results: Surgical interventions and postoperative elapsed without complications. At two years postoperatively, the patient showed satisfaction with the surgical outcome, with good clinical and radiographic evolution, without pain, limb length discrepancy of 2 cm, walking without crutches and an Harris Hip Score of 81 (Good ) and a Knee Society Score of 77 (Good). Conclusions: The management of nonunion has remained a difficult challenge due to frequently associated bone defect, shortening and deformity. Internal fixation doesn't address the problem of deformity, shortening and bone loss, and require significant surgical exposure. On the other hand, bifocal compression-distraction with external fixator provides stable fixation, is minimally invasive and has the ability to address simultaneously shortening and deformity and achieve compression at the nonunion site. Distraction osteogenesis with external fixator is presented as a simplified alternative solution, but effective, allowing the patient to return to satisfactory function and independence in activities of daily living. Acknowledgements: The authors did not receive grants or outside funding in support for preparation of this manuscript.


  PP 211: Management Of Pseudoarthrosis Defects Of Upper Limb And Deformities Around The Elbow By Ilizarov Technique Top


Md Mofakhkharul Bari

Bari Ilizarov & Orthopaedic centre, Dhaka, Bangladesh

Background: The management of pseudoarthrosis defects of upper limbs and deformities around the elbow is a challenging job for orthopaedic surgeons. Methods: From Jan. 1997 to Jan. 2012(15 years), we have been managing pseudoarthrosis and defects of upper limbs with deformities around the elbow joint (Pseudoarthrosis – 87, upper limb defects – 76, deformities around the elbow – 46) in Bari-Ilizarov Orthopaedic Centre and in NITOR. Patient age ranged from 6 to 62 years. Results: The results are excellent and fair if meticulous intelligent follow-up is maintained properly. Conclusions: The management of pseudoarthrosis defects of upper limbs and deformities around the elbow by ilizarov technique is efficient and effective in treatment armamentarium. Acknowledgements: Dr. Md. Shahidul Islam, Prof. MD; FCPS, Bari-Ilizarov Orthopaedic Centre. Dr. Nazmul Huda Shetu, M.S (Ortho), Consultant, Bari-Ilizarov Orthopaedic Centre. Dr. Md. Mahfuzer Rahman, D. Ortho- Consultant, Bari-Ilizarov Orthopaedic Centre.


  PP 212: Functional radiography following an Ilizarov hip reconstruction: Visualizing motion around the pseudojoint Top


Daniel Villarama Dungca

Jose R. Reyes Memorial Medical Center, Manila, Philippines

Background: Results of Ilizarov Hip Reconstruction following infective hip arthritis have been favorable in literature. However, we have not encountered any report on how the reconstructed hip behaves during motion and weight bearing. We therefore performed a fluoroscopic investigation on the motion of the pseudojoint. Methods: We performed a pelvic support osteotomy with the Ilizarov method for an 18-year-old female who had lysis of the femoral head secondary to tuberculous hip arthritis. At five years follow-up, the patient is ambulant with a pain-free hip and negative Trendelenburg sign. We performed fluoroscopic imaging to look at the motion of the hip in different ranges of motion as well as in weight bearing. Results: The dynamic images showed that the proximal femur was able to move in a stable manner throughout the different ranges of motion. No telescoping nor subluxation was noted while performing the said motions. The proximal femur valgus-extension osteotomy was also shown to be supporting the pelvis by abutting against the ischial tuberosity on single leg stance. This confirmed all the published advantages of this reconstructive procedure in creating a stable and functional hip joint. Conclusions: This is the first reported case on this procedure in our country. The dynamic images showed a better picture of how the pseudojoint functions in three-dimensional real-time motion, in contrast to the static two-dimensional pictures of conventional radiography. This leads to a better appreciation of how this type of reconstruction provides a better function for patients undergoing this procedure. Acknowledgements: The author has no conflict of interest in this study.


  PP 213: Surgical treatment of complex neurologic foot deformities with Ilizarov external fixation and distraction Top


Alexander Kirienko, Emiliano Malagoli

Humanitas Research Hospital, Rozzano, Italy

Background: Diseases linked to lesions of the upper or lower motor neurons often cause severe and rigid deformities of the foot and ankle. Treatment of a neurological foot with rigid deformity is rather difficult and recurrence of the deformity is a common problem. The goal of treatment for a stiff deformity of the neurological foot is to convert a deformed foot and drive in a plantigrade foot. Methods: Author's experience in the treatment of the neurological foot with the Ilizarov fixator based on application of the method in 51 cases. Were outcomes of polio in 27 cases. Six of these patients were treated with closed method, in 5 cases was performed “V” osteotomy, supramalleolar osteotomy in 2 cases, triple arthrodesis and ankle arthrodesis in 3 cases, arthrodesis of Chopart 1 case. In 13 cases were performed tibial lengthening, Achilles tendon lengthening in 8, arthrodesis of the knee 1. Fourteen patients (17 limbs) were suffering from Spina Bifida with higher prevalence of foot deformities in vertical calcaneus (5 feet) and varus and valgus (8), foot instability 4, ankle deformities in 4 cases, the knee flexion contracture in 4 cases. Surgeries were performed of the proximal tibia osteotomy (6), supramalleolar osteotomy (5), arthrodesis of the subtalar and Chopart (8), anterior arthrorisis (3), “V” osteotomy (1), “Y” osteotomy (4). Other 6 patients were suffering from Charcot-Marie -Touth disease with prevalence of equino-cavus and varus. In 2 cases was performed correction with Y osteotomy, other 4 patients were operated with triple arthrodesis with progressive distraction. Mean follow up in these patients was 7,42 years (range 13 to 16 years). correction period ranged from 2 months to 3.5 months. Average time of fixation for the period of the foot portion was 3.1 months and 5.1 months for the tibial portion. Results: We observed residual deformity in 6 cases treated. Dysesthesia seen in 5 cases, superficial necrosis in 3. One patient during treatment with 3-ce arthrodesis and leg lengthening developed contracture of the knee. Two patients after triple arthrodesis had relapsed and were re-operated with V osteotomy. Conclusions: It is essential overcorrect all components of a deformity to reduce the risk of recurrence. We think that a triple arthrodesis after Ilizarov method is not considered a failure in the correction of deformities of the neurological foot. We were able to minimize the bone resection to conserve height and length of the foot. Acknowledgements: .


  PP 214: Bone Transport Over The Plate For The Segmental Defect Of Forearm Bone - A New Technique To Reduce The Time For External Fixation: Top


Chang-Wug Oh, Joon-Woo Kim, Kyeong-Hyun Park

Kyungpook National University Hospital, Daegu, South Korea

Background: Distraction osteogenesis has been solved a large segmental bone defect of long bone. However, it may be very difficult to perform to perform the ilizarov bone transport in the forearm bone defect, because of complex internal structures and expected complications. To reduce these risks, a new technique of bone transport involving the use of an external fixator and a plate was devised for segmental bone defect of forearm arm bones. Methods: A plate was fixed to bridge the proximal and distal segments of forearm (radius or ulna) on the volar side. Then, a mono-lateral lengthening external fixator was then fixed on the radial or ulnar side, without the contact of the pre-inserted plate or its screws. An corticotomy was performed to distract the bone. The distraction started at 10 days, with a speed of 1mm/day. A second operation was performed at the time of contacting the distraction segment to the target segment. Several screws were fixed at the transported segment through the empty plate holes. At the same stage, bone grafting was performed at the docking site, with the external fixator removed. Results: Two cases of infected nonunion of forearm (1 radius and 1 ulna) were included in this technique. After several times of debridement and resection of infected bone, the index procedure was performed. Mean defect size was 6 cm. The time for external fixation was 91 days (range, 77 to 105 days), and the mean external fixation index was 15.1 days/cm. In all cases, primary union of the distraction and docking site was achieved with an excellent bony result. No patients had an angular deformity of over 5 degrees. No deep infection recurrence occurred. Conclusions: The present technique shows that bone transport over the plate can achieve successful results and reduce external fixation time in patients with segmental bone defects of the forearm bones. It may allow patients to return to daily life earlier with relatively few complications. Acknowledgements: No conflict of interest


  PP 215: Tumors Of The Shoulder Girdle: Reconstruction Challenges And Strategies - Experience Of A Center Top


Joao Maia Rosa1, Arnaldo Sousa1, Luis Lopes Coutinho1, Pedro Mota2, Vania Oliveira1, Pedro Cardoso1

1. Centro Hospitalar do Porto - Hospital Santo António, Porto, Portugal

2. Centro Hospitalar de Trás os Montes e Alto Douro, Chaves, Portugal

Background: Limb preservation surgery in shoulder girdle tumors is a major surgical challenge due to the size of those lesions, their location, the large volumes of bone and soft tissue that we often are obliged to resect, and the need of reconstruction. Reconstruction with prosthesis, structural allograft or a mixed alternative is often recommended in all types of Malawer resections. The aim of the authors is to present the experience on Malawer resections made in the service in the last 8 years and to reflect on the need for reconstruction considering the most current literature. Methods: Twelve Malawer resections were performed. 6 Type I, 4 Type II, 1 Type III and 1 Type IV. The proximal humerus excision was performed because of the presence of 2 osteosarcomas, 2 chondrosarcomas and 2 giant cell tumors. The reconstruction was done in all cases with reverse arthroplasty, using a system of prosthesis and allograft system in one case. Excision of the body of the scapula, total or subtotal (Type II) was performed in 4 chondrosarcomas and no reconstruction was performed. Total scapulectomy (Type III) was performed on a massive Ewing's sarcoma and no reconstruction was done, and the humerus was suspended on the scapula with non-absorbable suture and a Trevira sleeve. The extrarticular resection of the scapula (Tickoff-Linberg procedure) was done due to a synovial sarcoma and no reconstruction was done. Results: With an average follow up of 4.4 years (6 months to 8 years) all patients are alive. The patient with Ewing's sarcoma has lung dissemination. In all cases the margins were widened. There was recurrence of the synovial sarcoma that was then treated with a new surgery and chemotherapy, and is currently with no evidence of disease. The function in patients undergoing humeral prosthesis is very good, with a mean score of 21/30(MSTS). On the group that underwent scapulectomy the MSTS is on average higher (24/30) but it required a lot of physiotherapy time and a slow functional gain. The function in both patients of resections III and IV is markedly lower:12/30 and15/30, respectively. Conclusions: If the need for a reconstruction in the proximal humeral excision is indisputable, on the other hand after the scapulectomy the replacement by allograft or prosthesis does not seem to have any advantage, since the ablation of the different muscle groups compromises the shoulder mobility and there are a series of complications, from disassembly to infection, pointing the decision, mostly, for non-reconstruction. Acknowledgements: the authors have nothing to disclose


  PP 216: Foot Stump Distraction Lengthening In Posttraumatic, In Congenital And Diabetic Patients, With Ilizarov Method. Top


Alexander Kirienko, Emiliano Malagoli

Istituto Clinico Humanitas, Rozzano, Italy

Background: In Chopart and Lisfranc level amputations the heel often deviates into equinus and varus or 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 and prevent ulceration. Methods: 11 patient with short foot stump were treated with percutaneous osteotomy of the anterior part of the calcaneus and neck of the talus or cuboid and cuneiforms, 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 four cases. In the beginning, longitudinal distraction for anterior lengthening was done, than the correction of equinus 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 27 mm. Mean time of consolidation period was 77 days. The average age of the 3 women and 8 men was 31.9 years (range, 15-62). Postoperative complications included minor wound healing problems in 7 patients, wires breakage in two, wound breakdown requiring revision in 1. All patient 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). Conclusions: This technique with the use of the Circular external fixator could be a salvage solution to the problems that often exist with Chopart and Lisfranc stump. Acknowledgements: .


  PP 217: Treatment Of Bone Defect Using External Arc Fixation System Salamehfix 1 Top


Ghassan Salameh

Salamehfix Limb Lengthening & Reconstruction, Tartous, Syria

Background: Bone defect as a result of trauma, infection or gunshot defect with a soft tissue defect also require bone reconstruction surgery to replace bone defect and soft tissue lesion and the most effective method is external fixation system using bone regeneration and lengthening method and require an external fixation system which is more comfortable to patient in size, less painful, hinged to correct any angular deformity in addition to lengthening which allows also stable fixation. Methods: The External arc fixation system Salamehfix1 can be assembled from three small arcs for one segment lengthening and 4 arcs for two segments of lengthening depending of patient size, so that for every patient a special size can be arranged. The arcs are deferring in diameter and perimeter depending on the extremity shape so that the fixator will take the shape of the extremity on which it applies and the mostly used half pins for bone fixation which transfix the bone in different angels and levels and lead to stable fixation also existing simple hinges between arcs can correct any angular deformity. Results: From 2000 to 2016, 192 patients was treated mean age 43 years (range. 21 -68 years) with mean bone loose of 7.8 cm (range . 2- 17 cm )with various reasons and locations in upper and lower extremities, mean duration follow up 37 months, mean external fixation time 294 days , 93 excellent, 157 good , 38 fair, 4 poor there where 6 problems , 7 obstacles according to Paley,s classification of complication , there was one persisting nonunion which required additional grafting . Conclusions: The external arc fixation system Salamehfix 1 is effective in bone defect treatment and more comfortable to the patient in size, stability and correction of combined angular deformities. Acknowledgements: The external arc fixation System Salamehfix1 is a comfortable and effective method of treatment bone defects gives good results and is wise to use.


  PP 218: Outcome following treatment of diaphyseal femoral osteomyelitis using a monolateral external fixation system Top


Nazri Bin Mohd Yusof, Ahmad Fadzli Bin Sulong

international islamic university of malaysia, Kuantan, Malaysia

Background: The traditional monolateral fixation is not strong enough to overcome the strong deforming force of the strong adductor muscles which lead to varus deformity. The ring fixation, although provide a stable fixation of bone, is bulky and uncomfortable for the patients. This paper presents our result of treating patients with femoral osteomyelitis treated with a modern unilateral external fixation device. Methods: This was a prospective study of 22 consecutive patients treated for femoral osteomyelitis from 2010 till 2014. Only patients with minimal 2 years follow up were included in the study. The mean age of the patients was 28.7 (range 13 to 71) years old. Patients with osteomyelitis were divided into 3 types. type I is haematogenous osteomyelitis with pathological fracture (4 patients); type II is infected open fracture (3 patients) and type III is implant related infection (15 patients). Patients with type I osteomyelitis is treated initially with incision and drainage, and skeletal traction. External fixation is inserted after 2 to 3 weeks when the thigh swelling has reduced. In patients with type II osteomyelitis, the fracture end is resected until healthy bone. In type III osteomyelitis, the implants (2 intramedullary nails and 13 plates) are removed during the initial debridement. In 18 cases, acute compression was done after resection. In 4 cases, bone transport was done to fill the defect after the infection has been controlled. Results: Infections were resolved in all patients. All except one achieve union with mean union time of 8.5 (range 4-30) months. The mean limb length discrepancy is 2.2 cm (range 0-6 cm). Six patients (27%) have refracture following removal of the external fixation. One refracture because of persistence infection at the docking site. Three refracture at the docking site; one underwent interlocking nail, one reinsertion of LRS and one refuse further intervention. One patient had refracture at the thin bone segment. The fracture end was allowed to be overlap to get a bigger bone diameter and he was treated with reinsertion of external fixation and lengthening. One adolescent patient had fracture at the screw site was treated with skin traction. Conclusions: Monolateral external fixator is an effective alternative for stabilisation and reconstruction of femoral osteomyelitis. Caution should be taken when removing the frame to reduce the incidence of refracture. Acknowledgements: We do not have any conflict of interest in this study.


  PP 219: Bone Transport For Chronic Tibia Osteomyelitis, Is It Necessary With Antibiotics Embedded Bone Cement Technique? Top


YongHong Zhang1, Sihe None Qin2, Dong None Wang1, Laiyou None Liu1

1. the 2nd Hospital of Shanxi medical university, Taiyuan, China

2. Rehabilitation Hospital of the National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: To evaluate if the antibiotics embedded bone cement reduce the recurrence of chronic tibia osteomyelitis after bone transport technique. Methods: 18 patients with chronic tibia osteomyelitis were randomly divided into two group. 10 patients were treated without antibiotics embedded bone cement, 8 were left vancomycin embedded bone cement (Vancomycin 3 gram in 20-gram bone cement) in the docking site. when the docking site was tight, the bone cement beads was put out gradually. The results were graded using Paley' s criteria. Results: One of the 10 patients without bone cement were lost to follow up, the others were all followed up with a range of 12 ~ 47 months with average of 31months, all were recovered from infection. The average wound closure time is 63 days for the bone cement group, and 69 days for the non-bone cement group, bony consolidation time for the bone cement group is 4.4 months, and the control group is 4.3 months. The complications were pin site infection, bone cement group 7, non-bone cement group 9; equine was 0 for both group; malalignment over 10°was 5 in bone cement group, and 3 in the control group, all were managed during follow-up; stiffness was 1 for bone cement group, 2 for non-bone cement group; and joint dislocation was 0 for both group. According Paley's rating scale, 7 excellent and 1 good for the bone cement group7 excellent and 2 good for non-bone cement group. Conclusions: Thorough debridement could be enough for the treatment of chronic tibia osteomyelitis with bone transport technique even without antibiotics embedded bone cement in the docking site. Acknowledgements: Thank all our group team for all their effort and cooperation!


  PP 220: Rehabilitation Of Patients With Congenital Pseudarthrosis Of The Tibia (Experience Of Ilizarov Center) Top


Dmitry Yurjevich Borzunov, Sergey Alexandrovich Kutikov

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: Congenital pseudarthrosis of the tibia (CPT) is a severe pediatric pathology that remains extremely challenging for management. Multiple recurrences result in considerable pathological changes in bone and soft tissues that make solving clinical tasks difficult. Segment fixation is a method of choice but the majority of surgeons prefer transosseous or intramedullary osteosynthesis, or their combination. However, neither technique guarantees consolidation and is able to ensure absence of recurrence. Methods: We analyzed outcomes of 61 patients that were treated with technologies of transosseous osteosynthesis in the period between 2000 and 2015. All patients had pathological fractures. CPT was classified according to Crawford. Patients were divided into 4 groups in regard to the technologies of transosseous osteosynthesis used. Monofocal osteosynthesis was used in 27 cases, bifocal osteosynthesis in 25, and two patients were treated with polyfocal compression distraction osteosynthesis. The combination of the Masquelet induced membrane technique and Ilizarov bone transport was used in seven cases. The CPT area was bridged with an end of one of the fragments in five cases. Overlapping of bone fragments was used in nine patients. The split ends of both fragments were plunged into ea. Results: Bone union was achieved in 60 patients after the first operation. Recurrences in the long-term happened in 35 cases (57.4%). One recurrence occurred in 16 cases; ten patients had two recurrences and three had three refractures each. Additional means of fixation should be used after removal of the Ilizarov apparatus in order to reduce recurrences. However, wearing an orthosis is uncomfortable and does not provide sufficient stability. In our opinion, a more logical solution is to use intramedullary rods or wires. Combination of the Ilizarov apparatus and intramedullary wires coated with hydroxyapatite were used in five patients. These patients did not have any recurrence at follow-ups from one year up to 6 years. Conclusions: The advantages of transosseous osteosynthesis are its low invasiveness, high rates of short-term good and satisfactory outcomes, early weight-bearing, and the possibility to gradually correct multiplanar deformities and lengthen bone fragments in limb length discrepancy. A relative shortcoming is the necessity to wear the external fixator that worsens patient's quality of life. However, the recurrence rate is rather high after the removal of the Ilizarov apparatus. Acknowledgements: not available


  PP 221: Arthrodesis Of The Knee And Bone Lengthening With Ilizarov Apparatus Followed By Nailing With A Nail With A Core Of PMMA Cement With Antibiotics. Top


Nuno F. Craveiro Lopes

Red Cross Hospital, Lisbon, Portugal

Background: Knee arthrodesis using a long nail is described as an effective treatment option after failure of the infected total knee arthroplasty. However, this technique involves a risk of reinfection and appreciable leg length discrepancy. The aim of this study was to evaluate the result of a staged approach to this disease, including a first procedure with acute knee coaptation and femoral or tibial lengthening with Ilizarov apparatus, followed by nailing with a long interlocking nail with a PMMA cement core that deliverer antibiotics (SAFE DualCore Universal Nail). Methods: We retrospectively reviewed the results of 9 patients treated with this technique after removal of knee revision arthroplasty after repeated infections. The study group included six women and three men with a mean age of sixty-two years at the time of arthrodesis. All patients were treated with a protocol including debridement, acute knee coaptation and lengthening of the femur or tibia with a Ilizarov frame. The average bone loss was 8.6 cm. In one of the patients who had a bone loss of 12 cm, we have proceeded to a bifocal converged transport, femoral and tibial. After the terminus of the lengthening period, the Ilizarov apparatus was converted to a long SAFE nail with PMMA cement core with antibiotics second the antibiotic sensibility test. All patients underwent the administration of systemic antibiotics during the postoperative period. The mean follow-up was 6 years and eight months. Results: The average time of use of the Ilizarov apparatus was 3 months. 8 of the 9 patients healed their bone infection. The patient in which a converged transport was done, had a relapse of the bone infection and underwent trans-femoral amputation. In 2 patients, there was recurrence of soft tissue infection in fistulous tracks, which healed after directed intravenous antibiotic therapy. Arthrodesis consolidation was obtained in 8 of 9 cases, in an average of 6 months and patients resumed painless gait with walking aids. The final average leg length discrepancy was 3.5 cm. Conclusions: The knee arthrodesis and bone lengthening with Ilizarov frame followed by nailing with SAFE nail for the treatment of infected knee arthroplasty after successive attempts of revision has proved to be an effective technique, not only to achieve a high rate of consolidation, as to compensate for bone loss and prevent reinfection of the joint area. Acknowledgements: The author have no conflict of interests to declare.


  PP 222: Treatment of Recorrent Giant Cell Tumor with Bloc Ressection and External Fixation to Bifocal Transport and Arthrodesis Top


Gerardo Lopez Mejia

Christus Muguerza Saltillo, Saltillo, Mexico

Background: The TCG is a low-grade neoplasic lesion that appears in the epiphyseal and metaphyseal region of long bones,although is nenign it tends to destruction appears in patients betweeen 20 and 50 of age.There are multiple medical(donusumab) and surgical(osseous curettage,bonegraft,liquid nitrogenus and bone cement).So it is a high rate of recurrence,taking into account that the malignant. Methods. Patients with TCG in bone long with resecction of tumor and into external fixation in tibia and femur LRS,corticotomy in both bones with trasnportation bifocal and ending and thus the limb salvage in arthrodesis. Results: This demostrates the efficacy of tissue culture throug the bifocal elongation despite the inconvenience that the use of external fixation cause. Conclusions: It demostrated the effectiveness of technique of bloc resection with transportation and ending bifocal bone elongation despite the inconveniece that the use of external fixation cause.The manegment through tumor prostesis is good but taking into account that most patient with this desease are young and active patient the duration of the prostesis in not much.The final question woulkd be is an amputation andd a prosthetic posterior pelvic limb vs. a single rigid leg(arthodesis). Acknowledgements: Hospital Christus Muguerza Saltillo.


  Reconstruction after upper limb trauma Top



  PP 223: Two stage reconstruction of septic non-union of the humerus with the use of circular external fixation Top


Gerhard Pienaar1, Nando Ferreira1, Leonard Charles Marais2, Charles Serfontein2

1. University of Stellenbosch, Cape Town, South Africa

2. University of KwaZulu-Natal, Pietermaritzburg, South Africa

Background: Achieving quiescence in chronic osteomyelitis remains challenging. Wide resection of all infected and necrotic tissues improves the chances of achieving remission of the disease. Extensive debridement however decreases the already compromised bone stock that increases the complexity of reconstruction. Methods: We report on the outcome of eight patients with Cierny and Mader stage IV chronic osteomyelitis of the humerus who underwent debridement followed by bone graft and circular fixator application as a second stage procedure. Results: Resolution of infection and humeral shaft union was achieved in all patients. Conclusions: Our study finds that two-stage reconstruction of stage IV chronic osteomyelitis with the use of circular external fixation is effective in achieving infection control and union in these complex cases. Acknowledgements: There are no conflicts of interest


  PP 224: A new approach for treatment distal humerus fractures in elderly patients using dynamic external fixator Top


Marcio Aurelio Aita, Victor Silveira Simões, Douglas Hideki Ikeuti, Edison Kenji Nakano

Faculdade de Medicina do ABC, Santo André, Brazil

Background: The hypothesis of this study is to use an osteosynthesis method, which seeks to facilitate intra operative surgical management of these fractures, reducing the time of the procedure, hospitalization and rehabilitation, risk of infection and aggression to soft tissues. The objective is to measure the radiographic, clinical and functional outcomes of patients with diagnostic of complete articular fractures of the elbow treated with the use of articulated external fixator. Key words. elbow, fractures, distal humerus fractures, instability,elderly. Methods: In this study, ten patients with fractures were analyzed (closed or open) and or fracture-dislocations, elbow, classified as AO 13C. Surgical treatment of these patients was by percutaneous method, minimally invasive, using the specific dynamic external fixator for the elbow, without direct approach to the fracture site, with or without compression screws or Kirschner wires to assist stabilization these fractures. The Schantz pins selected were 5 mm to stabilize the humerus and 4 mm for the ulna. Study Design. Prospective cohort. Results: The mean range of motion was 134° of flexion, extension was of - 5°. All elbows were clinically stable. The mean VAS was 2.2 and DASH was 14.3. All fractures were healing. All patients had humeral-ulnar concentric congruence and radio capitellum. Regarding complications, we observed a patient who presented with pain in ulna pin location, which was resolved with the removal of this, after two months, another patient had pneumonia and came to death. Follow up was 15,44 months. Conclusions: Radiographic analysis of patients treated with this technique showed fracture healing with reduction and maintenance of articular congruity. In clinical and functional aspects, we noted that patients had a functional range of motion, pain relief and quality of life. Acknowledgements: Translation service provided by Sandra Miaguti .


  PP 225: The Ilizarov external fixator for the treatment of unstable distal radius fractures preliminary results of a retrospective cohort study of 42 patients Top


Carlo Villacreses1, Karin Larsson2, Anders Nilsson3, Telmo Ramos4

1. Department of Orthopaedics, Lidköping, Sweden

2. Department of Occupational Therapy, Skaraborg Hospital, Skövde, Sweden

3. Department of Hand Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden

4. Skaraborg Hospital, Lidköping, Sweden

Background: Unstable distal radius fractures are difficult to manage and so various treatment modalities have been described. The use of external fixation is promoted for the management of these fractures as alternative to ORIF with screws and plates. The aim of the present study was to evaluate the clinical and radiological results in extra- and intra-articular unstable distal radius fractures treated with the Ilizarov method. Methods: We reviewed a cohort of 42 isolated unstable distal radius fractures (11 were extra-articular and 31 intra-articular) that were treated at our institution using the Ilizarov external fixation with radio-carpal non-bridging technique. Post-operative unrestricted training was allowed. Radiological parameters such as radial inclination, length, tilt, and ulnar variance were measured. The functional evaluation was conducted by measuring the range of motion at the wrist joint as well as the grip strength. The wrist function was evaluated with the VAS Pain, VAS Satisfaction, EQ-5D, PREW, DASH and Gartland and Werley scores. Results: The median age of the patients was 60 years old (range 29—69). The duration of follow-up was a median 5 years (range 3—7). The complications of the treatment were four cases of superficial pin-site infections that responded to oral antibiotics (8%), one patient had developed an extensor pollicis longus rupture (2%) and other a pseudarthrosis (2%). The ranges of motion of the injured wrist compared with the injured side at the follow-up examination to both subgroups were a median over 80% in all movements. Grip strength (recorded as a percentage with respect to the uninjured side) was a median 85 % (34—113) to the extra-articular subgroup and 85 % (20—146) to the intra-articular subgroup. The self-appraisal scores indicated that the patients tolerated well the treatment. The overall result was judged as satisfactory in 90% of the patients. Conclusions: The Ilizarov method produces a good clinical outcome and is a valuable treatment alternative in unstable distal radius fractures. Acknowledgements: The Research Fund at Skaraborg Hospital, Sweden supported this study. The funding agency was not involved in the design or the performance of the study.


  PP 226: Application of external fixator in the treatment of fractures of the distal radius, indications and long term follow up Top


Sergio Antonio Iriarte

Clínica del Sur, La Paz, Bolivia

Background: The fractures of the distal end of the radius are more frequent in adults than in children. In the last decades, there has been a bigger concern about the classification, the treatment and the rehabilitation of these fractures, as sequels that leave are often disabling, especially in young people and for the working laws. The indications of monolateral external fixator were necessary. Methods: The patients treated with Monolateral External Fixator in our Department, presented unstable or intra-articular fractures of the distal end of the radius, accompanied or not of fracture of the ulnar styloid, they corresponded to the types. V to VIII of the classification of Frykman or types. 2.3 A-3, C-1, C-2, C-3 and B-3 of the classification of Müller from the AO. Other indications were. Loss of the reduction of the fracture with other methods, exposed fractures and bilateral fractures. We use monolateral fixator with four penetration points, two in the lower shaft of the radius and two in the second metacarpal. In some cases, it was necessary to fill the space with cancellous iliac bone graft. In most of the cases the maintenance of the reduction was carried out with distraction and stabilization with the molotateral fixator. In some cases, we used additional Kirschner wires or screws. The treatment of 197 patients was analyzed, 13 of them presented bilateral fracture, in total 210 wrist fractures, from April 1993 to April 2016; the age variation was 16 to 83 years old with a 35-year-old age average. Men prevalence 81%. In all of them were carried out clinical and radiological exam. Results: Consolidation in 100% of the cases; deformity absent or discreet 87%; functional result. excellent or good 75%; time of treatment from 6 to 8 weeks; time of consolidation 6 weeks. Conclusions: Most of our patients were young people, who had suffered work or traffic accidents. 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. Acknowledgements: I wish to express my sincere gratitude to my patients and all my work team!


  PP 227: Management Of Post-Traumatic Humeral Diaphyseal Nonunion With Bone Loss With Bone Transport Using Unilateral External Fixator Top


Lei Huang

Beijing Jishuitan Hospital, Beijing, China

Background: post-traumatic humeral diaphyseal nonunion with bone loss is challenge problem for orthopedic surgeon. Methods: even patients with post-traumatic nonunion with bone loss of the humeral diaphysis were treated with bone transport using unilateral fixator(LRS). The mean age of the patients was 36 years, and the mean total amount of humeral defect was 6.4 cm. All nonunion were atrophic and four were infected, 4 were in the distal part of the humerus, 3 were in the middle. Results: All patients got union of the humeral fracture with resolution of infection at a mean external fixation time of 9 months. Restoration of normal humeral length was achieved in 6 patients. The 7th patient had a residual limb length discrepancy of 1cm. All had improvement in shoulder motion, 4 had stiffness of the elbow after arthrodesis of the Elbow with a plate. No patient had a refracture after removal of the fixator. All patients had reduced pain and improved function at completion of the treatment. Conclusions: The bone transport with unilateral fixator not for all humeral nonunions with extensive bone loss, does offer a viable salvage procedure in this challenging clinical problem. Acknowledgements: the author has not received any benefit from any company or organization.


  PP 228: Non-Union Of Post Operative Nailing In Upper Limb Treated With Simple Frame Keeping The Nail In Situ Top


Prasad Nvsv Pavuluri

srujan ortho and accident care, Khammam, India

Background: Non-union in humerus is a very common problem and faced by almost every orthopaedic surgeon dealing trauma. Plating is gold standard in humerus and fore arm bones but nailing is also becoming common nowadays. In cases of nonunion with plating, we have to remove plate for fixation with Ilizarov as it will not allow compression or distraction. Gravity plays a grave role in humerus. To counter this effect devised a simple two ring frame and compression was given to achieve union. Methods: Two half rings or 5/8 rings were fixed at each end of the bone avoiding the nail in it either by shanz pins or wires and are connected either directly or through a middle ring if the length is more. The locking screws were removed at one end avoiding the protrusion of nail in to the joint if compression is given. After achieving union, the locking screws were reapplied and frame is removed. Results: Good union was achieved in all the cases. Conclusions: This is a very simple technique. No need of opening of the fracture site so that the vascularity of the bone ends is preserved. No need of bone grafting and you can perform accordion maneuver if necessary. Acknowledgements: nil


  PP 229: Outcomes of the management of neglected elbow dislocation using a modified hinged Ilizarov external fixator Top


Juanito Sanqui Javier, Dandro Paulo Lat

Department of Orthopaedics, College of Medicine, University of the Philippines Manila, Manila, Philippines

Background: Treatment of neglected elbow dislocation is far more difficult compared to simple closed reduction for the acute type. Allowing early elbow motion while maintaining the joint congruity is the challenge presented in the management of chronic elbow dislocations. This study aims to evaluate the outcomes of managing neglected elbow dislocations by open reduction and early range of motion with the elbow joint kept reduced by a modified hinged Ilizarov fixator. A couple of holes in the 5/8th Ilizarov ring were modified which allowed more accurate placement of the hinges along the elbow axis of rotation. Methods: This is a retrospective study of patients with neglected elbow dislocation and who underwent the previously stated surgical procedure. Chart and radiograph reviews were done. Outcomes were assessed by the change in range of motion, stability and presence of pain. Results: The outcome in nineteen patients with an average age of 22.7 years (9-45 years) was assessed. Follow-up ranged from 4 to 56 weeks (mean 16.4 weeks). The mean duration of dislocation is 6.8 months (1-24 months). The average pre-operative range of motion is 15 degrees of elbow flexion-extension arc and 75 degrees pronation-supination arc. These improved to 92 degrees elbow flexion-extension arc and 152 degrees pronation-supination arc. Only 2 patients had mild pain on range of motion of the elbow. Two patients developed pin tract infections that resolved with release of pin tracts and short course oral antibiotics. One patient developed triceps muscle weakness that improved to a motor grade of 4/5 after rehabilitation. None of the patients had valgus or varus instability. There were no reported redislocations. The duration of dislocation and the final arc of motion have no significant relationship. Conclusions: Neglected elbow dislocations can be managed satisfactorily by open reduction, early range of motion and maintenance of joint congruity by a modified hinged Ilizarov fixator. Acknowledgements: The authors have no affiliations with or involvement in any organization or entity with any financial interest or other equity interest, or non-financial interest in the subject matter discussed in this study.


  Reconstruction of lower limb deformity in children Top



  PP 230: The Acetabulum In Congenital Femoral Deficiency.: CT Analysis Of Anteversion / Retroversion And Size Top


David Steven Feldman, Dror Paley

Paley orthopedic and spine institute at St. Mary's Medical Center, West Palm Beach, United States

Background: Congenital Femoral Deficiency (CFD) is a rare disorder (1 in 50,000 live births) involving the femoral head, femoral neck and the acetabulum in affected children. It also often involves the musculature, the knee, leg and foot as well. While the femoral deformity has been well described there is a paucity of information regarding the acetabular structure and development in CFD. This has become much more important as internal lengthening have allowed non-constrained lengthening of the femur, putting the CFD hip at risk for subluxation and dislocation. The purpose of this study is to determine the acetabular morphology in CFD Paley types 1A/B and 2A/B. Methods: We reviewed one hundred consecutive cases of CFD Paley types 1A/B and 2A/B treated at our institution over the past seven years. Age at presentation, gender and diagnosis was recorded. Associated deformities were noted. All patients who had preoperative plain radiographs, CT Scans and MRI were reviewed for version, acetabular volume and femoral head/acetabular mismatch. The presence or absence of acetabular dysplasia was noted on plain films. Results: Of the one hundred patients eighty-seven had all studies available for review. Thirteen patients were excluded due to lack of available studies. Average age of the patients was 4.5 years (2.6 to 13.8). Acetabular dysplasia was noted with greater than 25% uncoverage in 65 patients (74.7%). Of the eighty-seven – sixty-eight (78.2%) were noted to have acetabular retroversion with insufficient posterior walls. Thirteen patients (15%) had normal version of the acetabulum and nineteen patients (21.8%) had anteversion of the acetabulum. Volume was noted to be insufficient in 9 patients (10.3%) and copious in 3 patients (3.4%). Conclusions: Acetabular retroversion with posterior wall insufficiency is the most common finding in CFD. Untreated, this risks a posterior hip dislocation particularly during or even after femoral lengthening. While retroversion is the most common finding in CFD, the surgeon must be aware that the patient may have an anteverted cup and therefore require anterior coverage in those cases. All acetabular dysplasia should be treated and protected prior to femoral lengthening as this may not become evident until the second or even third lengthening procedure. Acknowledgements: The authors report no conflict of interest concerning the materials or methods used in this study.


  PP 231: Hemiepiphysiodesis For Lower Deformity In Pseudoachondroplasia: Indications, Results And Pitfalls Of Treatment Top


David Steven Feldman, Dror Paley

Paley orthopedic and spine institute at St. Mary's Medical Center, West Palm Beach, United States

Background: Pseudoachondroplasia associated with severe limb deformity and short stature is a rare disorder confirmed by a defect of the Cartilage Oligomeric Matrix Protein COMP gene. The purpose of this study is to review the effectiveness in treating lower extremity deformity with hemiepiphyseal plating in patients with lower extremity limb deformity secondary to Pseudoachondroplasia. Methods: We reviewed fifteen consecutive patients with Pseudoachondroplasia treated in the past ten years. We reviewed age, gender, deformity direction and magnitude. Age at time of procedure and location of Hemiepiphysiodesis was recorded. Degree and timing to correction or failure was determined. Results: Five patients (10 limbs and 18 segments) underwent Hemiepiphysiodesis. Four boys and one girl were treated. Average age of Hemiepiphysiodesis was 5.8 years of age (range 3.4- 12.1). Repeat and opposite Hemiepiphysiodesis was performed in two patients (three limbs). One patient (two limbs - four segments) had definitive treatment with bilateral distal femoral and proximal tibia medial Hemiepiphysiodesis at age 12. Three limbs that had distal femoral varus were corrected and then the untreated tibiae developed valgus. Medial tibial plates were utilized for correction. Two patients (four limbs - 8 segments) demonstrated no improvement with plates. All patients with procurvatum 4 of 5 required ostetomies to correct sagittal plane. Conclusions: Hemiepiphysiodesis can be utilized to temporize coronal plane deformity in Pseudoachondroplasia. Most patients will still require osteotomies at an older age. Early use in the sagittal and coronal plane may help resolve this problem. Careful attention must be given to overcorrection and untreated tibia or femur in developing a deformity during treatment. Acknowledgements: The authors report no conflict of interest concerning the materials or methods used in this study.


  PP 232: Limb Lengthening And Deformity Correction In Pseudoachondroplasia: Indications, Procedures And Outcomes Top


David Steven Feldman1, Dror Paley1, Murteza Ali Kazim2

1. Paley orthopedic and spine institute at St. Mary's Medical Center, West Palm Beach, United States

2. Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Background: Pseudoachondroplasia associated with severe limb deformity and short stature is a rare disorder confirmed by a defect of the Cartilage Oligomeric Matrix Protein (COMP) gene. The purpose of this study is to review the types of deformity encountered in Pseudoachondroplasia and the strategies in both reconstruction and limb lengthening unique to pseudoachondroplasia as well as the outcome of these procedures. Methods: We performed an IRB approved retrospective review of fifteen consecutive patients treated with Pseudoachondroplasia from 6/1/2006 through 6/1/2016 of two surgeons. We reviewed the patient's age, height, predicted height, gender, magnitude of deformity and limb length difference. Surgical procedures performed and radiographic and clinical outcome were reviewed. Results: There were fifteen patients, ten males and five females. The average age upon presentation was 6.2 years (range 2.5 to 17 years of age). All 30 limbs were involved with deformity. 23/30 limbs had procurvatum of the distal femur with recurvatum of the proximal tibia. 17 limbs were in valgus and 13 were in varus with three patients having a wind swept deformity. Five patients (10 limbs) underwent hemiepiphysiododesis. Repeat and opposite hemiepiphysiodesis was performed in 2 patients (three limbs). One patient (bilateral hips) had a triple pelvic osteotomy. 10 patients underwent proximal femoral valgus osteotomy. 9 patients underwent elective successful four segment lengthening. Two patients (three limbs) had hemiplateau elevation and lateral femoral condylar advancement of the knee. Thirteen of fifteen patients (28 limbs) underwent deformity correctional osteotomies. Conclusions: Pseudoachondroplasia is a rare complex disease that requires the surgeon to correct deformities in multiple bones and joints. The deformities will often recur and may actually reverse to the opposite deformity. Limb alignment and joint preservation is crucial when undertaking lengthening in this patient population. Acknowledgements: The authors report no conflict of interest concerning the materials or methods used in this study


  PP 233: Indication And Outcomes Of Peroneal Nerve Decompression In Patients With Multiple Hereditary Exostoses Top


David Steven Feldman1, Dror Paley1, Murteza Ali Kazim2

1. Paley orthopedic and spine institute at St. Mary's Medical Center, West Palm Beach, United States

2. Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Background: Peroneal nerve entrapment is found in patients with multiple hereditary exostoses (MHE), caused by sessile and/or pedunculated osteochondromas located around the lateral proximal fibula and tibia. We conducted a retrospective study on our MHE patients treated over a seven-year period. In total, we had 61 patients with MHE, 15 of whom had peroneal nerve compression symptoms for a total of 21 limbs. Methods: The patient data was collected from July 2009 until January 2017, which included 15 patients (21 limbs) out of 61 MHE patients with clinical symptoms of peroneal nerve compression due to an osteochondroma. We reviewed the patients' age, gender, body mass index, affected side, localization of the exostosis, time to recover, and the outcome of the nerve release by evaluating pain, muscle strength and sensory disturbance preoperatively and postoperatively. Results: Nine male and six female patients with an average age of 20.6 years (range, 4 – 35) were treated. Out of 21 cases eleven (52.4%) were right limbs and ten (47.6%) were left limbs (6 bilateral, 9 unilateral). The most frequent affected localization was the fibular head (45.8%). Other locations included fibular neck and less commonly the proximal tibia. Preoperatively 18 cases had pain (85.7%), 3 had muscle weakness (14.3%), and 4 had paraesthesia (19.0%). In two cases (9.6%) the procedure was done prophylactically. After surgery only one case had some residual pain (4.8%), all regained full muscle strength (100%) and one patient remained with some residual paraesthesia (4.8%) The mean time to recover from the mentioned symptoms was 4.9 weeks (range, 2 -16) and the mean follow-up time was 19.0 months (range, 3.0 – 98.4). Conclusions: Peroneal nerve decompression in patients with MHE is safe and effective in ameliorating symptoms and restoring function. We highly recommend treating all peroneal nerve compression caused by osteochondromas by surgical decompression without delay. Further, it should be considered as a prophylactic measure prior to tibia valgus deformity correction. Prolonged recovery time and/or permanent nerve injury may arise with delay in treatment of nerve symptoms. Acknowledgements: The authors report no conflict of interest concerning the materials or methods used in this study


  PP 234: Regenerate behaviour in congenital pseudarthrosis of tibia: Excellent regenerate formation with Gigli Saw osteotomies when performed very proximally Top


Milind Madhav Chaudhary

Background: Pseudarthrosis of tibia(CPT) presents with many vexing problem. recalcitrant non-union, severe deformity, poor bone stock & limb shortening. Attempts at healing necessitate resection of bone to healthy area which further increases the shortening. Limb Lengthening is not often described in this condition. Many references in literature point to poor regenerate formation. Cho reported on 22 regenerates in which almost half needed some support and augmentation to heal. Many authors describe treatment using Ilizarov techniques but do not specify the amount and type of regenerate. We focus this study on the amount and quality of regenerate formation in CPT. Methods: 57 patients with Congenital Pseudarthrosis of Tibia were treated by us with the Ilizarov techniques over the last 26 years. They underwent a total of 68 procedures. 46 regenerate lengthenings were performed in 43 patients amongst them. Corticotomy lengthening was performed in 43 instances. Two tibiae were lengthened using Distraction Epiphysiolysis of distal tibia. One tibia was distracted through a hypertrophic nonunion to unite & get 2 cm length. 42 of the 43 corticotomies were performed using a Gigli saw osteotomy. Only one was performed as a drill hole corticotomy in a 55-year-old patient with recalcitrant pseudarthrosis. All were performed within 3.2 to 6.1(average 3.8cm) cm from the joint line. They were performed at an average percentage length of 17.8 % (range 12.3 to 30) from the top of the bone. Results: 38 were normotrophic regenerates, two developed pseudarthrosis & three were atrophic. One regenerate pseudarthrosis persists 20 years after surgery. The second one healed with a vascularized fibular graft. All five were performed significantly lower through or adjacent to lytic or cystic cavities. One atrophic regenerate resulted in a severe recurvatum deformity. The other two healed without the need for a bone graft. All normotrophic regenerates consolidated well without grafting or aids. Length discrepancy(LLD) was decreased in all these patients. Conclusions: Regenerate lengthening in CPT helps in reducing LLD and forms quite well. Care must be taken to perform it as high in bone as possible and stay away from lytic or cystic bone areas in upper tibia. A gigli saw facilitates performing it at a very high level to ensure good regenerate formation through healthy bone. Acknowledgements: the author thanks Dr Aniruddha Sinha Sarkar for his help in measurements.


  PP 235: Lengthening is safe, easier and quicker in younger children with congenital postero medial bowing of tibia Top


Milind Madhav Chaudhary

Int Deformity & Lengthening Institute, Akola, India

Background: Congenital Posteromedial Bowing of tibia is a benign condition which presents with a dramatic deformity at birth. The deformity resolves spontaneously but the Limb Length Discrepancy(LLD) increases. Lengthening in this condition has not been reported often. Some authors have presented poor results when performed early and recommend delaying lengthening. Based on our experience we recommend that lengthening can safely be started early as it helps reduce eventual LLD at maturity. Methods: We present our experience of lengthening in 22 children with Congenital PosteroMedial Bowing over the last 21 years. 24 tibiae were lengthened to create 26 regenerate lengthenings. 13 children were ≤5 years of age at an average of 2.96 years (1.5 - 5) and 11 were >5 years with an average of13.3 years (8 to 24). The preoperative frontal plane deformity was more in younger children19.15° vs9.13° in older ones. Sagittal plane deformity was also more in younger 19.7° vs 7.3°in older children. This also proves the well-known fact that the deformity reduces with age. Two tibiae had double level lengthening. Two had lengthening over IM nails. Three of 13 ≤5 group had upper third corticotomy vs. all 11 of the older ones. Results: Though younger children had less absolute lengthening at avg 3.4 cm (2-4.5) it constituted a larger -23.4%-percentage lengthening (13.5-35%). Older children had more average -4.7cm-quantum lengthening (3 to 6.5cm), but it was lesser as percentage lengthening at an average of 17%(11.5-28.4%). Ex fix duration was significantly lesser at 119 days in younger children than in older ones at 238 days. This resulted in more disruption of schooling & difficulties with fixator wear in older children. All regenerates were excellent except in one child who needed bone grafting as he was given steroids in post-op phase by a paediatrician. Regenerate bone took much longer to mature in older children and young adults. Post-op care was easier in younger children & they experienced lesser difficulties and pain than older ones. Conclusions: Congenital posteromedial bowing of tibia is a benign condition where the bowing deformity spontaneously reduces but LLD increases. Literature is scant on lengthening in this condition. Limb lengthening can safely be performed early in this condition as it takes less time, achieves more percentage length and creates less disruption in the schooling and activities of older children and young adults. Acknowledgements: The author gratefully acknowledges the help of staff of Int. Deformity & Lengthening Inst in performing the surgeries, care of the patients and gathering the data for this study.


  PP 236: Hip Pelvic Support Osteotomy: Long term results in childhood considerations on limits Top


Maurizio Angelo Catagni1, Francesco Guerreschi2, Luigi Lovisetti1

1. G.B. Mangioni Hospital, Lecco, Italy

2. Ospedale Alessandro Manzoni, Lecco, Italy

Background: Abstract Text. Instability of the hip in a teenager or young adult is a difficult problem to treat. This condition is often associated with bone loss of the proximal femur, severe limb length discrepancy (LLD). All these factors complicate the problem. The underlying etiologies in these patients are untreated or unsuccessfully treated developmental dislocation of the hip (DDH), sequela of neonatal septic arthritis of the hip, osteomyelitis of the proximal femur and aseptic necrosis of the femoral head. Septic or repeated aseptic failure of hip arthroplasty are another cause. Shantz and others have addressed this problem with a proximal femoral valgus osteotomy. This sub-trochanteric abduction osteotomy provided stability to the hip and maintained some motion. The drawbacks of this approach are further leg shortening and disturbance of the mechanical axis of the leg. Possibly inspired by these early authors, G. A. Ilizarov developed a technique using Ilizarov external fixator and the biologic principles that he elucidated to treat these problems with one operation. Using this innovative concept, Ilizarov was not only capable of correcting the instability of the hip, but was also able to eliminate the resultant leg length discrepancy (LLD) and mechanical axis deviation that resulted from the historic sub-trochanteric pelvic support osteotomies. Ilizarov added another distal osteotomy to achieve lengthening and restoration of normal mechanical axis of the extremity after proximal femoral osteotomy. Ilizarov describes his “Pelvis Support Osteotomy” (PSO) and presents 20 cases in his book “Transosseous Osteosynthesis” . PSO using Ilizarov method was found to be an effective solution for the challenging problems described above. Recently, great interest is directed toward hip preservation surgery, pelvic support should be considered one of the hip preservation surgeries. The patients can avoid THR for many years after pelvic support osteotomy. In some case, with complete hip dislocation, the PSO can result in “for a life operation” . Methods: Results: Conclusions: Acknowledgements:


  PP 237: Release, gradual Ex-Fix correction and skin graft: A new treatment model for severe childhood ankle burn contractures Top


Tim Nunn1, Richard Gardner1, Tewodros Tilahun1, Mesfin Etsub1, James Fernandes2

1. CURE Ethiopia, Addis Ababa, Ethiopia

2. Sheffield Children's Hospital, Sheffield, United Kingdom

Background: Burns are a common childhood trauma in Ethiopia. Severe untreated joint contractures in childhood due to full thickness burns are a challenge to manage. Scar tissue and skeletal growth causes severe bone and joint deformity. Described treatment techniques focus on acute correction and flap coverage of exposed joints and tendons. This case series outlines a treatment for such severe cases that corrects deformity and avoids the need of a flap. Methods: We present a 10-patient series where severe deformity was corrected after release of the scar using external fixator techniques with fine wires. Plantar skin was left intact and all wires were passed through intact skin. Joints were not opened and tendons not exposed. Burn scar excision was to the fat layer only. Toes totally encased in scar tissue were removed. Acute partial correction was achieved and the ex-fix applied. Residual correction was achieved by serial frame adjustments with dressing changes of the wounds under anesthetic. Where osteotomy was performed gradual correction at 1mm per day was used. Skin graft was applied once a mild overcorrection was achieved. The external fixator was removed following graft healing and a cast applied. Follow-up was 5-20 months from frame removal. Results: The median number of dressing changes and frame adjustments was 9, scheduled x3/week. No flaps or amputations were required. Grafts healed 100% without exception. Two patients with severe midfoot abduction contractures required additional mid-foot osteotomies for bony correction 6 months post grafting. Selected patients had a subtalar stabilisation procedure when the subtalar joint was incongruent. One patient required a tibial-calcaneal fusion for degenerative changes in the ankle joint and later required excision of a small plantar bony prominence under the 5th metatarsal. Two patients had mild ipsilateral knee burn contractures which were released with a multiple 'Z' plasty technique. Good ankle joints ware preserved and subtalar fusion performed for those with incongruent post reduction talo-calacaneal articulations. All patients were happy with their correction and walking well. Conclusions: Early results suggest that scar release, graduated correction and grafting is a successful method for salvage of severe neglected post-burn deformities of the foot and ankle. Flap reconstruction was not necessary in any case. We propose that this is a reliable and powerful method for treatment of these challenging deformities. Acknowledgements: We wish to thank Tsion Tesfaye, Research Nurse for ensuring good follow-up of these patients.


  PP 238: The development and validation of a neglected clubfoot score to predict the response to Ponseti casting for children aged 2-10 Top


Tim Nunn, Richard Gardner, Tewodros Tilahun, Mesfin Etsub

CURE Ethiopia, Addis Ababa, Ethiopia

Background: Neglected clubfoot is a common problem in many low or middle-income countries. A scoring system with good pre- treatment construct validity is needed for clinical use and research. The aim was to develop a simple and reliable clinical scoring system for untreated clubfeet and assess how this score predicted the response to Ponseti casting. Methods: We measured all elements of the Dimeglio and the Pirani scoring systems to determine which aspects were useful in assessing children with neglected clubfeet between the ages of 2-10 in 42 feet. The utility of the selected variables was subsequently assessed prospectively on a separate consecutive cohort of children aged 2-10 comprising 100 clubfeet (64 patients). Casting followed Ponseti principles using long leg casts with cavus correction first. Cast changes were performed every 2 weeks. Failure of casting was defined as 9 casts without mid-foot correction. Equinus correction was achieved using percutaneous achilles tenotomy under general anaesthesia. The ankle posterior capsule was not released. Once a minimum of 15 degrees of dorsiflexiin wad achieved a tibialis anterior tendon transfer was performed on all patients over the age of 3. The severity was also compared with maximal pressures and footprint area measured using pedobarography. Results: Inter-observer and intra-observer agreement was found to be greatest using the following clinically measured angles of the deformities. These were Plantaris, Adductus, Varus, Equinus and Rotation around the talar head (PAVER). Using these data the PAVER score was derived from both the measured angles and a multiplier according to age. The multiplier was 1,1.5 and 2 for ages 2-4, 5-7, 8-10 years respectively. This was strongly associated with the total number of casts to achieve a full correction (tau=0.71). 11% failed casting and a score greater than 18/30 indicated a cast-resistant clubfoot. An association was found between PAVER score and elevated foot pressures and reduced footprint area. Conclusions: The score demonstrated good construct validity. The score could be used clinically for prognosis and treatment and for research purposes to compare the severity of clubfoot deformities. Acknowledgements: The authors acknowledge the work of Tsion Tesfaye, Research Nurse for data collection. We are grateful for sponsorship from CURE UK originating from Tropical Health and Education Trust (THET) and Vitol Oil Plc. We also want to thank Novel, Munich, Germany for the loan of the pedobarograph used in this study.


  PP 239: The use of Ilizarov external fixator to correct severe lower limbs deformities in sacral agenesis Top


Hilario Boatto, Osvaldo Clinco Jr, Carlos Luiz Engelen, Thiago Amorim Bastos, Robinson Toshimitsu Kyiohara, Marcelo Fumio Utsunomiya

Federal University of Sao Paulo, Sao Paulo, Brazil

Background: The autors show the technique and results using Ilizarov method to perform a gradual correction of severe lower limbs deformities in a patient with sacral agenesis, 90 degrees knee flexion deformities, bilateral eqüinus feet and popliteal pterygium. Methods: The correction was made by gradual distraction between a femoral frame with one arch and one ring and the tibial frame with two rings. The frames were connected by two hinges placed at the convex side of the defromity and two distraction rods posteriorly. The distal tibial ring was connected to the hindfoot and the gradual distraction is used to correct the foot deformity. The external fixator was used for 6 months . Results: The knees full extension was obtained and the feet were corrected without neurovascular complications. Conclusions: The Ilizarov Method is efficient to correct severe lower limb deformities in sacral agenesis. Acknowledgements: No disclosure


  PP 240: The Use Of Ilizarov External Fixator To Correct Severe Deformities In Lower Limbs In Myelomeningocele Top


Hilario Boatto, Osvaldo Clinco Jr, Alexandre Rial Dias, Fabio Assunçao E Silva, Glauber Kazuo Linhares, Ricardo Krikor Dejehizian

Federal University of Sao Paulo, Sao Paulo, Brazil

Background: Between january 2001 and December 2014 fifteen patients with feet and knee defomities 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 were 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. Methods: The deformities were corrected using Ilizarov Method and gradual distraction. The circular external fixator were placed at the femur with one arch and one ring connected to the tibial frame (two rings). Two hinges were placed at the convex side of deformity and two distraction rods posteriorly. The feet were corrected using two half rings, one at the forefoot and another at the hindfoot. The feet frame was connected two the tibial distal ring and the gradual correction was performed. Results: The deformities were well correct and recurrence was observed in 4 patients that didn't 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 myelomeningocele. Conclusions: The Ilizarov External Fixator Device is an efficient Method to Correct Severe Deformities in Myelomeningocele. Acknowledgements: No disclosure


  PP 241: The Use Of Ilizarov Technique To Correct Severe Lower Limbs Deformities In Arthrogryposis- 15 Years Of Follow Up Top


Hilario Boatto, Osvaldo Clinco Jr, Alexandre Rial Dias, Glauber Kazuo Linhares, Fabio Assunçao E Silva, Thiago Amorim Bastos

Federal University of Sao Paulo, Sao Paulo, Brazil

Background: 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 patient's 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 were 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. Methods: Knee flexion deformities and feet deformities were corrected using Ilizarov frame in femur conected to the frame in tibia. One arch and one ring were placed at femu and two rings at the tibia. They were connected by two hinges at the convex side of the deformity and two distraction rods placed at the posterior side of the knee. Feet deformities were corrected by using one half ring at the hindfoot and one-half ring at the forefoot. The adduction supination and equinus were corrected simultaneously by gradual distraction. Results: The correction was achieved in a 100% of the patients and partial recurrence was observed in 8% of feet deformities (3 patients) and in 11% of knee deformities (3 patients) less than 30 degrees of flexion. Conclusions: Ilizarov Method is a safe and effective method to correct severe deformities in arthrogryposis multiplex congenita with absence of major complications . Acknowledgements: No Disclosure


  PP 242: Trans-Articular Osteotomy Of The Distal Femur With Ilizarov External Fixator For Treatment Of Knee Valgus Deformity After Neonatal Septic Arthritis Top


Jabrayil Alakbarov

Scientific-Research Institute of Traumatogy and Orthopedics, Baku, Azerbaijan

Background: A 3-year-old girl was admitted to our hospital with valgus deformity of left knee. On the thirtieth day after a baby was born neonatal septic arthritis was diagnosed and open joint surgery was used to drain the joint and combinations of antibiotics were given. The patient couldn't walk and knee was unstable. After X-ray examination, we revealed deficiency in lateral femoral condyle and 65' of valgus deformity. After application of Ilizarov external fixator we performed supracondylar oblique osteotomy and began distraction of the lateral side 2mm daily. At 58th day the deformity was corrected and we fixed EF for 2-month period. After removal of frame we stabilized the knee with casting for additional 12 days and then began physiotherapy. Totally after 4.5 month of treatment the patient can walk, has stable knee with full range of motion. Methods: Results: Conclusions: Acknowledgements: .


  PP 243: The Possibility Of Treatment Of Congenital Pseudoarthrosis Of The Tibia With Bone Tissue Engineering And Ilizarov Methodology. Top


Roberto Guarniero1, Daniela Franco Bueno1, Carla Cristina Gomes Pinheiro2, Guilherme Bottino Martins3, José Roberto Bevilacqua Guarniero3

1. University of Sao Paulo School of Medicine, Sao Paulo, Brazil

2. Hospital Sirio Libanês IEPE, Sao Paulo, Brazil

3. Hospital Sirio Libanês IEPE Pediatric orthopaedics, Sao Paulo, Brazil

Background: Researchers have been focusing on the development of bone tissue engineering strategies and osteogenic substances that may offer alternative methods with minimal donor site morbidity for Congenital Pseudoarthrosis of the Tibia (CPT). Therefore, in order to use non-invasive source of stem cells with osteogenic potential, we have used dental pulp stem cell (DPSC) obtained from left inferior incisive deciduous teeth of the patient with CPT to make bone tissue engineering. Methods: The cells were obtained from deciduous dental pulp using previously described pre-plating technique. These cells, through flow cytometry analysis, were mainly positively marked for five mesenchymal stem cell antigens (CD29, CD90, CD105, CD73, CD166), while negative for hematopoietic (CD45) and endothelial cell marker( CD31). After induction under appropriate cell culture conditions, these DPSC were capable to undergo chondrogenic, adipogenic and osteogenic cell differentiation, evidenced by immunohistochemistry. Our surgical protocol includes Ilizarov's methododlogy with the circular external fixator and bone transportation with an appropriated resection of the tissue at thje site of the pseudoarthrosis(PA); at the docking site of bone transportation a graft based on DPSC is added. Results: It was demonstrated that DPSC together with a biomaterial composed of collagen and hydroxyapatite lead to bone tissue reconstruction in the previous site of the PA. Conclusions: It is shown that DPSC of CPT patient have phenotypic and behavior characteristics similar to other adult stem cells in concern to bone tissue engineering, both in vitro and in vivo. Our findings suggest that DPSC obtained from patient with CPT represent a promising source of stem cells for the tibial long bone reconstruction treatment (bone tissue engineering), particularly in young patients. Recently we obtained ethical permission to start the clinical trials using DPSC to perform bone tissue engineering for CPT patients opening new avenues to perform new treatment strategies to them. Acknowledgements: The authors declare that there is not conflict of interest and would like to acknowledge the IEPE - Instituto de Ensino e Pesquisa - Hospital Sirio e Libanes São Paulo for the help in this research and also the Infantile Hospital “Menino Jesus” São Paulo.


  PP 244: Quantification of foot deformities and gait deviations in children with arthrogryposis using gait analysis Top


Louise Reid Nichols, Lucio Perotti, Chris Church, Maureen Donohoe, Kathryn Fazio

Nemours duPont Hospital for Children, Wilmington, United States

Background: Arthrogryposis multiplex congenita is a congenital condition characterized by joint contractures with. resulting foot deformities and gait deviations. Arthrogryposis can vary greatly with respect to limb involvement, but. involvement of all four limbs is most commonly seen [Carlson, 1985]. The most common clinically diagnosed foot. deformity in arthrogryposis is clubfoot, although equinocavus foot and congenital vertical talus are also common. Gait deviations have been studied and assessed clinically and improvement is often achieved with orthotics. The aim. of the present research study was to quantify gait deviations and foot deformities in children with arthrogryposis. with detailed gait analysis including multi-segment foot kinematics and foot pressure analysis. Methods: After an IRB-approval, children with arthrogryposis were evaluated retrospectively and compared to data. for typically developing children. Data included in this study consists of full gait analysis with multi-segment and. single-segment foot kinematics, kinetics, pedobarograph, physical examination, and radiographic measurements. In. addition to evaluating the sample as a whole, children were grouped by age, orthotic use, and history of surgical. intervention. Results: Forty-two children with arthrogryposis age 10 ± 5 years old (2-20 years old) were evaluated. Physical exam and kinematic data showed that children with arthrogryposis walked with a crouched gait, exhibited stiffness in the hips, knees, and ankles and showed limitations in their gross motor functioning (p<0.006). Power generation was low at the ankle and was high at the hip (p<0.01). Multi-segment foot kinematics revealed stiffness in hindfoot. plantarflexion and residual forefoot adduction (p<0.03). Foot pressure showed reduced heel impulse, excessive. midfoot contact, and overall varus foot position (p<0.002). Categorization by age revealed greater stiffness at the. hips and knees in older children (p<0.01). Children with KAFO's showed the most stiffness (p<0.05) compared to. those with AFOs or no orthotics. No significant differences were seen between the foot posture of children with. clubfoot treated operatively or by Ponseti technique except for greater internal rotation at the foot (p=0.0158) in Ponseti treated feet. Conclusions: Children with arthrogryposis walk with a crouched, stiff gait and have foot deformities. Quantification of contractures and deformities may help assess outcomes and guide treatment. Acknowledgements: No conflicts of interest.


  PP 245: Management of Congenital Talipes Equino Varus with Ilizarov & Jess (Joshi's external stabilization system) external fixation - Our experience Top


Harshad Mohanlal Shah1, Rahul P1, Ravi Varma V. N.2, Naveen Kumar Lokesh1, Rahul Hemant Shah1

1. Ramaiah Medical College & Hospitals, Bengaluru, India

2. J S S Medical College, Mysuru, India

Background: The incidence of neglected, recurrent, relapsed and rigid feet was common in Indian scenario due to low socioeconomic status, ignorance and lack of opportunity. Methods: 33 feet in 22 patients with neglected or relapsed (recurrent) club foot deformities treated by External Fixators have been analysed (Ilizarov and JESS). There were 16 (73%) males and 6 (27%) were females; Age was ranging from 7 months to 15 years with an average of 5.9 years. 14 patients with 22 (67%) feet were of neglected type and 8 patients with 11 (33%) feet were of recurrent / relapsed type. Unilateral and bilateral were equal in number. Clinical assessment was done using Caroll's criteria. Total of 13 feet were treated by Ilizarov External Fixators and 20 feet were treated by Jess External Fixators. Out of 33 feet 14 (42.4%) underwent previous procedures. The average pre-operative Talo Calcaneal Index was 32* and post operative was 48*. Results: The patients were followed up for an average of 3.1 years (6 months to 8 years), the fixator period was 23.6 weeks in patients treated with Ilizarov and 13.6 weeks in JESS. The following complications were encountered, temporary edema noted in 4 feet, superficial pin tract infection in 8 feet, skin necrosis in 1 feet, loosening of pins in 4 feet, rocker bottom foot in 1 foot, hematoma in 1 foot, flexion contractures of toes in 14, osteomyelitis of tibia in 1 patient. Results were evaluated using the Hospital for Joint Diseases, Orthopaedic institute functional rating system for club foot and showed 6 excellent (18.2%), 21 good (63.6%), 4 fair (12.1%) and 2 poor (6.1%). The results correlated with the age of the patient and severity of the deformity. Conclusions: Treatment by External Fixator with Ilizarov external fixator and JESS is thus a very good method of treatment for difficult club feet. Acknowledgements: No conflict of interest.


  PP 246: Ilizarov External Fixation For Management Of Severe Relapsed Clubfeet In Older Children: 42 Clubfeet Included. Top


Mohamed El-Sayed, Ashraf Atef

Tanta University, Tanta, Egypt

Background: Although the standard treatment of clubfoot deformity is conservative by serial casting techniques, relapses are not uncommon. Management of relapsed clubfoot deformity in older children is an orthopedic challenge. There is a growing interest in management of such complex deformities using the Ilizarov technique. Methods: In this study, the Ilizarov frame was used to correct severe relapsed clubfoot deformities in older children, whom underwent previous surgical interventions. 42 relapsed clubfeet were included. The Dimeglio classification was used for clinical assessment of the relapsed feet pre-operatively as well as post-operatively. Results: After an average follow-up period of 4.6 years, and according to the Beatson and Pearson numerical assessment, favorable results (excellent or good) were found in 37 feet, while poor results took place in only five feet. Conclusions: Based on the final clinical and radiographic results, the Ilizarov technique could be considered as a good management alternative for such severe deformities. Acknowledgements: Tanta University


  PP 247: Limb Sparing Reconstructive Surgery And Ilizarov Lengthening In Fibular Hemimelia Of Achterman–Kalamchi II Patients. Top


Mohamed El-Sayed1, Johannes Correll2

1. Tanta University, Gharbia, Egypt

2. Heidelberg University, Bayern, Germany

Background: Fibular hemimelia is the commonest congenital deformity or absence of long bones. It encompasses a spectrum of anomalies affecting femur, knee, tibia, ankle, and foot. It maybe associated with other complex syndromes as Femur Fibula Ulna Syndrome (FFU), but mostly occurs as an isolated deformity. Management of this complex deformity is controversial, and the question has always been; is amputation a must? . Methods: The aim of this study was to evaluate the long-term results of management of fibular hemimelia (Achterman–Kalamchi, type-II) using limb reconstructive surgeries, followed by staged lengthening by the Ilizarov method. Results: We reviewed 157 consecutive patients (180 limb segments) with a mean follow-up period of 10.7 years (1.2–21 years). The results were favorable, and all the patients walked independently. Conclusions: Although, this type of management is technically demanding and entails a lengthy procedure with many complications anticipated, the Ilizarov lengthening after limb reconstruction is still an attractive option for management of this type of limb deficiency. Acknowledgements: Tanta University Hospitals. Aschau Specialized Pediatric Orthopedic Hospital


  PP 248: Technique For The Correction Of Congenital Femoral Deficiency.: SUPERHIP: CFD Reconstruction Experience In Latin America Top


Miguel Angel Galbán Md., León Gonzalo Mora H. Md.

CORA Group - Clínica El Rosario, Medellín, Colombia

Background: Introduction. Congenital femoral deficiency (CFD) ranges from the angulation of the proximal third of the femur to its total absence. Our experience with this procedure in the last 8 years will be hereby exposed. Methods: Methods. 44 patients with Types IB, IC and IBC CFD (Paley). The technique described by Dror Paley was applied to all of them. 11 patients were ruled out because of insufficient follow-ups. 33 patients underwent a 6-year follow-up (2-8). Ages from 1 to 4 years old. The procedure has 3 parts. release of the soft parts, femoral osteotomy, in order to correct the “Shepherd staff” deformity and Pelvic osteotomy in order to correct the acetabular covering deficit. Results: Results. 33 limbs with CFD, two patients with Type IC (neck), one patient with type IBC and 30 with type B (sub-trochanteric). All of these, required liberation of the soft parts, femoral osteotomy and pelvic osteotomy. The immobilization of the femoral osteotomy was made with different systems. initially Steinmann cerclage intramedullary nails were used, then pediatric angular plaques, and finally 140-degree LCP plaques were used. All of these, required blood transfusion. The average chirurgical act lasted 4 hours and 10 minutes. All of the osteotomies consolidated, with the exception of one neck-type case in which the deformity relapsed and it required a new intervention and the use of BMP-2 in the neck, attaining consolidation. 25 were required to stabilize the knee through the SuperKnee technique. Conclusions: Discussion and conclusions. This chirurgical technique addresses this complex deformity in an integral way. Various aspects of CFD are corrected, though the severe shortening is left for future lengthening, which can be faced thanks to the stability obtained in the hip. Acknowledgements: To Dror Paley for his support and teachings. To CORA Group. Miguel A. Galbán MD; León Mora H. MD; Carlos Sarassa MD; Hebert León MR. CORA Group. Centro de Excelencia Cirugía Ortopédica Reconstructiva y Alargamientos (Center of Orthopedic Reconstructive Surgery and Lengthening). Medellín, Colombia


  PP 249: Technique For The Correction Of Deformities In Type 3C Fibular Hemimelia: Modified SuperAnkle: Tactics And Tips. Top


Miguel Angel Galbán Md.

CORA Group - Clínica El Rosario, Medellín, Colombia

Background: Introduction:. Postaxial hypoplasia can be often found along with Fibular Hemimelia. This congenital deformity can be serious and include tibial anteromedial angulation and severe valgus feet. Some authors consider these deformities unsolvable and recommend amputation and prostheses. Paley described the technique as “SuperAnkle”. We presented this modification which allows the reconstruction of these congenital deformities in an acute manner, allowing correct alignment for subsequent lengthening. Methods: Materials and methods:. 11 patients with Type 3C Fibular Hemimelia (Paley), a bilateral one for 12 limbs. 6-year follow-up (2-16). Ages between 6 and 38 months. Techniques for the handling of soft and osseous tissues were employed. The SuperAnkle has been modified in various aspects in order to attain the correct alignment in an acute manner using internal fixation though K nails and the applying of an inguino-pedic cast for 6 weeks. Results: Results:. Alignment of the tibia, ankle and foot was attained in 12 limbs. The most common, unforeseen difficulty was the necrosis over at the edges of the lateral scar close to the ankle, which was handled with dressings and cicatrization by secondary intention. Conclusions: Discussion and conclusions:. This modification of the technique allows the correct alignment of the limb in early stages, allowing the patient to walk while wearing footwear in order to compensate for the length discrepancy and leaving an aligned limb so that in time the osseous lengthening is facilitated. Acknowledgements: To CORA Group. Miguel A. Galbán MD; León Mora H. MD; Carlos Sarassa MD; Hebert León MR. CORA Group. Centro de Excelencia Cirugía Ortopédica Reconstructiva y Alargamientos (Center of Orthopedic Reconstructive Surgery and Lengthening). Medellín, Colombia


  PP 250: The Role Of Hemiepiphysiodesis In The Treatment Of Fibular Hemimelia: How To Counteract The Strong Valgus Recurrence With Minimal Invasive Procedures Top


Monica Paschoal Nogueira1, Fernando Farcetta2, Talita Abibi1

1. HSPE - State Hospital of São Paulo, São Paulo, Brazil

2. AACD, São Paulo, Brazil

Background: Introduction/Background. Hemiepiphysiodesis has been used as a concomitant treatment for the recurrent valgus in fibular hemimelia, besides leg, ankle and foot reconstruction. Hemiepiphysidodesis is able to treat valgus in the distal femur common in this condition, as well as valgus in the proximal tibia. The relapse/ rebound phenomenon is not rare and is stronger in children with more severe deformities. This study describes treatment in a cohort of fibular hemimelia children concerning valgus deformity correction. Methods: Methods. A cohort of children with fibular hemimelia is followed with observation of angular deformities shortening LLD, use of eight plate for valgus deformity correction. It was documented. age, side, bone, plate placement and removal date, screw size related to the thickness of physis, LDFA, MPTA and Ldta before and after correction. Correction time, correction magnitude, correction speed in degrees per month, position of the plate in the profile to be or not be centric, occurrence of overcorrection, implant rupture, pain, infection or keloid. Results: Results. Eleven patients with hemimelia fibular were studied, two were bilaterals, being 11 femur and 7 tibias. The correction rate of these patients was 0.7 degrees per month, ranging from 0.3 to 1.3 degrees per month. The mean time of correction was 11 months, ranging from 7 to 24 months of correction time. Three patients used three times eight plate hemiepiphysiodesis treatment to obtain adequate alignment until skeletal maturity, and four patients used this treatment for twice. No patient presented physis lesion during the treatment. Nine patients undergone superankle procedure as described by Paley. Conclusions: Conclusions. Hemipyphysodesis with eight plate is an effective treatment to address recurrent valgus deformities of the lower limbs in patients with fibular hemimelia, constituting an important tool in the reconstructive management in these patients. Acknowledgements: Authors aknowledgement Dror Paley for the development and description of fibular hememelia treatment


  PP 251: Possibility of correction of neglected and relapsed clubfoot using the Ilizarov method, a series of cases Top


Guilherme Bottino Martins, Roberto Guarniero, Luis Fernando Rossi, José Roberto Guarniero

Hospital Menino Jesus, São Paulo, Brazil

Background: The Ponseti method is now the treatment of choice for idiopathic clubfoot, including in patients previously submitted to surgeries. Situations such as inveterate, relapsed or associated syndromes are challenging, and there is no consensus in the literature about the best treatment option for these cases. The objective is to present the indications of the Ilizarov method for clubfoot correction, the results and complications of our series of cases. Methods: Between December 2008 and May 2014, 27 feet of 24 patients, aged between 5 and 18 years, were operated on. Nine of these feet were inveterate and 18 had recurrences of deformities. The mean time of maintenance of the frame was 99 days (range 56 to 168 days). Follow-up time ranged from 1 to 6 years. The assembly used is reproduction of that described by Prof. Alexander Kirienko (Ilizarov Technique for Complex Foot and Ankle Deformities), which allows simultaneous correction of all deformities. It's composed of two rings on the distal tibia, one half-ring on the rearfoot and one half-ring on the forefoot. Coordinated movement of the rods did correction of deformities, until the foot is in overcorrection position. The external fixator remained stationary for another four weeks. After the removal of the frame, a short leg cast was applied, and maintained for more eight weeks. Results: Twenty-five feet were plantigrade after correction and two presented residual deformity in equinus. There was improvement of gait in all the cases. The main complications were. superficial infection (eleven cases), two cases of partial correction of deformities and one early recurrence of deformities. Conclusions: The Ilizarov method allows the correction of all clubfoot deformities, reduces risks of neurovascular and skin complications, prevents foot's shortening and doesn't cause additional stiffness. In children up to 12 years of age, it is possible to perform closed correction, only by arthrodiastase. In older patients, osteotomies and soft tissue lengthening may be indicated. It is a technique with a long learning curve, and requires a multiprofessional team. Further follow-up is necessary to detect recurrences of deformity and other late complications. Acknowledgements: The authors declare no conflict of interest.


  PP 252: Lengthening Of The Femur With A Fully Implantable Motorized Nail In Children With Open Growth Plates Top


Rainer Paul Baumgart

ZEM-Germany Limb Lengthening Center Munich, Munich, Germany

Background: Limb length discrepancy in children with open growth plates were treated until now conservatively or by callus distraction using external fixation. Fully implantable systems were used only after maturity. Could it be an option to use these systems earlier in cases where the lengthening needs to be done in two steps because of the huge amount? Which option can be offered by a fully implantable motorized lengthening nail?. Methods: In 16 patients (9f, 7m) with the medium age of 11,8 years (8-15) fully implantable distraction nails were used at the femur in a special minimal invasive technique to correct a limb length discrepancy of >4cm. In 5 cases, a relevant deformity was corrected in the same surgery. In all cases a final step of lengthening was planned at the femur and at the tibia as well at maturity. Results: In 15 cases the goal of lengthening was achieved without any complication. In one case of proximal femoral deficiency lengthening had to be stopped because of increasing tendency of knee joint luxation. Bone formation occurred circular around the nail in all cases. Full load bearing was possible in the average after 2,2 day/mm. No technical problems occur. 11 patients had a temporarily reduction of range of motion during lengthening which was recurrent completely. In one case growth irritation in the lateral X-ray was observed which was corrected at the final step. At the end of treatment functional and cosmetic result was perfect in all 15 cases. Conclusions: Fully implantable motorized distraction nails are a favorable option at the femur even for children with open growth plates older than 10 years to correct limb length discrepancy and axis deviation. The treatment has a low pain level, is comfortable and nearly no scars are visible. The treatment needs experiences with minimal invasive nailing technique and should be done in specialized centers only. Preoperative planning and clinical and radiological control by the surgeon himself is mandatory. At the tibia, there is no experience up to now. Acknowledgements: The author is a paid consultant of Wittenstein intens and implantcast, Germany


  PP 253: Retrospective analysis of the sequential treatment of patients with partial agenesia or total peroné. Follow up to skeletal maturity Top


Ignacio Ginebreda, Sergi Rodriguez, Pilar Rovira, Anna Isart, Jordi Tapiolas

Hospital Universitari Dexeus, Barcelona, Spain

Background: Fibula agenesis, total or partial, requires a treatment strategy from an early age. The presence of associated lesions, the prognosis of global limb dysmetria and the axial axis deviation that we can find generates a therapeutic range ranging from amputation in early childhood to multiple treatments that try to guarantee a normometric limb and an overall limb functionality. Methods: We performed a retrospective study that analyzed the sequential procedure in the treatment of fibular agenesis in 10 patients 9 men and 1 female (12 segments, 2 bilateral). Patients were classified using the Aschtermann-Kalamchi and Paley classification. Bilateral involvement and associated lesions such as talus hypoplasia, a shortened femur, metatarsal agenesis, or hypoplasia of the external femoral condyle were also assessed. The mean age at onset of treatment was 4.8 years. We evaluated our surgical protocol that includes the different procedures, the prognosis of the dysmetria (segmental growth curve), the axial corrections and the need for a planed foot. Results: In all cases, functional extremities were obtained with a planed foot, knee stability and axial parameters within those accepted by the alignment test. All subjects had a free gait without crutches, most of them used orthoses to complete the foot defect. The average number of interventions per patient from the beginning to the end of physiological growth was 5 procedures; The final discrepancy ranged from 0 to 25 mm, in one case the anterior cruciate Ligamnet plasty was fected. Conclusions: In all cases, functional extremities were obtained with a plani grade foot, knee stability and axial parameters within those accepted by the alignment test. All subjects had a free gait without crutches, most of them used orthoses to complete the defect. foot. The average number of interventions per patient from the beginning to the end of physiological growth was 5 procedures; The final discrepancy ranged from 0 to 25 mm, in one case the anterior cruciate Ligamnet plasty was fected. Acknowledgements: Especially the families of children with this serious pathology for their trust in our team. To our Pediatrician. Dr. JM Gairí, our coordinator Miriam Perez and our Secretary Maribel Gámez


  PP 254: Lengthening With Monolateral External Fixation Versus Magnetic Limb Lengthening Nails In Congenital Femoral Deficiency Top


Ahmed I. Hammouda1, Vivian L. Szymczuk2, Martin G. Gesheff3, Shawn C. Standard3, John E. Herzenberg3

1. Department of Orthopaedic Surgery, Al-Azhar University, Cairo, Egypt

2. University of Illinois College of Medicine at Peoria, Peoria, United States

3. International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, United States

Background: Limb lengthening is an established treatment for mild/moderate congenital femoral deficiency (CFD) and fibular hemimelia (FH) cases. External, internal, and hybrid fixation have been described for CFD. Our aim was to determine the outcomes and complications of lengthening with monolateral external fixation or magnetic limb lengthening nails in patients with CFD. Methods: Medical records of 62 patients (62 femora) with CFD (some with concurrent FH) were retrospectively reviewed. All underwent femoral lengthening. 32 patients had monolateral external fixation (Group A) and 30 patients had magnetic limb lengthening nails (Group B). Mean age for Group A was 9.4±3.8 years and for Group B was 15.4±4.9 years. Mean follow-up was 4.5±2.7 years for Group A and 1.9±0.7 years for Group B. Results: Mean lengthening achieved was 5.6±1.7 cm for Group A and 4.8±1.4 cm for Group B (p=0.05). Mean distraction index was 0.7±0.2 mm/day for Group A and 0.7±0.2 mm/day for Group B (p=1.00). Mean consolidation index for Group A was 29.3±12.7 day/cm and 34.8±11.2 day/cm for Group B (p=0.08). Mean arc of motion for Group A was 1°±2° to 123°±12° before surgery, -1°±4° to 70°±30° at completion of distraction, and 1°±5° to 81°±30° after consolidation. Mean arc of motion for Group B was 1°±3° to 128°±23° before surgery, 1°±3° to 96°±28° at completion of distraction, and 0°±2° to 122°±23° after consolidation. While preoperative flexion was similar between both groups (p = 0.35), Group A had significantly less range of motion at the end of distraction (p = 0.0007) and at final follow-up (p < 0.0001) than Group B. Obstacle and complication rates were similar for both groups, but Group A had a 63% problem rate while Group B had a 23% problem rate (p=0.004). Conclusions: The magnetic limb lengthening nail system represents a noted improvement in treatment modalities of this complex disorder. When compared with limbs treated with monolateral external fixation, limbs treated with the magnetic lengthening nails had superior final range of motion, lower rate of problems, and similar distraction and healing indices. One downside is the inability to hinge across the knee to prevent subluxation. Therefore, preoperative knee reconstruction must be performed as needed and postoperative bracing protocols must be followed. Acknowledgements: AIH, VLS, and MGG have nothing to disclose. SCS receives royalties from NuVasive Specialized Orthopedics and Pega Medical and is a consultant for NuVasive Specialized Orthopedics. JEH is a consultant for Orthofix, OrthoPediatrics, NuVasive Specialized Orthopedics, and Smith & Nephew; receives research support from NuVasive Specialized Orthopedics; and is on the editorial board of the World Journal of Orthopaedics. The following companies supported a non-profit organization that is part of Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). CS Medical Supply, Metro Prosthetics, and Stryker. The following organizations supported an annual course for orthopedic surgeons that is held by Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). Baxter, DePuy Synthes, Merete Technologies, MHE Coalition, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Smith & Nephew, Stryker, and Zimmer Biomet.


  PP 255: Metatarsal Lengthening By Callotaxis For The Correction Of Congenital Brachymetatarsia - Review Of A Case Series Top


Rita Grazina, Gustavo Martins, Andreia Ferreira, Domingues Rodrigues, Mafalda Santos

Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova De Gaia, Portugal

Background: Congenital brachymetatarsia is a rare condition with an incidence of about 0.02-0.05%. Other etiologies are known, such as humoral, traumatic or iatrogenic. It most commonly affects the fourth metatarsal and has a female predisposition of 25:1. Bilateralism occurs in as much as 75% of cases. It is caused by a premature closing of the epiphysis that leads to a shortening of the involved digit, causing cosmetic concerns and interfering with shoe wearing. Multiple surgical procedures have been described. In this study, the authors used callotaxis for gradual elongation of the metatarsal. Methods: A retrospective study was conducted, analyzing the results of patients with congenital brachymetatarsia that undergone surgical elongation between May 2016 and January 2017. A total of 3 patients was included. one patient had shortening of the 4th left metatarsal, one of the 4th right metatarsal, and the other, diagnosed with Stickler syndrome, of the 4th right metatarsal and the 3rd and 4th left metatarsals. Results: All three patients were girls with a mean age of 16 years (14-18 years). They were all asymptomatic and esthetic complaints were the cause for surgery. In the 5 treated metatarsals, a mean lengthening of 19.27 mm was achieved with a mean loss of 0.85 mm. The mean lengthening period was of 27.3 days, with a mean healing rate of 4.59 days/mm until complete callus formation. One patient had a superficial pin tract infection that was completely solved with oral antibiotic. In this series the most commonly affected metatarsal was the fourth, in 60% of cases. After removal of the external fixator, all patients were satisfied with the esthetic result and healing was adequately achieved with no further complications. Conclusions: As a conclusion, lengthening through callotaxis constitutes a relatively simple and well tolerated procedure that achieves good results and matches patients' expectations. Acknowledgements: No conflict of interest to disclose.


  PP 256: Guided growth, external fixation or bios in treatment of children with long bone deformities: Which method to choose? Top


Victor Vilensky1, Ekaterina Zakharjan1, Alexander Pozdeev1, Leonid Solomin2

1. The Turner Scientific and Research Institute for Children's orthopedics, Saint-Petersburg, Russia

2. Vreden Research Institute of traumatology and orthopedics; General Surgery Chair of Saint-Petersburg State University, Saint-Petersburg, Russia

Background: The purpose of the study was to estimate retrospectively the results of treatment of children with long bone deformities that were treated with use of different methods. Methods: Three groups of patients were analyzed. 1 group – 100 children that were performed osteotomies and gradual correction of deformities and lengthening by computer assisted six axis Ortho-SUV Frame (OSF). This method of treatment was used in patients that had deformities associated with shortening. Group 2 formed 62 children that were performed guided growth (GG) by 8-plates and screws. The criteria for this method of treatment were. young age of the patient and activeness of the growth plates. Group 3 (corrective osteotomies with internal fixation by intramedullary locking nails) was formed by 40 children of the elder age group that had deformities not accompanied by shortening and the growth plates were closed. In group 1 estimated the following parameters. period of deformity correction (DCP), external fixation index (EFI), accuracy of deformity correction (AC), the number of complications (NC). In group 2 we estimated. AC and NC. In group 3 we estimated. AC, period of consolidation (PC) and NC. Results: In group 1 AC was found from 92% (in sagittal plane) till 96% (in frontal plane). PC varied from 9.18+2.76 days (for simple deformities - SD) till 24±14.72 (for complex deformities - CD). Meanwhile the period of lengthening was not taken into consideration. EFI varied from 31.2±15.1 days/cm in SD till 35.32±12,61 days/cm in CD. We faced with the following complications (%). pin-tract infection – 15, joint stiffness – 17, breakage of transosseous elements, non-union or atrophic regenerate formation – 3; secondary fractures and deformities – 4. In group 2 the AC varied from 85% (for sagittal plane) till 90% (for frontal plane). In 4 cases, we observed migration of 8-plates and screws that required its removal and re-implantation. In 5 cases of Ollier disease the guided growth was ineffective. In group 3 AC varied from 85% (for sagittal plane) till 90% (for frontal plane). TC according to x-ray findings was 135±43.2 days. In 1 case we observed peroneal neuropathy, in 1 case – recurrence of the deformity. Conclusions: All the analyzed methods of long bone deformities treatment in children and adolescents can be effective. To choose the method the age, the activeness of growth plates, absence or presence of shortening are to be considered. Acknowledgements: to The Turner Scientific and Research Institute for Children's orthopedics, Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University


  PP 257: Orthopedic surgery for treating lower limb deformity due to severe hand foot and mouth disease inducing neurological complications Top


Lei Shi, Sihe Qin, Xuejian Zheng

Rehabilitation Hospital of National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: Enterovirus 71 infection cause hand foot and mouth disease(HFMD) in children, induces neurological complications such as acute flaccid paralysis(poliomyelitis-like), HFMD outbreak in the Asia-Pacific region since 1997, Millions of children were sick, some severe HFMD induce lower limb deformity and Walking dysfunction. This study is to observe the clinical effects of orthopedic surgery for treating lower limb deformity due to severe HFMD inducing neurological complications. Methods: Eight patients with lower limb deformity due to severe HFMD inducing neurological complications were observed retrospectively from July 2011 to October 2013. Of them, three cases were male and five cases female. The average age was 6.2 years old (from 3 to 12 years old). In the preoperation, we check strength of muscle,analysed the cause of deformity, confirmed the muscle balance situation and presence of bone and joint deformity, drew up a operating plan, carry out tendon lengthening, tendon transfers, soft tissue release, epiphyseal stimulating, tibiofibula osteotomy, subtalar joint fusion respectively,using plaster or external fixator fixed; Through the improvement of the appearance and function evaluation therapeutic effect. Results: A mean follow-up of 24(12 to 36)months showed that all the patients were . satisfied to the outcome of lower limb appearance and functions improving,they were pain free and ambulating on the sole of whole foot. Conclusions: Lower limb deformity due to severe HFMD seriously endangering children's physical and mental health, as soon as possible by orthopedic surgery, can correcting muscle imbalances and soft-tissue or bony deformities. Static joint instability, restore normal plantar gait, curative effect is satisfied. Acknowledgements: There is no conflicts of interest in this study


  PP 258: Six-Axis Ortho-Suv frame in treatment of long-bone deformities in children and adolescents: Analysis of 250 cases Top


Victor Vilensky1, Ekaterina Zakharyan1, Alexander Pozdeev1, Leonid Solomin2

1. The Turner Scientific and Research Institute for Children's orthopedics, Saint-Petersburg, Russia

2. Vreden Research Institute of traumatology and orthopedics, General Surgery Chair of Saint-Petersburg State University, Saint-Petersburg, Russia

Background: The purpose of the study was retrospectively to analyze the results of 5-years experience of software-based Ortho-SUV Frame (OSF, www.ortho-suv.org) application in treatment of long bone deformities in children. Methods: We had analyzed 250 patients (292 frames) with deformities of long bones. Most of the patients had (according to the classification of long bone deformities (http://www.ortho-suv.org/images/stories/deform_class2.jpg) complex deformities (CD) – 103 cases and deformities of middle complicity (MD) – 88 cases. Simple deformities (SD) were found in 59 cases. The results were evaluated 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: The deformities were. congenital (105 cases), aquired deformties (93) and posttraumatic deformities (52). Found DCP was 12±10 days for SD; 17±9 for MD and 21±14 for CD. EFI for SD was 31±15 days/cm, for MD - 35±10 and for CD - 33±16. AC for deformities in frontal plane was 94% and for deformities in sagittal plane – 90%. The reached MAD in varus(valgus) deformities were 3+5(1+4). Reached mLDFA in varus(valgus) deformities was 90+3 (85+5). In procurvatum (recurvatum) deformities reached aPDFA was 77+5(82+6). Reached mMPTA in varus(valgus) deformities was 87+5 (90+8); mLDTA – 91+7(88+4). In procurvatum (recurvatum) deformities reached PPTA was 79+5(83+3), ADTA – 82,3+7,2(80+5). The patients had the following complications (%). pin-tract infection – 18; joint contracture – 12; breakage of transosseous elements - 3; non-union or atrophic regenerate formation – 3; secondary fractures and deformities due to further growth – 11. Conclusions: OSF provides high accuracy and short terms of deformity correction in children. It is a good background for its further use in pediatric orthopedic practice. Acknowledgements: to The Turner Scientific and Research Institute for Children's orthopedics, Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University and Ortho-SUV Ltd.


  PP 259: Ilizarov Technique Combined With Combined Surgery On The Treatment Of Congenital Fibula Hemimelia A Top


Jiao Shaofeng

National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: To explore the characteristics of congenital fibula hemimelia and the effect of Ilizarov technique combined with combined surgery. Methods: Review clinical data of 30 patients with congenital fibula hemimelia in Rehabilitation Hospital of the National Research Center for Rehabilitation Technical Aids from December 2001 to July 2014. There were 20 males and 10 females whose age ranged from 1 to 25 years old (average 13 years old). There were 3 cases of type I A (3 limbs), 12 cases of type I B (13 limbs), and 15 cases of type II (17 limbs) according to Achterman classification; with foot and ankle deformities. there were 3 cases of talipes equinovarus (3 feet) and 27 cases of talipes valgus (30 feet); absence of fibular toe. there were 9 cases (10 feet) of no fifth toe, 13 cases (15 feet) of no fourth-fifth toe, 2 cases of no third-fourth-fifth toe, and 6 cases of complete toe. Operation method. There were include 30cases (33 limbs) of fibular bands excision, peroneal tendon lengthening, and achilles tendon lengthening, 20cases (23 limbs) of distal tibial osteotomy, 18cases of proximal tibial osteotomy (including second operation), and 2 cases of femoral lengthening. All the patients were treated with Ilizarov technique for orthopedic and lengthening. Results: 30 patients were all followed up for 14-130 months (average 39 months); 4 caseswere operated 1 time, 12 caseswere operated 2 times, 9 caseswere operated 3 times, and 5 caseswere operated 4 times. There was no obviouslower leg shortening and ankle and foot deformities after operation at the final follow-up. Walking function and gait were significantly improved compared with preoperative state. Clinical effect was evaluated according to the criteria of fibula hemimelia functional score system. the excellent result was achieved in 21 patients, good in 8, and fair in 1. The excellent and good rate was 96.7 %. Conclusions: Congenital fibula hemimelia is a syndrome, which is partial or total aplasia of the fibula and usually is associated with other anomalies of tibia, femur, ankle joint, and foot. The method of Ilizarov technique combined with soft tissue release has satisfactory therapeutic effects of treating congenital hemimelia. Acknowledgements: Key words. congenital absence of fibula; fibula hemimelia; Ilizarov; combined surgery


  PP 260: Accurate correct the deformities around the knee with fixator-assisted plating technique in adolescents Top


Shu Zhen Deng, Jian Ping Yang, Zhong Li Zhang

Tianjin Hospital, Tianjin, China

Background: Deformity correction with external fixator are well-established procedure in the management of angular deformity around the knee in adolescents, but many external fixator-related complications, such as pin track infections, joint contractures and discomfort may occur. We use the fixator-assisted plating (FAP) technique to correct the deformities and evaluate the results. Methods: From March 2015 to July 2016, seven patients with angular deformity around the knee received surgical correction with monolateral external fixator assisted plating technique. Five males and two females were included in our study, the average age was eleven years and seven months at surgery (eight years one month to eighteen years old), with four distal femoral valgus and three proximal tibia varus. The reasons for deformities included distal femoral physis bar (4 patients), proximal tibia physis bar (1 patient), Blount disease (1 patient), hypophosphatemic rickets (1 patient). We evaluated the results of the angular deformities correction and the limb length discrepancy(LLD). Results: All patients acquired clinical follow-up and started full and unprotected weighting bearing 6 weeks after surgery. The deformities correction is satisfactory, the absolute value of mechanical axis deviation (MAD) average (38.9±10.2) mm before surgery and (8.3±5.8) mm after surgery. The mechanical lateral distal femoral angle(mLDFA) average (72.5±4.5) ° before surgery and (86.7±2.4)° after surgery, the mechanical medial proximal tibia angle(mMPTA) average (74.3±3.7)° preoperation and (88.1±1.2)° postoperation. All the results are normal. The limb length discrepancy(LLD) is (1.5±0.6) cm preoperation and (0.8±0.7)cm postoperation, all patients are asymptomatic when they walking. Conclusions: Fixator-assisted plating technique is responsible method which could accurate correct the deformities around the knee, and the patients do not need take the fixator and fell high comfortable after surgery and the fixation are reliable, meanwhile could improve the limb length discrepancy. This technique is suitable for adolescents with LLD≤2cm and could acute correct deformities around the knee. Acknowledgements: We thank professor Selvadurai Nayagam which work in Royal Liverpool Children's Hospital in England and also professor Chenhe Qin which work in Nanfang Hospital in Guangzhou of China for the technical guidance.


  PP 261: Outcomes of severe infantile Blount's disease managed by acute medial tibial plateau elevation and gradual deformity correction Top


Juanito Sanqui Javier, Bharat Timilsina

Department of Orthopaedics, College of Medicine, University of the Philippines Manila, Quezon City, Philippines

Background: Untreated Infantile Blount's Disease leads to severe multiplanar deformities of the knee. Aside from the angular and rotational deformities, joint laxity is also encountered. Surgical treatment requires complicated surgical procedures to correct the depressed medial tibial plateau, angular, rotational and length deformities. This paper aims to evaluate the outcomes of surgical correction of severe Infantile Blount's Disease by acute medial plateau elevation with correction of angular, rotational and length deformities using the Methods of Ilizarov and by an additional lateral proximal tibial hemiepiphyseodesis. Methods: This is a retrospective study of patients with Infantile Blount's Disease Langenskiold Stage 4 or above and who underwent surgical management as previously stated. Patent chart and radiograph reviews were done and outcomes were classified using the Schoenecker criteria. Results: Ten knees were included in the study. The tibio-femoral angle improved from an average of 43° to 7° with mean correction of 36.0°. The mean ADMTP (Angle of depressed medial tibial platueau) was 50 degree that improved to 23 degree. Range of motion improved by an average of 20 degrees. Three cases developed pin site infection with one requiring formal debridement. All infections resolved. Based on the modified Schoenecker criteria, there were 9 knees with good outcome and 1 with fair outcome. Conclusions: The multiplanar deformities in severe Infantile Blount's Disease can be satisfactorily treated by acute medial plateau elevation plus gradual angular, rotational and length deformities correction using the methods of Ilizarov. An additional lateral proximal tibial hemiepiphyseodesis is required. Acknowledgements: The authors have no affiliations with or involvement in any organization or entity with any financial interest, other equity interest or non-financial interest in the subject matter discussed in this study.


  PP 262: Treatment of severe congenital and traumatic clubfoot in older children with Ilizarov external fixator Top


Ming Li, Hang Liu

Orthopedic Center of Children's Hospital of Chongqing Medical University, Chongqing, China

Background: As for the patients of severe deformity or trauma, treatment with traditional operation couldn't reach ideal effect. This study was to investigate the curative effect of Ilizarov external fixator on patients of clubfoot in older children (above 6 years old). Methods: 126 patients (142 feet), 73 males and 53 females, were treated from August 2005 to May 2016, including 98 congenital patients (114 feet) and 28 traumatic patients (28 feet). There were 110 unilateral and 16 bilateral deformities. The mean age of children was 12.5 years (ranges from 6 to 17 years old). All of these patients were evaluated by ICFSG scoring system, including morphology (12 points), functional evaluation (36 points) and radiological evaluation (12 points). Patients were treated by Ilizarov external fixator combined with limited operation such as arthrolysis, achills tendon extension and V-shaped osteotomies. Results: All of the 126 patients were followed up from 8 months to 10 years. The results were assessed using ICFSG score system. Congenital patients. 72 cases were excellent, 20 cases were good, 6 cases were fair, no case was bad. Traumatic patients. 18 cases were excellent, 6 cases were good, 4 cases were fair, no case was bad. The excellent/good rates of the two groups were 93.88% and 85.71%. The curative effects were evident. Conclusions: The method using Ilizarov external fixator to treat clubfoot in older children was mild injuried, secure and had excellent curative effect. It is an ideal choice to treat clubfoot in older children. Acknowledgements: We greatly thank the patients and their parents involved in this study.


  PP 263: Reconstruction Of The Tibia Of Children With Congenital Pseudarthrosis Of The Tibia In Russia Using Ilizarov Method Top


Ekaterina Anatolievna Zakharyan1, Aleksandr Pavlovich Pozdeev2

1. The Turner Scientific and Research Institute for Children's Orthopedics, Saint-Petersburg, Russia

2. The Turner Scientific and Research Institute for Children's Orthopedics, Pushkin, Russia

Background: The purpose of study was to refine frequency of etiological factors, characteristics and treatment of congenital pseudarthrosis of tibia (CPT). Methods: Materials and Methods. The analysis of complex research (anamnestic, clinical, radiological, physiological, morphological) and treatment of 300 patients with CPT. Results: Results. It was found that the causes of disease are. neurofibromatosis, myelodysplasia and fibrous dysplasia. In neurofibromatosis and myelodysplasia in the basis for pseudarthrosis are neurotrophic disorders. Typical is a latent pseudarthrosis at birth with the progression of deformity and thinning of the affected bone. Provoking factor of pseudarthrosis is a pathological fracture. Deformities, limb shortening, significant thinning and sclerosis of ends of bone fragments, degenerative changes in bone tissue throughout the diaphysis and epiphysis, lowered bone growth, weak ossification at the ends of bone fragments up to complete absence are observed. In fibrous dysplasia, the ends of the bone fragments are thickened, sclerotic, they reveal foci of fibrous dysplasia. We have developed a method of treatment congenital pseudarthrosis of the tibia which consists of two parts and allows to achieve union at 96% cases. We using Ilizarov technique combined with bone grafting, which was invented in 1980 by professor A.P. Pozdeev. At first, the method includes. open reposition of bone fragments (side by side), lateral compression osteosynthesis with cortical allogenous plates and fixation with Ilizarov technique. Union is achieved within 3-4 months. After achieved union we produce deformity correction of lower extremity. Our hospital has twenty years of experience treating patients with pseudarthrosis. Conclusions: Conclusion. It was found that two groups of CPT are. neurotrophic and dysplastic types. Neurotrophic CPT develop due to neurofibromatosis and myelodysplasia, dysplastic due to fibrous dysplasia. Features of the development and course of congenital pseudarthrosis of tibia have a direct correlation with the etiologic factor. Acknowledgements: This research was supported by The Turner Scientific and Research Institute for Children's Orthopedics. We are thankful to our colleagues who provided expertise that greatly assisted the research.


  PP 264: Deformity Correction And Lengthening For The Treatment Of Benign Bone Tumors Using External Fixation Top


Hidenori Matsubara, Toshiharu Shirai, Syuhei Ugaji, Hiroyuki Tsuchiya

Kanazawa university hospital, Kanazawa, Japan

Background: We present a retrospective study of patients suffering from a variety of benign tumours in whom external fixators were used to treat deformity and limb-length discrepancy. Methods: Since 1990, 43 limbs in 28 patients (13 male and 15 female) with a mean age of 13.7 years (5 to 43) were treated. The diagnosis was Ollier's disease in 18 limbs, osteochondroma in 12, fibrous dysplasia in 11, and non-ossifying fibroma in two. The lesions were treated in the femur in 18, in the tibia in 14 limbs, and in the forearm in nine. We performed deformity correction alone in 12 limbs, lengthening alone in 14 limbs, and deformity correction & lengthening in 17 limbs. Furthermore, plate conversion surgery was done for three limbs just after the correction or lengthening. The Ilizarov frame was used in 17 limbs, the Taylor Spatial Frame (TSF) in 15, the Orthofix fixator in six, the Monotube in four and the Heidelberg fixator in one. The mean follow-up was 87 months (6 to 249). We performed plate conversion surgery for three limbs. Results: The mean external fixation period was 155 days (33 to 352). The mean length gain was 3.2cm (1.0 to 6.8). The mean external fixation index was 70 days/cm (25.4 to 235) in the 26 patients who required limb lengthening. The mean correction angle for those with angular deformity was 23 degree (7 to 45). At final follow-up, all patients had returned to normal activities. Regarding the complications, two patients developed an equinus deformity that was treated successfully with physiotherapy after removal of the fixator. Early consolidation of the regenerate bone occurred in two patients requiring a repeat subcutanenous osteotomy. A second operation for limb lengthening or correction of deformity was required in six patients with Ollier's disease and one with an osteochondroma of the forearm. Conclusions: We believe that external fixation is an effective technique for treating deformity and limb-length discrepancy produced by benign bone tumors. It offers a good alternative to other conventional methods of management. There are disadvantages to the technique, such as pin tract infection, the bulk of the frame. TSF frame are easier adjustable than other external fixators for treating deformity and limb-length discrepancy simultaneously. Acknowledgements: No acknowledgements


  PP 265: The utility of Talectomy as a salvage procedure in the correction of rigid foot deformities in children Top


Mahmoud Abdel-Monem El-Rosasy, Ashraf Atef Mahmoud

Tanta University, Faculty of Medicine, Tanta, Egypt

Background: Rigid deformities of the foot in children may be congenital due to neuromuscular disorders or acquired due to soft tissue scarring after trauma or skin lesions. Correction of such deformities by soft tissue releases only may not be successful and the use of gradual correction using distraction histogenesis may not be suitable for this group of patients. Methods: Ten children (18 feet) with rigid foot deformity (cavovarus no. 16 and rocker bottom no. 2) were included in this study. Six children have arthrogryposis, three children have spina bifida and one child has epidermolysis bullosa with extensive scarring of foot skin. Their ages ranged from 2.5 to 12 years. The procedure included complete excision of the talus through Olier approach on the antero-lateral aspect of the foot in cases of cavovarus deformity and through anterior approach to the ankle and talus in two cases. Then the foot and ankle were held in the plantigrade position using either percutaneous Kirschner wires and cast (in younger children) or a simplified Ilizarov external fixator for eight weeks followed by a below knee walking cast for four weeks then prolonged use of plastic splint to maintain the foot position. Results: No neurovascular injury occurred due to deformity correction. The plantigrade position of the foot was maintained with no recurrence of deformity. Conclusions: Talectomy provides acute and relatively safe correction of sever and rigid foot deformities in children. Acknowledgements: The authors have no conflict of interest


  PP 266: Correction Of Neuromuscular Foot Deformities Using Circular External Fixator Frame In Retrospective Study. Top


Ibrahim Elsayed Abuomira1, Yasser Elbatrawy2

1. al-azhar university, Assiut, Egypt

2. al-azhar university, Cairo, Egypt

Background: Abstract Text. -Introduction. Causes of Neuromascular deformities. Poliomyelitis, Charcot foot, Cerebral palsy, Charcot Marie Tooth hereditary neuropathy and Spina bifida. One advantage of the Ilizarov method is that it allows surgeons to correct complicated deformities without incisions or osteotomies, particularly in pediatric patients. However, in adult patients, osteotomies are often necessary and Ilizarov developed medial and hindfoot osteotomies that allow correction of difficult foot problems. There are two types of treatment, closed treatment and open treatment. (Ilizarov G.A., 1988). Complex deformities in foot and ankle are the ideal indication for Ilizarov method. Ring external fixators, by virtue of their versatility, uniquely allow simultaneous correction of multiple deformities. The key to success in this group of patients is proper hinge placement. Aim of the Work. The goal of treatment is to provide painless, plantigrade, stable foot that can fit into a shoe without difficulty. Methods: In this study 48 feet and ankle deformities in 40 patients were operated upon using the Ilizarov technique and fixator during the period from Jan. 2006 – April 2016. All patients pre-operatively assessed by history taken, examination, X-ray and planning. Results: Conclusions: Acknowledgements


  PP 267: Surgical treatment for lower limb deformities in patients with cerebral palsy (twelve cases report) Top


Jianzhong Ge

Yangquan City first people's hospital, Yangquan, China

Background: The patients with cerebral palsy often suffer from lower limb deformities that will get worse with the increase of age. So it is very important to correct the deformities with surgical procedure as soon as possible. Methods: From January 2013 to January 2014,12 patients with cerebral palsy combined with lower limb deformities were treated.There were seven females and five males in this group.Their age ranged from 6 years to 35 years.Among them ,there were four patients who were incapable of standing by aids.8 patients hobbled in an awkard way.The lower limb deformities included double knee flextion deformities in 1 patients,talipse equinovarus in 2 patients,double hip adduction and knee flexion deformities in 2 patiens,single hip adduction combined with knee flextion and talipse equinovarus in 2 patients,double hip adduction combined with knee flextion and foot deformities in 5 patients .They were treated with tendon lengthening ,tendon displacement,arthrodesis and external fixation,in order to gain nomal axial alignment of lower extremity and stable joint.external fixation devices included Ilizarov external fixtor in 2 patients, combined external fixator in 6 patients and long leg cast in 4 patients. Results: Their axial alignment of lower limb acquired obviously restored, four paitents could stand with the aids,eight patients could walk by themselves and their gait improved. Conclusions: The surgical key points includes tendon lengthening,soft tissue balance and stabilizing joints.After all rehabilitation have important impact for the prognosis. Acknowledgements: We declare that there is no conflict of interest with others people and other organizations in this study.


  Reconstruction of multiphocal deformities in children Top



  PP 268: Results Of Lower Limb Reconstructive Surgery In Postmeningococcal Sepsis Secuelae In Children. Case Series. Top


Francisco Javier Downey-Carmona1, Roi Castro2, Jose Francisco Lirola1, Jose Manuel Martinez Salas1, David Farrington1

1. Hospital Virgen del Rocío, Sevilla, Spain

2. Hospital Universitario de Cabueñes, Gijón, Spain

Background: Bacterial sepsis due to  Neisseria More Details meningitidis is a serious disease in which 50% of untreated patients die. Despite good management of the disease, the number of sequelae caused directly or indirectly by the drugs used in its treatment, is not negligible. Surviving patients develop growth abnormalities due to early physeal closures that involve real difficulties in planning surgeries and anticipate future corrections of recurrences. We present a series of six patients with 10 bone segments with postsepsis meningococcal angular deformities treated in the same center and by the same specialist. Methods: Retrospective descriptive study with six patients in childhood with diagnosis of meningococcal sepsis. The mean follow-up was 4 years per patient. The treatment of the deformities of these patients was done by means of circular external fixators, monolateral, temporal hemiepifisiodesis and definitive epiphysiodesis. Results: Of the six patients treated, five were discharged from the child orthopedic unit with a mean age of 13.67 years. Of the six cases, four are men and two women. The mean age at the beginning of the orthopedic treatment was 9.83 years (range 5-13). The mean number of surgeries per patient was 4.83 (range 1-10). All of the patients presented deformities in the lower limbs, the most frequent of which was genu varum. The mean number of days of external fixator treatment per body segment (total of 10 bones treated) was 210.7 days. The mean length discrepancy between the two limbs at the end of treatment was 18.83 mm (From 2 to 65 mm). Conclusions: Due to the low prevalence of this disease, most of the studies are retrospective and have a small series of cases with poor evidence, so it is not clear which is the best treatment that can be given to these patients. It is possible to prevent the recurrence of deformity by means of definitive epiphysiodesis, which would avoid their recurrence, but would cause greater leg length discrepancies at the end of the growth. Long-term follow-up is necessary to avoid recurrences of deformities. More studies should be done with a larger number of patients, and more homogeneity among them to adapt and protocolize the treatments. Acknowledgements: No Conflict of Interest


  PP 269: Extensive Limb Lengthening (ELL) can be safely done for short limbed dwarfism. BENEFITS are functional & not merely cosmetic Top


Milind Madhav Chaudhary

International Deformity & Lengthening Institute, Akola, India

Background: Achondroplasia is the commonest form of Rhizomelic dwarfism. Females reach 3'11” and Males can reach 4'1”. Dwarfism hampers functioning in society that is designed for a normal population. Other causes of short limbed dwarfism like hypochondroplasia, Turners, ChondroMetaphysal Dysplasia, Osteogenesis Imperfecta & Spondylo Epiphyseal Dysplasia. Achondroplasia stands to benefit the most from extensive limb lengthening (ELL) since there is a mismatch between bony & soft tissue lengths. Resistance to lengthening by soft tissues is at a minimum. Significant length gain to give functional advantage. For many it can be a life changing to go from being a dwarf to being short normal. Methods: We report on 108 corticotomy lengthenings done in 90 segments in 21 Achondroplastic & 8 children with other forms of dwarfism. There were 74 lengthenings in 54 tibiae (10 had double level lengthening) Length gain ranged from 4.5 cm to 20 cm in a single segment. 22 single level lengthenings in femur with a gain of 8 to 17.5cm in one stage. 12 Humeral lengthening with a gain of 6.7 to 10 cm. Height gain after bilateral lengthening at end of treatment ranged from 4.5 cm to 25 cm and max gain including arms was 4.5 to 33 cm. The tibia gained an average of 63%(15%-88%) Femora gained an avg 49%(33-65%) Humerus was 49.75%(36-60%). Tibial Healing index was 30.44days/cm. For single level, 33.8days/cm & double level was 24.7days/cm. Femur needed 25.4days (20 -34days/cmm) and Humerus was 28.5 days/cm(20-36days/cm). Results: All 29 patients were satisfied with length gain. There were few permanent complications. One had 16° tibial valgus. needing an osteotomy, and 10°valgus in opposite femur needed guided growth for correction. Residual valgus of 14° in one tibia was a true complication. 8 premature consolidations needed re-surgery. No Regenerate # or need for bone grafting. One child refused repeat corticotomy & had residual LLD of 15mm. There were 4 neurapraxia. 2 in Lateral popliteal, 1 in posterior tibial and 1 in Radial nerves which recovered completely upon stopping distraction. Re-corticotomy resumed lengthening after nerves recovered. One patient had anterior subluxation of the knee, corrected by applying a frame to the femur. 4 equinus deformities needed a tenotomy & 1 needed a foot frame. Conclusions: ELL for achondroplasia gives a good height increase resulting in dramatic improvement in quality of life. If lengthening is started early it can give maximum benefits without disruption of normal social life. Acknowledgements: The author acknowledge help from Clinical Fellows & staff of Chaudhary Hospital, Akola in preparing this manuscript


  PP 270: Ulnarization For Radial Clubhand: Prevention Of Recurrence And Improved Appearance & Function By A New Operation. Top


Milind Madhav Chaudhary

International Deformity & Lengthening Institute, Akola, India

Background: Common treatments for Radial clubhand include centralization and radialization of the wrist. They aim to correct the deformity and keep the wrist and hand well centered over the forearm. However, problems like recurrence of the deformity, stiffness of the wrist and distal ulnar growth arrest with increasing shortening of the forearm are common complications. Paley described Ulnarization to correct the deformity, retain movement at the wrist and prevent its recurrence. Ulnarization shifts the wrist and hand from radial to the ulnar side of the distal ulna. The ulnar border of the distal ulna mechanically prevents radial deviation of the wrist. The second part of the operation transfers the flexor carpi ulnaris tendon from the pisiform to the dorsal side of the wrist. Methods: We performed five surgeries in four patients in seven years. Age ranged from 2-18 years. All had severe deformity and complete absence of radius. The incision crosses the forearm from ulnar to radial and extends into the palm. A pocket is created on the radial side of the distal forearm where the distal ulna is shifted. Blood supply to the distal ulnar epiphysis coming from the radial side is preserved. The tendons dorsal to ulna are released by sharp dissection. Complete release of capsule from the radial, volar and dorsal sides helps mobilize the distal ulna. Subluxation of wrist is prevented by fixation with a K wire. Ilizarov fixator fine tunes position of the hand and wrist on the distal ulna. Prominence of the distal ulna on the radial of the wrist looks like a prominent radial styloid. The appearance of the entire forearm and hand is dramatically improved. The wrist can dorsiflex due to transferred action of flexor carpi ulnaris. Results: Follow-up is three years to seven years. A short period of bracing or casting was needed in all patients. The improved appearance satisfied all of our patients. There was a mild recurrence of the volar flexion deformity at the wrist in two of five patients. There was very little recurrence of radial deviation deformity. Three had aplasia of the thumb for which they have not yet come for pollicization. Poor hand function has been chiefly due to lack of the thumb and stiffness of the fingers. Conclusions: Ulnarization shifts the hand and wrist to the ulnar side of distal ulna. Distal ulna prevents recurrence of deformity. FCU transfer permits wrist dorsiflexion. Appearance and function both improve after this surgery with less recurrence of deformity. Acknowledgements: Author acknowledges suggestions given by Dror Paley in performing these surgeries.


  PP 271: Followup Of 15 Years Of 23 Patient Treated For Blount Disease Treated In The Hospital Das Clínicas De São Paulo Top


Walter Hamilton De Castro Targa, José Henrique Peres Dos Santos, Paulo Roberto Dos Reis, Guilherme Pelosini Gaiarsa, Márcio Batista De Carvalho, Gabriel Errol Mendizabal Mendonza

Hospital das Clínicas de São Paulo - Faculdade de Medicina da USP, São Paulo, Brazil

Background: Blount disease (BD) is characterized by a progressive varus resulting from a growth retardation of the medial region of the epiphysis and the physis due to a disorganization of the endochondral ossification of the medial physis. The Langenskiold classification helps to understand the evolutionary nature of the lesion and guides the treatment. This study aimed to demonstrate the follow-up of 15 years of surgically treated patients at the Hospital das Clínicas - College of Medicine from University of São Paulo. Methods: Patients were classified according to the Langenskiöld classification and general patient data were obtained. Subsequently, surgical procedures were performed according to the classification and ambulatory follow-up was performed to evaluate the progression of the condition. After this initial classification, patients were subdivided according to the Targa and Catena Classification into 3 types, Type 1 - open BD physis, type 2 BD with open physis but with late onset and Type 3 patients with BD sequela with closed physis. Type 1 includes all patients classified as Langenskiöld and subdivided into group A for patients with Langenskiöld 1,2 and 3, group B for patients with Langenskiöld 4 and 5 and group C for patients with Langenskiöld type 6. For group A, only epiphyseal distraction with circular external fixator was performed. In group B, epiphyseal distraction was associated with corrective metaphyseal osteotomy with external fixator and in group C corrective external fixator osteotomy associated with chisel epiphysiotomy was performed. Patients of type 2 and 3 were treated according to their axis deformity with corrective metaphyseal osteotomies with external fixator. In the ambulatory, the follow-ups of gradual correction, final stabilization and subsequent programmed removal of external circular fixator. Results: Of a total of 23 patients, type 1 was detected in 10 cases, 8 of which bilateral, Type 2 was diagnosed in 2 cases, one was bilateral, and type 3 was found in 9 cases, 5 bilateral. The mean age of the patients was 17 years (4-33 years), the mean follow-up time was 15 years (12-20 years). They remained with an average time of 6.5 months with the external circular fixator (5 - 10 months). All presented a satisfactory alignment with the final angle of Valgo of 4 degrees. Conclusions: The use of a circular external fixator associated with osteotomy procedures has shown to be satisfactory and over time has generated an aligned and functional limb. Acknowledgements: The authors declare that there are no conflicts of interest in the production of this article.


  PP 272: Reconstructive Surgery Of Pelvic Ring In Children With Extrophy Of Bladder Using External Apparatus Top
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Alexander Vadimovich Gubin

Russian Ilizarov Scientific Center, Kurgan, Russia

Background: Surgical reconstruction of pelvic ring in children is a rare and severe surgical intervention. Reconstruction of the pelvic ring is an important stage for treatment of extrophy of bladder. However, there are no special pediatric instruments for correction and fixation of pelvis. Purpose of the work. To show possibilities of pelvic reconstruction for extrophy of bladder using external fixation systems. Methods: Material and methods. 32 reconstructive surgeries on pelvic ring in children were done together with a urological team of surgeons. External fixation systems based on Ilizarov elements, but own fixator design or fixators ExFix by Synthes were used. Results: Reconstructive surgeries using external fixation systems are possible in children at the age over 8 months with maldevelopment of pelvic ring. All patients develop complications during complex treatment of extrophy of bladder. In 70% of cases results of the surgical intervention can be significantly improved by means High level of anesthetic management and modern standard implants made complicated reconstructive interventions in pelvic ring possible in children of almost any age, including those as simultaneous surgeries for extrophy of bladder. of orthopaedic stage. Conclusions: High level of anesthetic management and modern standard implants made complicated reconstructive interventions in pelvic ring possible in children of almost any age, including those as simultaneous surgeries for extrophy of bladder. Acknowledgements: there is no conflict of interest


  PP 273: Treatment Of Complex Deformities In Osteogenesis Imperfecta With The Fassier-Duval Telescopic Intramedullary Nail Top


Miguel Angel Galban, León Gonzalo Mora

CORA Group - Clínica El Rosario, Medellín, Colombia

Background: INTRODUCTION:. The Fassier-Duval (FD) system's efficiency as a treatment for complex deformities in patients with osteogenesis imperfecta (OI), treated by the author* between 2006 and 2014, was reviewed. Methods: MATERIALS AND METHODS:. During an 8-year period, 156 patients were treated by the same surgeon*. 258 FD nails were implanted, 168 femurs and 90 tibias. 66 girls and 90 boys. Ages between 18 months and 12 years old. 59% with type III, 31% with type I and 10% with type IV. With a 4.4-year follow-up (1.2-8 years). Only patients that previously received bisphosphonates were included (zolendronic acid or pamidronate). Results: RESULTS:. The average age of the patients at the moment of the implantation was 5.6 years old. The general “mode/way” of necessary osteotomies in order to attain alignment was 2. The average osseous consolidation time was 66.36 days. During the follow-up time, the following findings stand out. 6 femurs and 4 tibias consolidated with deformities in the rotational plane (3.87%), only one patient was required to have a new chirurgical intervention for this reason (0.38%). 6 femur fractures and 4 tibia fractures with nail angulation (3.8%). 12 patients (4.65%) showed fractures without crease of the FD nail. 16 displacements or detachments of the distal end of the nail, 10 in femurs (3.8%) and 6 in tibias (2.3%). 8 proximal displacements (3%) of the female component, 4 tibias and 4 femurs, all of which required reinsertion. 10 apparent displacements because of osseous apposition over the proximal part of the nail (3.8%), 6 femurs and 4 tibias. There were no physis lesions. There was no avascular necrosis of the fragments between the osteotomies or the femoral heads. Conclusions: The severe osteoporosis that patients with OI show requires the stabilization and alignment of their long bones. The FD system shows inherent complications to the disease and, despite this, achieves the objectives of providing protection against fractures, alignment and stabilization. Acknowledgements: To Professor Francois Fassier for his support and teachings


  PP 274: Treatment Of Congenitial Multi-Joint Contracture Deformity With Ilizarov Method Combine Dynamic Balance Surgery Top


Jiao Shaofeng

National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: Discuss the therapeutic effect of combine ilizarov method and tendon transfer surgery to treat multi-joint contracture deformity. Methods: Treated 29 cases suffered multi-joint contracture deformity from 8.1998~12.2015. all of the patients were followed up for mean 42 months. Results: All the patients' limb function were modified after the surgery, no severe complications. Conclusions: Ilizarov method combine dynamic balance surgery is a good way to treat congenitial multi-joint contracture. Acknowledgements: key words Ilizarov method; dynamic balance; congenitial multi-joint contracture


  PP 275: How To Treat The Foot And Ankle Joint Deformities Of Spinal Bifida?: (705 Cases 17.8 Years Reports): Top


Jiancheng Zang, Sihe Qin, Shaofeng Jiao

Department of Orthopaedics, Affiliated Hospital of National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: Many foot and ankle deformities suffering Spinal Bifida in China. It is very difficult to treat as the same stage of deformity and sensory disturbance. The objective of this paper is to summarize the advantages and curative effect of the treatment for deformity of foot and ankle of Spinal Bifida using external fixation. Methods: From Oct 1986 to Aug 2016, 705 patients with foot and ankle deformity suffered Spinal Bifida were retrospectively analyzed, including male 332 cases, female 373 cases, with an average age of 17.8ys, left 170 cases, right 173 cases and bilateral 362 cases. According to the type of fixation, the number of Ilizarov external fixator group were 241cases, Hybrid external fixator group were 240 cases and 16 cases using the Ilizarov external fixator and Hybrid external fixator at the same time. Simultaneously, other surgeries, including subtalar osteotomy, triple joint osteotomy, first metatarsal osteotomy, Achilles tendon lengthening, Achilles tendon fixation surgery and posterior tibial tendon lengthening et al, had been done. Results: 705 patients received short-term follow-up, all deformities were corrected effectively and full foot weight-bearing restored. There was no serious complication of neural or vascular injury which external fixation related, pin set superficial infection in 15 cases, no deep infection, needle breakage in 3 cases, 1 cases with pin tract thermal burn at medial calcaneal, 2 cases with external fixation related to skin allergic eczema, 4 cases suffered anterior dislocation of the tibial-talar joint, change the configuration of external fixation and then reduction. 650 cases acquired clinical and telephone follow-up, an average of 18.5 years, AOFAS score was used to evaluate the clinical effect, an average of 88.7 points, which compared with pre-operation number, P=0.013<0.05, the difference has statistically significant. Based Qin Sihe standard of deformity correction evaluation, excellent in 480, good in 125 feet, the excellent-rate was 93.5%. Conclusions: Lower limb deformity and sensory disturbance is mainly problem for Spinal Bifida cases. Skeletal external fixation plays an excellent role in the treatment of various types of foot and ankle deformity of Spinal Bifida.It is effective, simple, minimally invasive, reliable adjustable and serious complications can be avoided. Acknowledgements: The authors declare that they have no conflict of interest.


  PP 276: Deformities Of The Hip Of Children With Congenital Pseudarthrosis Of Tibia: Analysis Of 70 Children Aged 4 To 18 Years Top


Ekaterina Anatolievna Zakharyan1, Alexsandr Pavlovich Pozdeev2, Victor Alexsandrovich Vilenskiy1

1. The Turner Scientific and Research Institute for Children's Orthopedics, Saint-Petersburg, Russia

2. The Turner Scientific and Research Institute for Children's Orthopedics, Pushkin, Russia

Background: The purpose of study was analysed deformities of the femur of children with congenital pseudarthrosis of tibia (CPT). Methods: Materials and Methods. We analyzed panoramic X-rays and CT of hips of patients with congenital pseudarthrosis of tibia. The 70 children aged 4 to 18 years participated in research. Results: Results. In the analysis of X-ray, we determined the following angles. LPFA, mLDFA, aPPFA, aPDFA. In the analysis of CT scans, we determined torsion component of the deformity of the hip. It showed an increase in the LPFA (valgus deformity) and aPDFA (antecurvation in the distal part of the femur), lengthening of the femur on the side of a false joint to 1-2 centimeters. Conclusions: Conclusions. Availability thigh strain in patients with congenital pseudoarthrosis of the tibia indicates defeat the entire lower extremity. It is necessary to carry out a panoramic radiograph of the lower limbs and to conduct a careful analysis of deformations to address the issue about the need to perform not only tibia but and hip corrections. Acknowledgements: This research was supported by The Turner Scientific and Research Institute for Children's Orthopedics. We are thankful to our colleagues who provided expertise that greatly assisted the research.


  PP 277: Correction Of The Deformities Of Children With Congenital Pseudarthrosis Of Tibia After Achieved Union Top


Ekaterina Anatolievna Zakharyan1, Aleksandr Pavlovich Pozdeev2, Victor Alexsandrovich Vilenskiy1

1. The Turner Scientific and Research Institute for Children's Orthopedics, Saint-Petersburg, Russia

2. The Turner Scientific and Research Institute for Children's Orthopedics, Pushkin, Russia

Background: The purpose of study was to improve the results of the correction deformities of the lower legs of children with congenital pseudarthrosis of tibia after achieved union (CPT). Methods: Materials and Methods. The analysis of complex research (anamnestic, clinical, radiological, physiological, morphological) and treatment of 70 patients with CPT after achieved union. Children aged 4 to 18 years participated in research. We decided all children in two groups. group 1 – lengthing and correction deformities using only Ilizarov method, group 2 – lengthing and correction deformities using orthopedics hexapod Ortho-SUV. Results: Results. Our hospital has twenty years of experience treating patients with pseudarthrosis. We have developed a method of treatment congenital pseudarthrosis of the tibia which consists of two parts and allows to achieve union at 96% cases. Patients with congenital pseudoarthrosis of the tibia after the union have a complex deformation of the lower leg. valgus and recurvation in the proximal tibia and valgus and antecurvation in the distal tibia. After achieving consolidation of nonunion and recovery medullary canal preliminary operations are made to restore limb length and deformity correction using the Ilizarov method. In our work to plan the correction of deformity, we use reference lines and angles. For a more accurate and rapid correction we combine the use of the Ilizarov method with hexapod Ortho-SUV. In group 1 we used only one osteotomy in the proximal tibia, in group 2 we used osteotomy in the proximal tibia and in the distal tibia. Accuracy of correction of the deformity is between seventy-one percent and hundred per cent of the respective corners. Fixation index were 63 days/cm – 95 days/cm and depended from age of child. Final correction of shortening is not always possible to achieve in a single surgery, and therefore these patients performed two or three operations to restore limb length. Conclusions: Conclusions. Complex deformities of the tibia, and a high index of osteosynthesis of patients with consolidated congenital pseudoarthrosis of the tibia require careful attention of the surgeon in the treatment of these patients. Acknowledgements: This research was supported by The Turner Scientific and Research Institute for Children's Orthopedics. We are thankful to our colleagues who provided expertise that greatly assisted the research.


  Reconstruction of upper limb deformity in children Top



  PP 278: Treatment Of Posttraumatic Cubitus Varus In Children And Adolescents. Supracondylar Humeral Osteotomy Using Radial External Fixation. Top


Theddy Slongo

University Children's Hospital Dept. of Paediatric Surgery, Bern, Switzerland

Background: Precise adaptable fixation of a supracondylar humerus osteotomy with a radial/lateral external fixator to correct posttraumatic cubitus varus. Methods: Acquired, posttraumatic cubitus varus as a result of a mal-healed and unsatisfactorily treated supracondylar humerus fracture. Idiopathic, congenital cubitus varus (very seldom) if the child (independent of age and after complete healing) is cosmetically impaired; stability of the elbow is reduced due to malalignment (hyperextension); secondary problems and pain (e. g., irritation of the ulnar nerve) are expected or already exist; or there is an explicit wish of the child/parents (relative indication). In principle there are no contraindications provided that the indication criteria are filled. The common argument of age does not represent a contraindication in our opinion, since angular remodeling at the distal end of the humerus is practically nonexistent. Basically, the surgical technique of the radial external fixator is used as previously described for stabilization of complex supracondylar humeral fractures. With the patient in supine position, the arm is placed freely on an arm table. Using a 4–5 cm long skin incision along the radial, supracondylar, the extracapsular part of the distal humerus is prepared, whereby great caution regarding the radial nerve is advised. In contrast to the procedure used in radial external fixation for supracondylar humeral fracture treatment, two Schanz screws are always fixed in each fragment at a distance of 1.5–2 cm. The osteotomy must allow the fragment to freely move in all directions. The proximal and distal two Schanz screws are then connected with short 4 mm carbon or stainless steel bars1. These two bars are connected with each other over another bar using the tub-to-tub technique. Now the preliminary correction according the clinical situation can be performed and the clamps are tightened. Due to the excellent stability, further immobilization is not necessary. Results: Adequate healing is usually expected within 6 weeks. At this time, the external fixator can be removed in the fracture clinic. Because the whole operation is performed in an extra-articular manner and the mobility of the elbow is not affected, deterioration of function has never been observed. Also regarding the cosmetic/anatomical situation, good results are expected because they were already achieved intraoperatively. Conclusions: Acknowledgements: Nill


  PP 279: Correction Osteotomy Of Neglected “Monteggia” Lesion With An External Fixator. Top


Theddy Slongo

Orthopaedics University Children's Hospital Dept. of Paediatric Surgery, Bern, Switzerland

Background: Definite reduction of the dislocated radial head to prevent further damage and loss of function in case of a neglected radial head dislocation following Monteggia lesion. Three different operation methods are demonstrated. Methods: A correction must be striven for in any fresh injury. The indication has to be made according to the complaints in chronic dislocations. A correction is very difficult and not always successful. The surgical technique depends on the underlying disease and the kind of deformity, as well as on the instruments and implants available. There are different techniques. exclusive angulation osteotomy of the ulna (short interval after injury < 3 months), angulation osteotomy and additional lengthening of the ulna (mostly > 3 months after injury); an open procedure is seldom necessary and should be avoided. Depending of the child's age, the technique used and the implant chosen (external fixator, plate), a cast-free treatment should be striven for (better function). Results: The results depend on the surgeon's experience, the accuracy of planning, and the technique chosen. An intensive postoperative physiotherapy is mandatory, frequently with initial application of CPM (continuous passive motion). Loss of correction and residual malalignments are well known and not rare. They occur mostly in instances of insufficient stability and centralization of the radial head, respectively. Conclusions: There are no evident numbers but this is confirmed by clinical experience. Acknowledgements: Nill


  PP 280: Treatment Of The Congenital Transverse Deficiency Of The Upper Extremity: Experience Of 39 Cases Top


Theddy Slongo

Orthopaedics University Children's Hospital Dept. of Paediatric Surgery, Bern, Switzerland

Background: The goal of this study was to gauge the profile and the treatment of congenital transverse deficiencies of the upper extremity and reviewed our experience in the lengthening of the forearm stump using Ilizarov technique. Methods: There were 39 children with congenital transverse deficiency of the upper extremity in the Department of Pediatric Surgery, Bern University Children's Hospital (Switzerland) from 1987 to 2003. 28 of these patients were found to have forearm amputation. 15 of them underwent lengthening of the forearm stump using the Ilizarov technique in order to achieve more adequate length for properly prosthesis fitting. Two children received lengthening of the humerus stump by the same device. For those patients who had no indication for surgery or lengthening was not able due to social contraindications, treatment consisted of early as possible prosthetic fitting of the deficient limb. Results: The maximum forearm length achieved was 8 cm, with the mean 6.6 cm. There was no complication during operation and only few complications during total lengthening period. Majority of the patients had no complaints regarding the stump after lengthening and were immediately fitted with the prosthesis. Only four patients had some complaints regarding the stump after lengthening. There were no substantial problems relative to prosthesis fitting. Adequate lengthening of the stump not only ensured a perfect fitting of the prosthesis in follow-up, but also enabled the child to use the impaired extremity more actively in its daily living. Conclusions: The Ilizarov technique was seen to be a micro-invasive, reasonably safe and reliable device for lengthening the stump in case of congenital transverse deficiency of the upper extremity. Acknowledgements: Nill


  PP 281: Correction Of Bowing Deformities In Paediatric Femur And Tibia By Ilizarov Technique Top


Prof Md. Mofakhkharul Bari

Bari Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Background: Abstract Text. Aim. Correction of multiplanar bone deformities in children is indicated for prevention of secondary orthopaedic complications. Different problems related to surgical intervention were reported. non-union, delayed union, recurrent deformity, refracture, nerve palsy and pin tract infection. The aim of this study was to show the results of children femur and tibia bowing deformities by Ilizarov technique. Methods: We analysed 31 cases of children femur and tibia bowing deformities under the age of 13 yrs. Simultaneous deformity correction in femur and tibia was done with Ilizarov device in ipsilateral side. Contralateral side was operated after 15 days. Results: The duration of Ilizarov fixation was 130 days on an average. The deformity correction was achieved with a proper alignment in all the cases. Conclusions: Bowing of femur and tibia can be corrected simultaneously by Ilizarov fixation with minimum complications. There were no recurrent deformities in our cases. Keywords. Bowing femur and tibia, Deformity correction, Ilizarov fixator. Acknowledgements: n/a


  PP 282: Reconstruction Interosseous Membrane More Ulna Distraction Osteogenesis In Treatment Multiple Cartilaginous Exostosis Top


Marcio Aurelio Aita1, Fabio Lucas Rodrigues1, Rodrigo Montemor Bernardo1, Daniel Rebolledo1, Danilo Gabriel Barronovo1, Gustavo Mantovani Ruggiero2

1. Faculdade de Medicina do ABC, Santo Andre, Brazil

2. SP HAND CENTER, Sao Paulo, Brazil

Background: Literature review. The treatment of those forearm deformities is difficult and complicated. There is no consensus to overall management. As there is still a lack of long-term results, the indications for surgery, various surgical options, and the timing of the intervention have been matters of controversy in the literature. Would DRUJ be stable when ulnar lengthening is combined with excision of exostosis? Is it possible to reduce the radial head with this technique?. Clinical relevance. We would like to suggest an interosseous membrane (distal oblique band) reconstruction to improve this treatment. We believe that, that suggestion could maintain DRUJ more elbow stable and functional. We agree that the best time to perform the corrections is early and gradually. We prefer to correct the ulna, radius, DRUJ and elbow in many steps than in only one procedure. Methods: Study Design. Prospective study. Case report and showed new technique . Level of evidence. IV, Case Series, Therapeutic Study. Case description. By presenting one patient with such a disease, 11 y.o., boy, congenital deformity his right, dominant forearm, type II b, by Masada classification. Distraction the ulna, resection of exostosis and reconstruction of the distal part of the interosseous membrane was performed. Results: One year later, the patient experienced good evaluation. Wrist flexion was 70°, extension 60°, radial deviation 20° and ulnar deviation 30°. Forearm pronation was 60o, supination = 90°. Elbow flexion = 120°, extension = - 5°. DASH = 5, VAS = 0 and grip strength = 92% of non-affected side. Forearm radiographic aspects showed healing the distraction, articular congruency the DRUJ and radiocapitellum joint. The distraction distance was 28 mm, the distraction period was 67 days, the consolidation period was 96 days, the period of fixator treatment was 92 days. The distraction speed was 0.5 mm/day. Conclusions: This method is safe and we can obtain the stability and joint congruency of the DRUJ and Elbow. The good radiographic, clinical and functional results were obtained, then, improved life quality of that patient. Acknowledgements: Translation service provided by Sandra Miaguti .


  PP 283: Ilizarov upper limb lengthening in congenital and aquired pathologies: Limitations and complications Top


Evgeny B Grebenyuk, Magomedsaigit O Muradisinov, Liudmila A Grebenyuk

Russian Ilizarov Center, Kurgan, Russia

Background: Upper limb lengthening is not as frequent compared to that of lower limb. Upper extremity length discrepancy does not cause severe functional impairment in mild to moderate cases. Although deformed and shortened upper limb result in significant cosmetic defect in. such patients. The purpose of the study was to determine the limitations and benefits of the Ilizarov lengthening method applied on upper limb. Methods: We reviewed 48 cases of Ilizarov upper limb lengthening, including 39 forearms and 9 humerus lengthenings. Results: The amount of lengthening in humerus group exceeded that of the forearm significantly (7.5 cm versus 4.8 cm respectfully). The complication rate was higher in forearm group, where main limitation observed was the finger flexion contracture. Humerus lengthening, on the other hand, did not demonstrate as many complications as anticipated, including a good elbow joint recovery. In some congenital forearm cases, bone regeneration was significantly compromised, which was not seen in acquired and humerus lengthening cases. The radial nerve neuropathy rate did not differ between forearm and humerus groups. Conclusions: Ilizarov upper limb lengthening can be indicated in significant deformity and/or limb length discrepancy. Forearm lengthening is limited by finger flexion contracture, especially in cases of congenital deformity. Humerus lengthening in our study did not result in higher risk of radial nerve neuropathy compared to forearm lengthening. Acknowledgements: N/A


  PP 284: Bilateral Humeral Lengthening In Achondroplasia Top


ANNA Isart, Pilar Rovira, Jordi Tapiolas, Ignacio Ginebreda

HOSPITAL UNIVERSITARI QUIRON - DEXEUS, Barcelona, Spain

Background: Patients with achondroplasia have upper extremities shorter at the expense of the humerus segment. Elongation provides a better overall skeletal proportionality and significantly improves their access to their perineal region to make their own personal hygiene. The purpose of this study is to describe the method and results of our series of humeral lengthening in achondroplastic patients. Methods: A retrospective study of 55 patients with short stature with achondroplasia, in which bilateral humerus lengthening was performed from 1989 to 2015. We obtained pre-and postoperative radiographic measurements. We contacted patients by telephone to complete a questionnaire regarding their satisfaction, hygiene and functional status. Results: There were 110 humerus, in 28 males and 27 females, with a medium elongation of 9.9 cm in right side and 9.5 cm in the left side, with an average of 220 days of external fixator. There were 2 problems and 12 obstacles. The average distance between the pin and the second proximal osteotomy was 1.5 cm, with no significant differences between the pin position and type of callus elongation. In most cases, these were external or straight callus. Before elongation, 77.1% of patients had trouble making their perineal hygiene and 85.4% could not put their hands inside their pockets. Upon completion of the lengthening, 100% of patients could perform both tasks and 94,5% of patients were very satisfied with the procedure. Conclusions: The elongation of the humerus in achondroplastic patients is a technique that aims to restore more functional-cosmetic upper extremities, achieving significant improvements in the autonomy and quality of life of patients, with a relatively low complication rate and a very high patient satisfaction. Acknowledgements: Our thanks to all patients for the participation and all members of our team, especially Miriam Garcia.


  PP 285: The Ilizarov Technique For The Treatment Of Congenital Absence Of The Radius----Treatment Experience In 8 Cases Top


Qin Sihe

National Research Center for Rehabilitation Technical Aids, Beijing, China

Background: A retrospective analysis of the clinical effect of Ilizarov technique for the treatment of congenital absence of the radius, to investigate the congenital absence of the radius reconstruction strategy. Methods: From May 1984 to December 2014, 471 cases with upper limb malformation accepted orthopedic surgical treatment in Qin Si he orthopaedic surgical department. Follow-up 8 cases of the patients with congenital absence of the radius.There were 6 males and 2 females in the study, with a minimum age of 7 years and a maximum age of 24 years (range) in all of the 8 cases.Before surgery,the cases were presence of radial deficiency, dislocation of wrist radial deviation of bending, forearm shortening, thumb disability.The surgical treatment is divided into three steps:1.The palm bone and ulna needle mounted Ilizarov ring type external fixator, drafting soft tissue of forearm, wrist radial deviation correction of dislocation;2.The ulna osteotomy and prolonging the forearm, if not longer forearm after osteotomy with fixation of wrist, forearm soft tissue relaxation to continue drawing.3.The center of the wrist and distal ulna fixation.10 demolition of children under the age of external fixation with multiple subcutaneous needle temporary fixation, forearm maintained 2 years after AIDS wrist fusion, external fixator used in all China products . Results: 8 cases were followed up, the trilogy of reconstruction of congenital absence of the radius (stick hand) deformity, all achieved satisfactory results with no complications affecting hand function appeared. Conclusions: Sinicized Ilizarov technology for the treatment of upper limb deformities and hand deformities, create a minimally invasive, simple, efficient, low cost of medical care model.Trilogy therapy for stick hand is simple, minimally invasive medical method.The medical process can be controlled, does not affect the original function of hand. The slow distraction is a tremendous force, comply with the laws of nature, with strange effects. Acknowledgements: [Key words] Ilizarov technique, congenital absence of radius, deformity correction


  Regenerating agents of articular cartilage Top



  PP 286: Autologous Chondrocyte Implantation In The Elbow – : Elbow Radio-Capitellar MACI. Results In 21 Cases Top


Minoo Keki Patel

Centre for Limb Reconstruction, Melbourne, Australia

Background: MACI is Matrix Assisted Autologous Chondrocyte Implantation. MACI can be used to treat chondral lesions in the elbow including osteochondritis dissecans (OCD) and traumatic chondral injury, both of which are common in the lateral compartment of the elbow. We present our series of 21 cases. Methods: We collected prospective data in 21 cases of capitellar chondral MACI. The size of the lesion was documented. The function of the elbow was documented with range of movement, DASH and Mayo scores. All cases had an MRI scan at 12 months post MACI. Arthroscopic or open technique is used to debride the lesion and harvest cartilage, usually from the detached fragment and the borders of the lesion. A chondral explant the size of a 'tic-tac' (7 x 3 mm) generally suffices. Cartilage from OCD lesions is generally of poor quality unless the injury is fresh, and should be supplemented from explants from the OCD crater edge. The chondrocytes are grown in the lab and later transferred to a collagen patch for implanttion. Replantation is performed using an open technique. Results: All cases regained functional range of movement and returned to pre-injury activities. post injury MRI scans at 12 months showing incorporation of the graft though minor signal changes persisted. Conclusions: MACI is a reliable technique for treating chondral lesions in the elbow. Acknowledgements: Nil


  PP 287: Charcot ankle Top


Gamal Hosny

Benha Univeristy, Cairo, Egypt

Background: Charcot arthropathy continues to be a challenging problem for orthopaedic surgeons. Untreated or improperly treated Charcot feet or ankles may lead to deformity, callosities over areas of excessive weightbearing, ulceration, sepsis, and amputation. Methods: 67 cases with Charcot ankle arthropathy were treated with single stage procedure & application of Ilizarov externa fixation.There were 3 bilateral cases. In 19 cases with osteomyelitis resection of the infected bone, deformity correction with circular external fixation, and culture-specific parenteral antibiotic therapy. There was ulceration on the lateral side of the ankle in 13 cases.The average age was 44 years [range 20 – 78 years].Bone gap more than 3 cm was evident in 9 cases which required bone transport. Results: Tibiotalar or tibiocalcanean fusion was achieved in 59 cases.The average follow up was 6 years[range 1 -15 years]. The average AOFAS score improved from 25.4 preoperatively to 64.3 postoperatively (p < 0.05). There was marked improvement of the postoperative satisfaction rate. Conclusions: Ilizarov method is a valid option for treatment of Charcot ankle arthropathy.


  Basic Research Top



  EP 1: Biomechanical investigation of different frames of 3D unilateral external fixation device with 3 components Top


Milan Milorad Mitkovic

Orthopaedic and traumatology clinic, Clinical center Nis, Nis, Serbia

Background: The goal of this study was to compare suitabilities of different frames of external fixator. with parallel pins, external fixator with convergently oriented pins, with carriers of clamps and without carriers of clamps. Methods: As material we used simple 3D unilateral external fixator with 3 components. This device provides possibility of forming of many different frames as each component can be connected to one or two other components on 2-3 different ways. Frames were applied on bones models - plastic tubes (Iuvidur). Gap on fracture area was 8 mm. On these bone model's fragments, there were applied 100N of force, in 2 directions. perpendicular on long axis of bone models, with position in 2 planes (plane A and plane B) perpendicular to each other. In the frame of fixator with parallel pins one of these directions was in the plane of all pins, while in the frame with convergent pins directions were in the plane of one of pair of pins. At the same time there were measured fragments movements produced by the loads used . Results: It has been obtained following results. in fixator with parallel pins, all in one plane, stability is 4 times bigger in the plane of the pins then in perpendicular plane, while stability in 90 degrees convergent orientation, stability is nearly same in both planes. According to the literature, external fixator with convergent pins has similar stability as Ilizarov external fixator. Conclusions: External fixation device with 90 degrees convergent pins gives balanced 3D stability similar to natural long bones and similar to Ilizarov system. Acknowledgements: There were no any conflict of interest.


  EP 2: Comparative Study Of Tightening Torque Of Fixed-Wire Screw Used In External Circular Fixator – Ilizarov Top


Guilherme Valdir Baldo1, Mario Cavalcanti De Albuquerque1, Gracielle Cardoso1, Renato Amorim1, Carlos Rodrigo Roesler2, Jonathan Silva1

1. Hospital Governador Celso Ramos, Florianópolis, Brazil

2. Universidade Federal de Santa Catarina, Florianópolis, Brazil

Background: The proper functioning of the Ilizarov device depends mainly of the wire tensions, and its maintenance is responsible for micro movements and compressive loads. Evaluate if different torques applied to wire fixation influence the maintenance of the pre-tension applied to wires, through the evaluation of its sliding, when subjected to static axial loads.Methods: 15 specimens composed of a ring of 180mm, a smooth 1.8mm wire attached to the ring along its diameter by eccentric wiring after a tension of 110Kgf. Three sets of ring / wire / fixed-wire screw system were analyzed with a sample of 5 sets in each group (n = 5). In group 1, torque of 10 N.m was applied; In group 2, 14 N.m, and 18 N.m for the group number 3. For every group, it was used a metal ring with internal radius of 180 mm and plain guide wire with a diameter of 1.80 mm. The systems were assembled by the same surgeon and the torque value was controlled using an E-Torc A torque wrench. All tests were performed in a Universal Mechanical Testing Machine (Emic - mod. DL3000), the load cell used being 500N, model Z500 / 10317028. The statistical analysis of the data was performed through a hypothesis test - Kruskal-Wallis ANOVA. Results: The characteristic failure mode for each specimen was plastic deformation. The five models that were submitted with a torque of 10N, the force average required to obtain the displacement of 29 mm was 1576.82N and the average slip was of 7.64mm. However, the specimens that had been applied the torque of 14N, the average force required to obtain the displacement of 29 mm was 1637.92 N and the average slip was of 7, 61mm. Finally, the specimens that had been submitted to a torque of 18N, the main force required to obtain the displacement of 29 mm was 1640.82 N and the average slip was of 7.86 mm, noting that two specimens didn't have their test completed due to wire breakage. Conclusions: In this study, the data did not show statistical significance in relation to the torque applied to each group and the slip of the wire. Therefore, even not showing a statistic difference, the results dhows a tendency that heavier torques (more than 10N) need a bigger axial force to promote sliding of the wire. The experiment evaluated the behavior of the models when submitted to a static load. In order to try to simulate the clinical conditions of the patient, it would be necessary to continue this research. Acknowledgements: I declare there is no conflict of interests


  EP 3: Tourniquet Release In Total Knee Arthroplasty - What Is The Best Strategy? Top


Pedro Teixeira Mota1, António Lemos Lopes2, Marta Maio2, Rita Sapage2, Carlos Pintado1

1. Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal

2. Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal

Background: Total Knee Arthroplasty (TKA) is one of the most common orthopedic procedures performed worldwide and generally is done using a tourniquet. The ideal time for tourniquet release is not consensual and there are two different strategies. tourniquet release before wound closure and tourniquet release after wound closure and appropriate dressings. In theory, the first strategy allows hemostasis before wound closure, which decrease postoperative bleeding and hence, the need for blood transfusion, but several studies have failed to demonstrate this advantage. Methods: A retrospective study was conducted and every primary TKA performed in our institution in 2015 were included. The patients were included in one of two groups. early tourniquet release and late tourniquet release, meaning tourniquet release before wound closure and tourniquet release after wound closure and dressings. The split was non-randomized and made upon surgeon preference. The two groups were characterized according to gender, weight and height, body mass index (BMI) and osteoarthritis degree. Postoperative pain (highest value in the first 24h) was compared. Preoperative hemoglobin and hematocrit levels were recorded and compared with postoperative values. Blood transfusion was also recorded. To determine blood loss Mercuriali's formula was used. Results: 113 patients were included in the study. 45 were in the early opening group and the other 68 in the late opening group. The two groups were similar in gender, age, weight, height, BMI and arthritis degree. Postoperative pain was 3,33 in the early release group and 3,59 in the late release group, which did not represent statistical difference. The average blood loss was 545 mL in the first group and 497 mL in the second, not demonstrating statistical difference. The need for transfusion was similar between the two groups, with 10 patients being transfused with two blood units in each group. We found statistical difference in the average time for surgery, lasting 59 minutes in the early release group and 53 in the late release group. No major complications were found. Conclusions: According to our study, early tourniquet opening does not decrease blood loss, transfusion needs nor postoperative pain in patients submitted to primary TKA and is associated with a prolonged surgical duration. We present here a retrospective, non-randomized study with a relatively small sample, which we consider as limitations of the study. Acknowledgements: The authors has nothing to disclose


  EP 4: Porcine Brain Extract Promotes Osteogenic Differentiation Of Mesenchymal Stem Cells And Bone Consolidation In A Rat Distraction Osteogenesis Model Top


Gang Li1, Jia Xu2, Yimin Chai3

1. The Chinese University of Hong Kong, Shatin, Hong Kong SAR

2. Department of Orthopaedic Surgery, Shanghai, China

3. Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China

Background: Distraction osteogenesis (DO) is the gold standard to treat large bone defects, but long consolidation period is a major limitation. Innovative efforts to promote osteogenesis are needed. Porcine brain extract (PBE) was reported to enhance the proliferation and differentiation of multiply primary cells. In this study, we aimed to develop a method for collecting PBE and investigate its effects on osteogenic differentiation of rat bone marrow derived mesenchymal stem cells (rBMSCs) and bone consolidation in a rat DO model. Methods: The PBE was collected from neonatal brain tissues of porcine fetus and was used to treat rBMSCs. Following PBE treatment (700 ng/ml), osteogenic differentiation was accessed. Further, we locally injected PBE (7 μg/ml, 100μl) or PBS (100μl) into the gap in a Sprague-Dawley (SD) male rat DO model every three days till termination. X-rays, micro-computed tomography, mechanical testing, histology and immunohischemistry examinations were used to exam the quality of the regenerates. Results: The alkaline phosphatase, calcium deposits, and steogenic markers in the PBE treated rBMSCs were significantly increased. In the rat model, new bone properties of bone volume/total tissue volume and mechanical strength were higher in the PBE treated group. Histological analysis also confirmed more mineralized bone after PBE treatment. Conclusions: The current study reports a standard protocol for PBE collection and demonstrated its positive effects on osteogenic differentiation and bone consolidation in DO. Since the PBE is readily available and very cost effective, PBE may be a potential new bio-source to promote bone formation in patients undergo DO treatment. Acknowledgements: This study was supported in part by SMART program, Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong and the research was made possible by resources donated by Lui Che Woo Foundation Limited.


  EP 5: Human Fetal Mesenchymal Stem Cell Secretome Enhances Bone Consolidation In Distraction Osteogenesis In Rats Top


Gang Li1, Jia Xu2, Xiaohua Pan2, Yimin Chai3

1. The Chinese University of Hong Kong, Shatin, Hong Kong SAR

2. Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shenzhen, China

3. Shanghai 6th People's Hospital, Shanghai, China

Background: Distraction osteogenesis (DO) is one of the most dramatic reconstructive technique for inducing bone regeneration, but it involves an undesirably long period for bone consolidation. Developing innovative approaches to enhance bone consolidation is in burning need. Human fetal mesenchymal stem cells (hFMSCs) have been shown to express more primitive developmental genes than those of human adult mesenchymal stem cells (hAMSCs), which is a preferable source for cell therapy and tissue regeneration. In present study, we investigated the immunogenicity of using human mesenchymal stem cells (MSCs) secretome on rat cells, the effects of secretome on osteogenic differentiation of rat MSCs (rBMSCs), and the potential application of hFMSCs secretome in promoting bone consolidation in a rat DO model. Methods: Secretome was collected from MSCs culture and was used to treat rBMSCs. Following secretome treatment, cell proliferation, alkaline phosphatase, Alizarin Red S staining, and mRNA expression of osteogenic differentiation related genes including ALP, Runx2, OCN, OPN, and Osx in the rBMSCs were checked, as well as mixed rat peripheral blood lymphocyte reaction. hFMSCs secretome was injected locally into the regenerates at the end of lengthening every 3 days in the rat DO model, till termination. The regenerates were subject to weekly X-rays, micro-computed tomography (μCT) and mechanical testing examination. The bone quality was assessed by histology and immunohistochemistry examinations. Results: Compared to the secretome from rBMSCs and hAMSCs, hFMSCs secretome had the best osteogenic induction ability and low immunogenicity. hFMSCs secretome with different doses showed no effect on cell viability. hFMSCs secretome at the dose of 100 μg/μl could significantly increase the expression of alkaline phosphatase and all the osteogenic marker genes, as well as the amount of calcium deposits in the rBMSCs. Finally, the local application of hFMSCs secretome in distraction regenerates in a rat DO model significantly improved bone consolidation according to the results of μCT, mechanical test, histological and immunohistochemistry analysis. Conclusions: The current study demonstrated that hFMSCs secretome promotes osteogenesis of rBMSCs and bone consolidation during DO. hFMSCs secretome may be a new therapeutic strategy to enhance bone consolidation in patients undergoing DO treatment. Acknowledgements: The work was partially supported by grants from National Natural Science Foundation of China (NSFC No.81371946, 81374568) to Gang Li. Hong Kong Government Research Grant Council, General Research Fund (CUHK470813 and 14119115) and a project grant from China Shenzhen City Science and Technology Bureau (JGJHZ20140419120051680 and JCYJ20150630165236960) to Gang Li are gratefully acknowledged. This study was also partly supported by SMART program, Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong.

Complications of osteotomies and lengthenings


  EP 6: High Tibial Open Wedge Osteotomy Nonunion Management - Case Report Top


Pedro Teixeira Mota1, António Lemos Lopes2, Marta Maio2, Rita Sapage2, Carlos Pintado1

1. Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal

2. Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal

Background: High tibial osteotomy (HTO) is a well-established procedure for the treatment of unicompartmental osteoarthritis of the knee. Although known to be successful, osteoarthritis often progresses and some patients will need a total knee arthroplasty (TKA). Methods: We present the case of a patient submitted to HTO of the right knee, the complications we faced and its treatment. Results: A 58-year-old male patient, diagnosed with bilateral unicompartmental osteoarthritis of the knee was submitted to a medial opening wedge HTO of the right knee. Six months after the surgery the patient refered worsening of the pain in the medial compartment of the knee. The x-ray showed nonunion of the osteotomy with failure of the two proximal screws. The patient was submitted to TKA, with a cemented prosthesis and an adicional cemented tibial stem was used. Autologous cancellous bone graft, harvested from the bone fragments from the osteotomies was used as well. After eight months of follow-up, the patient complains of occasionally knee pain, walks without walking aids and has a KSS of 89. The x-ray shows union of the previous site of osteotomy and a good lower limb alignment. Conclusions: The amount of HTO performed has declined significantly in recent years, whereas total and unicompartmental knee arthroplasties has steadily increased (1). However, HTO remains a good option in young, heavy duty workers, which represents our population. Although there are a considerable number of studies reporting similar outcomes of TKA converted from HTO (3, 4), nonunion is a described complication of the procedure. Conversion to TKA seems the best treatment option for these cases but it can be challenging. The surgeon must be prepared to find considerable bone defects and to use adicional fixation elements. Acknowledgements: The authors has nothing to disclose


  EP 7: The Treatment Of Cubitus Valgus Using The Ilizarov Technique Top


Prof Md. Mofakahkharul Bari

Bari-Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Background: Cubitus valgus is the most common complication of lateral condylar fractures. Various combinations of osteotomy and fixation have been described to correct valgus deformity. Methods: We are using distraction osteogenesis with Ilizarov technique to treat 11 elbows in 11 patients with cubitus valgus. The clinical outcome was evaluated using the protocal of Bellemore et al. Results: The mean time to follow up was 20 months (15 to 35) and the mean time to Ilizarov frame removal was 14 weeks (10 to 18). Conclusions: The mean carrying angle was corrected from 35° (25° to 40°) to 10.4° (5° to 15°) in patients with cubitus valgus. There were 8 excellent and 3 good results. Acknowledgements: Keywords. Cubitus valgus; Ilizarov; Osteotomy


  EP 8: The Importance Of Post-Polio Knee Recurvatum In The Gait Pattern - Knee Recurvatum Femoral Osteotomy In A Polio Patient Top


João Maia Rosa1, Luis Lopes Coutinho1, Diogo Marques Pascoal2, João Esteves1, Adélio Vilaça1, Paulo Pereira1

1. Centro Hospitalar do Porto - Hospital Santo Antonio, Porto, Portugal

2. Centro Hospitalar da Cova da Beira, Covilha, Portugal

Background: Poliomyelitis is a disabling disease. Despite substantial progress toward its irradication, acute and residual poliomyelitis is still present nowadays. Deformities are due to muscle weakness and poor posture. The genu recurvatum occurs due to lack of power in the quadriceps to lock the knee in extension during gait, as a mild degree of hyperextension of the knee confers stability due to the anatomical self-locking mechanism. Osteotomies for correction of deformities around the knee joint not only corrects the deformity but also improves life's quality. Methods: We introduce a case of a 55-year-old man with polio, who suffered a supracondylar fracture of the left femur submitted to ORIF with plate and screws. Due to gait difficulties, he underwent knee realignment surgery - varization osteotomy. After surgery, the patient has never been able to perform gait without external support, and was unable to support the weight of the body on the limb due to the collapse of the knee. It was observed that the correction was made only on the sagittal plane. So, the new alignment led to a modification in the gait pattern due to imbalance of muscular forces, with marked instability. He was then submitted to anterior wedge osteotomy in the femur, and the “native” recurvatum was restored. At 3 years post-op, the patient is able to walk without external support or orthosis. Results: The gait pattern of patients with polio sequelae is very particular and depends on the dynamic balance between osseous and muscular structures. Quadriceps strength deficit is compensated by the hamstring constraint, allowing the locking of the knee in extension. In this case, the knee collapsed after the sagital alignment osteotomy, because there was no consideration about the coronal axis. By performing a distal femoral recurvatum osteotomy the anterior femoral bow of the femur is converted into a posterior bow and the knee will then lie behind the line of body weight Stability relies on the integrity of the posterior soft-tissue structures, so soft-tissue release should only be carried out in the presence of a severe flexion contracture. Conclusions: The surgeon managing the residual weakness of poliomyelitis and postpolio syndrome must have a deep understanding of its pathologic process, and implications in limb alignment, muscle imbalance and gait. Acknowledgements: The author have nothing to disclose

Congenital dislocation of the hip


  EP 9: Dega Osteotomy For The Management Of Developmental Dysplasia Of The Hip In Children Aged 2–8 Years: Results Of 58 Cases After 13-25 Years. Top


Mohamed El-Sayed1, Mohamed Hegazy2

1. Tanta University, Tanta, Egypt

2. Cairo University, Cairo, Egypt

Background: Developmental dysplasia of the hip (DDH) is a term used to cover a broad spectrum of anomalies ranging from mild dysplasia to high-riding dislocations. We report the management of DDH in children using the Dega osteotomy and their long-term follow-up. Methods: Fifty-eight hips from 48 children younger than 8 years treated using the Dega osteotomy between January 1988 and October 2000 were included in this multcenter study. Both prospective (41 hips) and retrospective (17 hips) cases were included, and follow-up was for a mini- mum of 13 years. Radiographs were made preoperatively, immediately postoperatively, after 6 weeks or at removal of the spica cast if any, at 6-month intervals and/or as indicated for 3 years postoperatively and then on annual basis until the last follow-up. A single-cut computed tomographic scan was performed for all prospective patients. Special attention was paid to the predictive measures of hip arthrosis and the survival of the hip after Dega osteotomy. Results: he final clinical outcome was favorable in 44 hips (75.9 %). Eleven hips needed a second surgery (acetabuloplasty and/or arthroplasty) during the follow-up period. Conclusions: In our pediatric patient population the Dega osteotomy proved to be an adequate measure for the management of this complex condition. The worst com- plication was avascular necrosis, and all of the affected hips ended with failure (pain, another surgery, or both). Acknowledgements: Cairo University. Tanta University


  EP 10: Ilizarov Hip Reconstruction Or Pelvic Support Osteotomy For Treatment Instability Of Hip Top


Prof Md. Mofakhkharul Bari

Bari-Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Background: Instability of the hip joint can be secondary to congenital pathologies like displastic dislocated hip (DDH) which are neglected and proximal femoral focal deficiency or acquired such as sequelae of infective or neoplastic process. An unstable hip is usually associated with loss of bone from the proximal femur, proximal migration of the femur, lower extremity length discrepancy, abnormal gait and pain. Ilizarov hip reconstruction or Pelvic support osteotomy (PSO) remains to be one of indicated surgical procedure to improve function of hip and gait. Goal of this presentation is evaluation of results; clarify indications, details of procedure and long-term follow-up. Methods: Since 1990, 35 patients with unilateral instability of the hip underwent Ilizarov PSO procedure. The age ranged from 6 to 40. Cause of femur instability was CDH 12; defect of femoral head, nonunion/defect of the neck of the femur 23. Mono level abductive osteotomy was performed in 9; double level (abductive in proximal part with varizational in diaphyseal part osteotomy) was done in 26. All patients were reviewed clinically at a followup time from 1 to 15 years. Results: Leg length discrepancy and mechanical alignment was reestablished in all cases. Complete improvement of Trendelenburg's sign was achieved in 30; Improvement of ROM, lumbar lordosis and gaits was achieved in 25 patients. All patients (35), who had pain syndrome before treatment mentioned improvement in short-term follow-up, but 8 (mostly age 35 and up), complained of pain in later period. Outcome were evaluated clinically by Harris hip scoring system. Conclusions: PSO presents valuable solution for treatment of instability of hip. Results of surgery should be estimated after extensive physical therapy directed for improvement of abductor function and resetting gait reflexes. Teenagers and young adult's patients can expect superior results. Patients should be well informed that procedure is not restoring anatomy of hip, and in future THR must be taken into consideration, which might conduct certain technical difficulties. However, majority of our patients significantly improved their living standards, and none of patients from our data underwent THR after Ilizarov PSO. The Ilizarov hip reconstruction osteotomy can successfully correct a Trendelenburg gait by stabilizing the hip and supporting the pelvis and simultaneously restore knee alignment and correct lower extremity length discrepancy. Acknowledgements: Dr. Md. Shahidul Islam, Prof. MD; FCPS, Bari-Ilizarov Orthopaedic Centre. Dr. Nazmul Huda Shetu, M.S (Ortho), Consultant, Bari-Ilizarov Orthopaedic Centre. Dr. Md. Mahfuzer Rahman, D. Ortho- Consultant, Bari-Ilizarov Orthopaedic Centre.


  EP 11: Total Hip Arthroplasty In Patients With Multifactorial Perceived Limb Length Discrepancy: Surgical Approach And Outcomes Top


S Robert Rozbruch1, Amgad M Haleem2, Kevin Wiley3, Raul Kuchinad4

1. Hospital for Special Surgery, New York, United States

2. Cairo University, New York, Egypt

3. University of Oklahoma Health Sciences Center, Oklahoma, United States

4. Calgari University, Calgari Alberta, Canada

Background: Patients with advanced hip arthritis can present with multifactorial limb length discrepancies (LLD) due to bony shortening from growth arrest, proximal hip migration, soft tissue contractures and pelvic obliquity. The patient perceives a LLD that is a combination of true LLD and apparent LLD. Methods: We retrospectively reviewed 7 cases with multifactorial perceived limb length discrepancy of 7.7 cm (range 3.6 to 11 cm) that underwent primary total hip arthroplasty (THA) and auxiliary soft tissue procedures. These patients included 5 males and 2 females; the mean age was 47.9 +/- 15.8 years at the date of surgery. Perceived LLD, true LLD, and apparent LLD were defined and were compared before and after surgery in this cohort of patients with a mean follow up of 57.4 months. Results: The mean perceived LLD at final follow up was 1.02 + 0.91 cm compared to 7.67 + 2.55 cm pre-operatively (p<0.05). Post-operative true LLD was 0.65 + 0.76 cm compared to 3.17 + 0.79 cm pre-operatively (p<0.05). At final follow up, all 7 patients were ambulating without any assistive devices and were satisfied with their surgical outcome. There were no injuries to the sciatic nerve. Conclusions: With careful pre-operative clinical and radiographic assessment as well as planning for multifactorial perceived LLD, this can be adequately corrected with primary THA and auxiliary soft tissue procedures resulting in good radiological and functional outcomes. The large apparent acute increase in leg length did not result in sciatic nerve injury since only modest increase in true leg length was performed. The rest of the correction was that of apparent LLD from pelvic obliquity, adduction contracture, and flexion contracture, which did not stretch the sciatic nerve. Acknowledgements: I am a consultant for Smith and Nephew, Nuvasive, and Stryker

Correction of Limb length inequality and cosmetic limb lengthening for short stature in adults


  EP 12: Bilateral High Tibial Osteotomy To Realign Lower Limb Mechanical Axis Top


Pedro Teixeira Mota1, António Lemos Lopes2, Marta Maio2, Rita Sapage2

1. Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal

2. Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal

Background: Varus knee is one of the most common anatomical variation affecting musculoskeletal system and is extremely frequent in pediatric age. Usually, newborn knees are varus, shifting to a neutral aligment at the age of two and to the adult physiological valgus at the age of three. Varus knees beyond this age can represent an anatomical physiological variation or can be pathological, as in Blount disease, systemic diseases (rickets), bone dysplasia, trauma, infection or neoplasms. Methods: We describe the case of a 21-year-old male patient, with bilateral varus knees, submitted to surgical correction of the deformity. Results: The patient complained of an excessive bowing of the lower limbs, with cosmetic implications. He also referred bilateral medial compartment pain, which represented some limitation to his sport activities. Physical examination showed bilateral varus knee. Lower limb mechanical axis demonstrated medial compartment overload. The patient was submitted to bilateral high tibial opening wedge osteotomy and a neutral mechanical axis was attained. Two years after the surgery the patient is asymptomatic. He has a Knee Society Score of 100 and maintain a neutral mechanical axis of lower limbs. Conclusions: Most of the time, varus knee represents an anatomical variation and not a deformity, thus not requiring any therapeutic attitude. Nevertheless, varus knee poses medial compartment over stress load, which can cause degenerative changes, predisposing to knee osteoarthritis. Additionally, changes in patellofemoral joint in individuals with varus knee are described, being this variation a risk factor for patellofemoral pain in athletes. Since it is a fairly common deformity, it is critical to determine whether varus knee represents a physiological condition or a pathological process, once prognosis and treatment differ considerably. In young adults with varus knee and medial compartment overload, high tibial opening wedge osteotomy is an effective method of lower limbs mechanical axis alignment. Acknowledgements: The authors have nothing to disclose


  EP 13: A Guide For The Placement Of The Proximal Pins In Femoral Lengthening Over An Intramedullary Nail Top


Ignacio Ginebreda1, Mercedes Reverté2, Anna Isart1, Pilar Rovira1, Jordi Tapiolas1

1. Hospital Universitari Dexeus, Barcelona, Spain

2. Hospital de la Vall D'Hebrón, Barcelona, Spain

Background: The aim of this study is to report our experience with femoral lengthening over an intramedullary nail and monolateral external fixation using a newly designed guide for the placement of the proximal pins of de monolateral fixator. Methods: Twenty-seven patients with femoral length discrepancy underwent femoral lengthening by a technique of femoral lengthening over a guided intramedullary nail. We studied demographic information, the number of prior surgeries, discrepancies in centimetres, the presence of another mechanical deviation, intraoperative data, the distraction process, nailing and complications. Results: Twenty-seven patients underwent femoral limb lengthening (twenty men and seven women). The mean age at the time of the surgical procedure was 25,6 years (range, twelve to forty-nine years). The aetiology of leg-length discrepancy was posttraumatic in 18 cases, dysplasia in 8 cases and poliomyelitis in one case. Twenty- four patients (88.9%) underwent lengthening over an anterograde intramedullary nail, and three cases (11.1%) underwent retrograde nailing. The mean values obtained were as follows. femoral limb length discrepancy, 43.85 mm (SD. 18.02); duration of external fixation, 60.41 days (SD. 18.86); external fixation index, 19.8 (SD. 4.8); femoral lengthening, 39.28 mm (SD. 16.80; range. 4.56-75 mm); and healing index, 48.3 days per cm (SD. 22.6). We encountered 9 complications (1 pin track infection, 1 deep infection, 2 joint contractures, 2 delayed unions, 1 premature consolidation and 2 axial deformities). Conclusions: Femoral lengthening over an intramedullary nail with monolateral external fixation has certain advantages such as a decrease in the time of external fixation and therefore, a lower risk of infection and improved recovery with regard to the functionality of the hip and knee joints. Acknowledgements: Our thanks to all patients and all members of our team


  EP 14: Cost Comparison Of Femoral Distraction Osteogenesis With External Lengthening Over A Nail Versus Internal Magnetic Lengthening Nail Top


S Robert Rozbruch, Shawn Richardson, William Schairer, Austin T. Fragomen

Hospital for Special Surgery, New York, United State

Background: Lengthening of the femur has classically been performed by utilizing distraction osteogenesis via the lengthening over a nail (LON) technique. However, the invention of the magnetic lengthening nail (MLN) has led to a shift towards internal lengthening techniques. Internal lengthening avoids the complications of external fixation, such as pin tract infection and skin traction, while providing accurate and easily controlled lengthening. Nonetheless, the relatively high cost of these implants has led many to question whether they are cost-effective compared to LON. Methods: We performed a retrospective review of femoral lengthening patients who had either LON (n=19, 2005-2009) or lengthening with an MLN (n=39, 2012-2014). The number of surgical procedures, time to union, amount of lengthening, and total cost from the payer perspective, including all surgical procedures and associated inpatient and outpatient visits, were compared. Results: There was no significant difference in demographics between the MLN and LON cohorts. The total length distracted was similar between groups (38.5 vs 41.4 mm, p=0.595). The patients treated with a MLN underwent fewer surgeries (2.5 vs 3.6, p=0.026) and had a shorter time to union (100.2 vs 136.7 days, p=0.001). The total cost to the payor was similar between groups ($49,696 vs $47,947, p=0.873). Conclusions: Treatment with MLN leads to on average one fewer surgical procedures and a shorter time to union compared to LON. Despite concerns regarding implant costs, the total cost from the payer perspective was similar between the two techniques. Given the clinical benefits to the patient with MLN, including avoiding complications associated with prolonged external fixation, fewer surgeries, and a shorter time to union, MLN is similarly if not more cost-effective when compared to LON. Acknowledgements: I am a consultant for Smith and Nephew, Nuvasive, Stryker


  New procedures and apparatus Top



  EP 15: External Bi Articular Fixation Of The Shoulder In A Convulsive Patient Top


Paulo Sérgio Contador Miras

Hospital Municipal Dr Mario Gatti, Campinas, Brazil

Background: n/a. Methods: We describe in this work a new technique of external bi articular fixation of the shoulder, a technique used in a case to complement the surgical treatment of previously non-resolved problems, which is the shoulder stabilization surgery in convulsive patients. For this technique, in addition to the conventional techniques of shoulder surgery for dislocations, we promote a stability and additional joint protection for these patients in their traditional postoperative period, since at this critical moment, these episodes may occur and new episodes of dislocation and loss of traditional reconstructions. We used the Ilizarov fixator with fixation on the scapula and clavicle for the proximal part and fixation of the humerus for the part distal to the joint, we described the technique of fixation with safety for neurovascular structures and double articulation, one that promotes the rotation and another the elevation of the Shoulder, without the need for prolonged immobilization that would lead to stiffness. We observed a good stability in the postoperative period, in spite of the fact that several episodes of seizures occurred, we did not obtain relapse of dislocations or loss of the traditional internal surgery, maintaining joint freedom. We suggest a classification for these cases. Results: We obtained good results with control of postoperative luxation rates despite several seizures occurred in this immediate period. Conclusions: We concluded that Ilizarov's device proved to be both versatile and effective, but further studies should be conducted for further statistics. Acknowledgements: There is not conflict of interests


  EP 16: Treatment Of Patella Fractures By Compressive External Fixation (CEF) Top


Md Mofakhkharul Bari

Bari Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Background: Recent traditional treatment of patella fractures is related with infection and failure of fixation. Methods: The complications that we see can be treated surgically which is cost effective and limits the function of the joint. But our locally made CEF device can effectively treat patella fractures with less complications. Results: The transverse fracture of patella with displacement was treated by compressive external fixation, based on Ilizarov tensioned wire construct. All the patients were allowed to do movements in the joints and weight bearing postoperatively. Eighteen fractures were treated with CEF. 11 patients were treated percutaneously. Sound union was achieved in all the fractures. Conclusions: The CEF device was removed at 6 to 8 weeks. 12 patients regained excellent motion with a mean Insall knee score of 96 points, in an average follow up of 4 years. Minor complications like wire inflammation was observed in 5 patients which was treated by local care and antibiotics. CEF technique is a safe and effective method of treatment in patella fractures with advantages over traditional methods in case with a poor soft tissue envelope. CEF allows rapid recovery and no secondary surgery is needed. Acknowledgements: Keywords:. CEF; Patella fracture


  EP 17: Use Of Physical Antimicrobial Spray For Pin Site Dressing A Double Blinded: Randomized Controlled Study. Top


Yeok Pin Chua1, Aik Saw2, Rukmanikanthan Shanmugan2

1. sunway university/ Sunway medical centre, Selangor, Malaysia

2. university malaya, Kuala Lumpur, Malaysia

Background: External fixation is a common device used for fracture stabilization, deformity correction and bone transport1. It provides relative stability, which allows fracture healing. Pin site infection is the most common complication of external fixation. There is no established protocol for pin site dressing which can reduce infection rate2. In our study, we will be comparing a physical antimicrobial spray to normal saline, to compare if there is a reduction in infection rate. Methods: We have included patients undergoing limb lengthening procedure or deformity correction from December 2013 to June 2014. The patients were randomized into 2 groups, Group A (JUC) and Group B (Normal Saline) respectively. The review of pin site is done at 2, 4, 8, 12 weeks after surgery. The pin site infection is done according to predetermined grading system. The results were compared using relative risk using. 95% confidence interval. Results: A total of 40 patients were included with 43 limbs. We have recruited 28 male patients and 12 female patients. We had 461 metal skin interfaces, with 1844 observations. Group JUC had 23 patients (24 limbs) and Group Normal Saline had 17 patients (19 limbs). Group JUC had on overall infection rate of 4.8% (n= 1016) as compared to Normal Saline, which had an overall infection rate of 14% (n= 828). The results showed to be statistically significant with a relative risk of 0.382 (0.250,0.584). A total of 28 males and 12 females we recruited in our study. The mean age group was 28 for JUC and 31 for Normal Saline. This age group of patients is also regarded as most prone to trauma and accident, hence contributing to the largest bulk of our study. Tibia fracture fixation formed the largest component of our study. Tibia being a common bone injured while an accident, common site for congenital anomaly and pseudoarthrosis makes it the largest component of our study. The trauma group had. an infection rate of 7.4% while the infected group had an infection rate of 9.2%. It was also statistically significant, (p < 0.001) with RR of 0.038. While comparing the other groups, congenital and developmental group had most number of infection at 10.6%. We used both the sprays using same protocol in the study. The JUC group had significantly lower infection rate 4.8% overall compared to Normal Saline which. had 14% , overall infection. Conclusions: The use of physical antimicrobial spray reduces the infection rate when used for pin site dressing. Acknowledgements: no conflict of interest


  EP 18: The benefits of osseointegrated reconstruction for post-traumatic trans-femoral amputees: Improvements in function and QOL Top


Kevin Tetsworth1, William Lu2, Vaida Glatt3, Munjed Al Muderis4

1. Royal Brisbane Hospital, Brisbane, Australia

2. Osseointegration Group of Australia, Sydney, Australia

3. University of Texas Health Science Center, San Antonio, United States

4. Macquarie University Hospital, Sydney, Australia

Background: Over the last two decades osseointegration reconstruction has emerged in an attempt to overcome the many issues associated with traditional socket-mounted prosthetics for amputees. By intimately connecting the artificial limb prosthesis to the residual bone, the problematic socket-residuum interface can now be potentially eliminated. The primary objective of this study was to assess the clinical outcomes and efficacy of this approach in post-traumatic unilateral trans-femoral amputees. Methods: Prospective case series of 32 post-traumatic unilateral trans-femoral amputees treated at a single center. The study included 25 males and 7 females, aged 24-67 (mean 46.8) years, with a minimum one-year follow-up. The main outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation (Q-TFA), the Short Form Health Survey 36 (SF-36), K levels, and the Six Minute Walk Test (6MWT) and Timed Up and Go (TUG) tests, pre- and post-operatively. Adverse events were recorded including infection, revision surgery, fractures, and implant failures. Results: Clinical outcomes were obtained pre- and post-operatively from 12 to 46 months, with a mean follow-up of 22 months. The mean post-operative values for all five validated outcome measures were significantly improved. Both the post-operative Q-TFA global score (46.88±3.51 to 83.62±3.47, p<0.0001) and the SF-36 physical component summary (36.89±1.81 to 48.49±1,69, p<0.0001) were markedly superior to those of the pre-operative values. K levels improved in 16 patients, and remained unchanged in 16 patients; no patient had a reduction in their K level (Chi2=16.01, df=2, p=0.0003). The 6MWT (193±31.67 to 434±23.78, p<0.0001) and the TUG (11.17±1.77 to 7.40±0.4, p=0.04) were also significantly improved. Conclusions: In these post-traumatic unilateral trans-femoral amputees, significant improvements were achieved in all of the outcome measures of health-related quality of life, ambulation ability, and functional levels. These findings are comparable to, or better than, those reported previously by other groups using alternative implants and rehabilitation protocols. Under the OGAAP-1 protocol the time interval between the initial procedure and fully independent ambulation was approximately 4.5 months. These results confirm the OGAAP-1 is a suitable alternative for post-traumatic unilateral trans-femoral amputees experiencing socket-related discomfort, with the potential to reduce recovery time compared to other staged treatment protocols. Acknowledgements: MAM discloses a financial relationship with the manufacture, distribution, and sales of the implants used in this study. The other authors (WL, VG, and KT) have no conflicts of interest to declare relevant to the current study.


  EP 19: Comparison of results following single stage and two-stage protocols for osseointegrated reconstruction and rehabilitation of lower-limb amputees Top


Kevin Tetsworth1, Munjed Al Muderis2, J Li3, William Lu3

1. Royal Brisbane Hospital, Brisbane, Australia

2. Macquarie University Hospital, Sydney, Australia

3. Osseointegration Group of Australia, Sydney, Australia

Background: Osseointegration has emerged recently as a novel approach for the reconstruction of amputated limbs. It overcomes many of the socket-related problems by directly attaching a prosthetic implant to the skeletal residuum. To date, the vast majority of osseointegration procedures worldwide have been performed in two stages, requiring at least 4 months and up to 18 months for the completion of reconstruction and rehabilitation from the time of the initial surgery. The study evaluates the safety and efficacy of a single-stage osseointegration procedure performed in our centres, which dramatically reduces the time of recovery to approximately 3-6 weeks. Methods: The inclusion criteria are age over 18 years and experiencing socket-related problems or difficulties in using a socket mounted prosthesis. Functional (Six Minute Walk Test, Timed Up and Go, and K-Levels) and quality of life (Questionnaire for persons with a Trans-Femoral Amputation, and Short Form Health Survey 36) outcome measures are recorded pre-operatively and at defined post-operative follow-up intervals up to 2 years. Post-operative adverse events (infection, revision surgery, fractures, and implant failures) are also recorded. The pre- and post-operative values are compared for each outcome measure, and the benefits and harms of the single-stage procedure will be compared to results obtained using our previously employed two-stage protocol. Results: Significant improvements for all outcome measures were observed compared to pre-operative values which were very similar to the results obtained using the two-stage procedure. The occurrence levels of adverse events including the infection rate and revision rate were also similar to the previously employed two-stage protocol. Conclusions: These preliminary results suggest that single-stage osseointegration surgery for lower limb amputees can be considered safe and effective treatment for those amputees experiencing socket-related discomfort. This protocol has the potential to shorten the rehabilitation time to 3-6 weeks, which dramatically reduces the total time of recovery and return to independent ambulation. Acknowledgements: MAM discloses a financial relationship with the manufacture, distribution, and sales of the implants used in this study. The other authors (RA, JL, WL, and KT) have no conflicts of interest to declare relevant to the current study.


  EP 20: Osseointegrated implants in patients with peripheral vascular disease: Preliminary results in a small series of five cases Top


Munjed Al Muderis1, R Atallah2, William Lu3, J J Li3, Kevin Tetsworth4

1. Macquarie University Hospital, Sydney, Australia

2. Radboud University, Nijmegen, The Netherlands

3. Osseointegration Group of Australia, Sydney, Australia

4. Royal Brisbane Hospital, Brisbane, Australia

Background: Osseointegration is an alternative treatment for amputees who have inability or difficulty wearing and using a traditional socket mounted prosthesis. Although the majority of limb amputations are due to vascular disease, this has always previously been considered an absolute contraindication for osseointegration surgery. For the first time, this case series reports the outcomes of osseointegrated reconstruction in patients with limb amputation due to peripheral vascular disease in Australia and the Netherlands. Methods: This is a multi-centre prospective case series with 12-month post-operative follow-up in patients with trans-tibial amputation and a history of peripheral vascular disease, who have received osseointegration implants during 2014–2015. Clinical and functional outcomes assessed included pain, prosthesis wearing time, mobility, walking ability, and quality of life. Adverse events were monitored and recorded, including infection, fractures, implant failure, revision surgery, further amputation and death. Results: Five trans-tibial amputees (aged 56–84 years) were included in the study cohort. All five patients were pain-free and using the osseointegrated prosthesis at 12-months post-operation. The mobility of all patients significantly improved at follow-up. Notably, three of the five patients were wheelchair-bound prior to osseointegration surgery, but all were able to walk again and perform daily activities. One patient experienced pain at the stoma site due to progressive peripheral vascular disease, which was treated successfully using vascular balloon dilatation. Two patients experienced a single episode of superficial soft-tissue infection treated with oral antibiotics. Conclusions: Patients with limb amputations and a history of peripheral vascular disease have been traditionally excluded from osseointegrated reconstruction. These results suggest an osseointegrated implant may be considered a feasible alternative to the conventional socket mounted prosthesis for these patients. The osseointegrated prosthesis may provide these patients with substantial functional benefits, including improved function, mobility, and quality of life. It is possible their enhanced mobility and improved quality of life and could even prolong their survival, but this remains to be seen. Further evidence is required to confirm the potential benefits of implementing osseointegration surgery as the standard of care for these patients. Acknowledgements: MAM discloses a financial relationship with the manufacture, distribution, and sales of the implants used in this study. The other authors (RA, JL, WL, and KT) have no conflicts of interest to declare relevant to the current study.


  EP 21: Osseointegrated implants in patients with diabetes mellitus: Preliminary results in a small series of eight cases Top


Munjed Al Muderis1, Kevin Tetsworth2, William Lu3

1. Macquarie University Hospital, Sydney, Australia

2. Royal Brisbane Hospital, Brisbane, Australia

3. Osseointegration Group of Australia, Sydney, Australia

Background: Osseointegration is a novel approach to eliminate socket related problems experienced by amputees. Over 70% of amputations in developed countries are due to vascular causes, with the prevalence of diabetes mellitus reaching pandemic status leading to more amputations. Traditionally, diabetic patients with amputations have been excluded from osseointegrated reconstruction due to higher risks of complications. This is the first study reporting on the clinical outcomes of diabetic patients receiving an osseointegrated reconstruction. Methods: Prospective case series with one-year follow-up in eight diabetic patients with trans-tibial or trans-femoral amputation, who received osseointegration implants between 2013 and 2016. Clinical and functional outcomes were assessed including pain, prostheses wearing time, mobility, walking ability, and quality of life measures. Adverse events were monitored and recorded, including infection, fractures, implant failure, revision surgery, further amputation, and death. Results: Three trans-tibial and five trans-femoral amputees aged 48-73 years were included in this study. All patients were pain-free and still using the osseointegrated prosthesis at 12-months post-surgery. The mobility of all patients improved significantly at most recent follow-up. Five of the eight patients were wheelchair-bound prior to surgery, but all were able to walk and perform daily activities at follow-up. Two patients experienced infection events which were treated by surgical debridement. One patient experienced peri-prosthetic fracture after a fall; this was stabilised with a lag screw and healed uneventfully. No other adverse events were recorded. Conclusions: Lower limb amputees with a history of diabetes mellitus have been traditionally excluded from osseointegrated reconstruction. Here we report the initial results of treating diabetic amputees with osseointegration, demonstrating improvements in function, mobility and quality of life. It may be possible that the improved function and mobility these patients now enjoy could provide some protection from the otherwise inevitable debilitating aspects of their underlying diabetic condition. This makes osseointegration an attractive alternative to conventional socket prosthetic mounts in selected diabetic patients. Acknowledgements: MAM discloses a financial relationship with the manufacture, distribution, and sales of the implants used in this study. The other authors (KT and WL) have no conflicts of interest to declare relevant to the current study.


  EP 22: Simultaneous Acute Deformity Correction And Lengthening Of The Lower Extremities Using Magnetic Limb Lengthening Nails Top


Ahmed I. Hammouda1, Vivian L. Szymczuk2, Martin G. Gesheff3, Janet D. Conway4, Shawn C. Standard5, John E. Herzenberg6

1. Department of Orthopaedic Surgery, Cairo, Egypt

2. Al-Azhar University, Peoria, United States

3. University Of Illinois College Of Medicine At Peoria, Baltimore, United States

4. International Center for Limb Lengthening, Baltimore, United States

5. Rubin Institute for Advanced Orthopedics, Baltimore, United States

6. Sinai Hospital of Baltimore, Baltimore, United States

Background: Our aim was to determine the results of using magnetic limb lengthening nails for simultaneous lower limb lengthening and acute deformity correction. Methods: Medical records of 25 patients (18 femora, 11 tibiae) were retrospectively reviewed. Mean age was 17 years (range, 8-49 years). Most patients were 20 years or younger (26 of 29 segments). Patients underwent simultaneous lengthening and acute deformity correction with magnetic limb lengthening nails between January 2012 and August 2015. Results: Mean follow-up was 2 years (range, 0.4-4 years). Mean lengthening goal was 4.7 cm (range, 1-8 cm). Mean angular deformity was 7° (range, 4°-11°). Mean rotational deformity was 18° (range, 10°-45°). Mean distraction index was 0.7 mm/day (range, 0.4-1.2 mm/day). Mean consolidation index was 43 days/cm (range, 17-108 days/cm). All segments achieved desired deformity correction. Preoperative and postoperative mean mechanical axis deviation was 1.3 cm (range, 0-3.5 cm) and 0.8 cm (range, 0-2.5 cm), respectively. Femora had mean preoperative and postoperative lateral distal femoral angle (frontal plane) of 85° and 89°, respectively. Femora had mean preoperative and postoperative posterior distal femoral angle (sagittal plane) of 76° and 84°, respectively. Tibiae had mean preoperative and postoperative medial proximal tibial angle (frontal plane) of 94° and 89°, respectively. Tibiae had mean preoperative and postoperative posterior proximal tibial angle (sagittal plane) of 72° and 79°, respectively. Rotational malalignment was corrected in all cases based on clinical examination of rotational profile. Two femora (7%) did not achieve lengthening goals due to knee rotatory subluxation and delayed regenerate healing. Conclusions: With preoperative planning and intraoperative fixator-assisted nailing technique, magnetic limb lengthening systems allow for lengthening and simultaneous acute angular, rotational, or combined deformity correction. One limitation is that the apex of deformity must be located at/near the lengthening osteotomy site. It is unclear whether deformities with magnitudes >15° can be accommodated. Acknowledgements: AIH, VLS, and MGG have nothing to disclose. JDC is a consultant for Biomet, Cerament, and DePuy Synthes; receives research support from Microbion, CD Diagnostics, and Acelity; receives royalties from the University of Florida; and receives fellowship support from Biocomposites. SCS receives royalties from NuVasive Specialized Orthopedics and Pega Medical and is a consultant for NuVasive Specialized Orthopedics. JEH is a consultant for Orthofix, OrthoPediatrics, NuVasive Specialized Orthopedics, and Smith & Nephew; receives research support from NuVasive Specialized Orthopedics; and is on the editorial board of the World Journal of Orthopaedics. The following companies supported a non-profit organization that is part of Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). CS Medical Supply, Metro Prosthetics, and Stryker. The following organizations supported an annual course for orthopedic surgeons that is held by Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). Baxter, DePuy Synthes, Merete Technologies, MHE Coalition, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Smith & Nephew, Stryker, and Zimmer Biomet.


  EP 23: Hindfoot Sagittal Plane New Reference Lines And Angles For Deformity Correction Planning Top


Leonid N. Solomin1, Konstantin A. Ukhanov2, John E. Herzenberg3, Eugene P. Sorokin2

1. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, St. Petersburg, Russia

2. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia

3. Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, United States

Background: The disadvantage of the known methods of analysis and planning of hindfoot deformities in the sagittal plane is difficulty or inability to perform it with concomitant deformation of the midfoot and ankle contracture or malpositioned arthrodesis. The aim of our study was to develop a method of analysis and planning of the calcaneus correction, based on the original definition of the reference lines and angles, which does not have conventional disadvantages. Methods: We analyzed 65 standing lateral foot films in normal adults, 23-54 years old were analyzed. We drew the talus joint line (points “a” and “b” - Line 1). We drew a second line, (Line 2) the calcaneal line, which starts at the back of the calcaneal tuberosity (point “d”), drawn perpendicular to a line from top to bottom of the calcaneal tuberosity. The intersection of the calcaneal line and the talar joint line form point (c) anteriorly. We measured lines ab, ac and cd, and their ratios. ac/ab, and cd/ab. Results: Talar joint line (Line 1) and calcaneal line (Line 2) intersect at a point (c), forming an angle 15.2° (+/- 3.4°). The ratio ac/ab = 2.56 (+/- 1.1). The ratio cd/ab = 4.59 (+/- 1.0). These ratios are constants for calculating the idealized joint lines for deformity planning. For deformity cases, draw Line 1, the talar joint line ab. Extend that line anteriorly to (c), which is a distance ab x 2.56 from point (a). From (c), draw an idealized calcaneal line, Line-2, at an angle 15° to Line 1. Place (d) on this line, at a distance ab x 4.59 from point (c). Next, draw the deformed calcaneal line (Line 3) and point (d') where it exits the calcaneal tuberosity. Use the same technique / landmarks as for drawing the normal calcaneal line. The intersection of Lines 2 and 3 is the apex of the deformity. Rotate the piece containing Line 3 around this apex, until it is collinear with Line 2, and (d) is coincident with (d'). Conclusions: We describe the normal sagittal plane relationships between the hindfoot (calcaneus - talus). This normative data is used for planning sagittal plane hindfoot deformity corrections. It can be used for hindfoot deformities analysis and correction planning. It is independent of ankle joint equinus or malpositioned ankle arthrodesis, which can be considered as separate deformities. Acknowledgements: Our sincere acknowledgements to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University and Rubin Institute for Advanced Orthopedics, Sinai Hospital


  EP 24: Acute correction of foot and ankle deformities with Ilizarov method New procedures and apparatus Top


León Gonzalo Mora H. Md.

CORA Group - Clínica El Rosario, Medellín, Colombia

Background: The management of severe ankle and foot deformities secondary to severe trauma, congenital problems such as recurrent, structured or forgotten equine varus adductus foot, afterburn or foot crushing are very difficult to manage and most often end in amputations or Severe gait disorders. We present a technique that associates acute correction and limb stabilization with the Ilizarov fixator, the Ilizarov method is applied for the residual correction of the length discrepancy and the residual deformities. Methods: An acute correction of the severe deformity of the foot is planned, a three-dimensional osteotomy is planned to correct all the deformities in the 6 planes, leaving a neutral foot, an arthrodesis of the Tibiotalar associated with a triple arthrodesis of the foot, Carefully evaluate the condition of the soft tissues to plan if a neighborhood or regional flap is needed. The Achilles tendon and the plantar fascia is enlarged, the fingers are stabilized and contractures are corrected in flexion or extension. Finally, the residual discrepancy secondary to acute shortening is determined and a low energy osteotomy is performed at Tibia and proximal Perone for an elongation by distraction osteogenesis. Results: This reconstruction treatment was performed at 40 extremities, in 8 cases the disorder was bilateral, average age of 42 years (25 - 70 years), 60% of the cases structured sequelae of equino varus adductus, 15% Charcoth disorder And 25% trauma sequelae. The success of the treatment is evaluated comparing the preoperative and postoperative values of Foot and Ankle Outcome Score, obtaining very significant changes in pain, functional recovery, independent gait and quality of life. Rate the results as good and excellent. There were complications without sequelae, necrosis of the flap edge by 20%, pin type 1 infection in 15%. Conclusions: This treatment is indicated in severe lesions and severe inveterate deformities of the ankle and foot as an effective and adequate alternative, with predictable results, using the Ilizarov method and external fixation with an application of the principles of reconstructive surgery and bone elongations. Acknowledgements: CORA Group . Medellín, Colombia


  EP 25: Bone Transport With Cables A Technique In Osteogenesis By Distraction: Tips And Tricks Of A Novel Technique New procedures and apparatus Top


León Gonzalo Mora H. Md.

CORA Group - Clínica El Rosario, Medellín, Colombia

Background: Technique described for the treatment of large segmental bone defects, greater than 10 centimeters. The traditional technique of distraction osteogenesis is performed with monolateral fixators and circular. They manipulate the bone transported with pins or K wires. They transfer the skin and produce pain by progressively breaking soft tissues;. In this technique the Osteogenesis by Distraction is realized with Cables of braided steel, without using the Pins . It offers significant advantages in bone transport of long defects of bone segments, causing less tissue damage, is less painful and less pin problems, without invagination of the tissues and without infection of the pin-skin interface. It only requires the stabilization of the proximal and distal fixator, but the transported segment is fixed by internal cables. Methods: The cable is placed in the segment of bone to be transported by placing the two cables of the cable through the medullary canal, a tunnel is made through the distal or proximal periarticular part and is connected to an external progressive traction system that allows progressive traction and Controlled, this osteogenesis by segment distraction at 1mm. per day. Once the time of distraction is completed at 20-30 days, the external fixator is replaced by a system of LCP plates for early rehabilitation and to avoid complications of external fixation. Opening site must be opened to cut the traction cable, remove fibrous tissue and apply autologous bone graft associated with BMP-2 Morphogenic Protein or DBM demineralized bone matrix. Stabilize the transported segments with a stable angle screw. Results: The technique is applied to 10 patients with bone defects with an average of 12cm (8-22cm). Very good tolerance to technique in the period of distraction, analogue pain scale 4 (2-5). Treatment-related complications were. Pin infection 10% (1 case-Type 1) handled with oral antibiotics, cephradine 500 mg / 8 h, no complications. Rupture of a cable at the end of distraction, during the compression period - without loss of traction without consequences; Cable outlet 5% skin discomfort (1 cable). Conclusions: It provides a possibility of bone transport of segments without direct contact of the callotasis with the external environment. It can be performed bifocal in large bone defects, is safe and has fewer complications during the period of distraction. It is an applicable and reproducible technique, good results in the formation of callus. Acknowledgements: To CORA Group


  EP 26: Midfoot Sagittal Plane New Reference Lines And Angles (RLA) For Deformity Correction Top


Leonid N. Solomin1, Konstantin A. Ukhanov2, John E. Herzenberg3, Anton V. Boychenko4

1. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, St. Petersburg, Russia

2. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia

3. Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, United States

4. St. Petersburg State University, St. Petersburg, Russia

Background: The aim of this study is to create a novel midfoot sagittal plane reference lines and angles (RLA) for deformity correction analysis and planning. Methods: A total of 64 weight bearing lateral x-rays of adults (23-64 y.o.) without foot deformity were analyzed. The value of angle between the talar joint line (points a and b) (line-1) and 1st metatarsal mechanical axis (line-2) was investigated. Point (c) is at the intersection of 1st metatarsal axis and anterior cortex. The ratio ac/ab was determined. Results: The angle between line-1 and line-2 is 23.6 deg. (+/-3.2). The ratio ac/ab = 4.17 (+/-0.19). The Therefore, the distance (ac) can be calculated by the formula [talus joint line length × 4.17] = (ab × 4.17). For deformity cases, start by drawing Line 1, the talar joint line (ab). Next, from point (a), draw an idealized 1st metatarsal line (Line 2) starting at (a), and measuring 23.6° relative to Line 1. The length of Line 2 (ac) is the length of Line 1 x 4.17, defining (c') Next, draw the deformed (actual) 1st metatarsal anatomic axis (Line 3) and point (c') where it exits the metatarsal head. The intersection of Lines 2 and 3 is the apex of the deformity. Rotate the segment containing Line 3 around this apex, until it is collinear with Line 2, and point (c) is coincident with (c'). These RLA and method of their use were successfully tested in the planning of 17 hindfoot deformities and analysis of treatment of 25 patients with foot deformities. Conclusions: Any deformation of the distal tibia, midfoot, hindfoot, as well as the position of the talus do not interfere with the proper planning and evaluation of its results. This method can be applied even malpositioned ankle fusion. Acknowledgements: Our sincere acknowledgements to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University and Rubin Institute for Advanced Orthopedics, Sinai Hospital


  EP 27: “Foot Quadrangle” As A Test Template For Planning Deformity Correction In The Sagittal Plane Top


Leonid N. Solomin1, Konstantin A. Ukhanov2

1. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, St. Petersburg, Russia, St. Petersburg, Russia

2. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia, St. Petersburg, Russia

Background: We developed new methods of analysis and planning midfoot and hindfoot correction in the sagittal plane (Solomin L. et al., 2016). The basis of the ways is the location and length of the talus block joint line (TBJL). The limitation of the methods is connected with changes, due to injury or disease, the size of the diameter (cross-section) of the calcaneus and head of the 1st metatarsal bone. The aim of the study was to develop a method, which would not depend on the mentioned parameters. Methods: A total of 65 full weight bearing lateral x-rays of adults (23-43 y.o.) without deformities were analyzed. Variation of the location reference (i.e., located most distal) points of the heel (d) and the 1st metatarsal bones (c) with respect to the extreme points of the TBJL (a and b) were investigated. Formed figure has the shape of a quadrangle, where the upper side ab and dc - downside. We determined the ratio of the sides and value angles of this quadrilateral. Results: The coefficients corresponding to a healthy foot were obtained. ad / ab = k1 = 1.56 (+0.24); bc / ab = k2 = 3.09 (+0.4); dc / ab = k3 = 3.77 (+0.78). The values of the angles, which must be in the non-deformed foot were identified. dab = 105.0 (+8.3) deg.; abc = 144.6 (+9.4) deg.; bcd = 31.3 (+2.6) deg.; cda = 79,2 (+9,8) deg. Thus, knowing the length of TBJL (in mm), we can construct a quadrangle and determine whether there is a deformation of the foot in the sagittal plane or not. For example, the patient has the TBJL length = 35 mm. By calculation received that k1 = 3.58; k2 = 2.23; k3 = 3.19; dab = 109.3 deg.; abc = 109.7 deg.; bcd = 46.5 deg.; cda = 94.5 deg. Since there is a decrease value of angle abc, increasing angles bcd and cda; decreasing k3, there is cavus foot deformity. Quadrangle is constructed with sides ab = 35 mm, bc = 35x3.09 = 108.15 mm; cd = 35x3.77 = 131.95 mm; ad = 35x1.56 = 54.6 mm and angles values adopted for the reference values. This quadrangle was used for planning deformity correction and analysis of its accuracy. Conclusions: This approach to the analysis and planning foot deformity correction in sagittal plane does not depend on the presence of the combined (midfoot + hindfoot) deformity, equinus of the ankle joint, ankle joint fusion in wrong position and the heel and metatarsal bones sizes. Acknowledgements: to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University.


  EP 28: Turning a new leaf. Fidelity 8-D by Ilizarov Technique. The purpose driven life. Top


PROF MD. Mofakhkharul Bari

Bari Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Background: Man is mortal and life is very short. The curtain rises and the curtain falls. Methods: However, each day is a challenge and a challenge is an opportunity to solve the unsolved problems, especially those which are “need based”. During my long period of Ilizarov surgery since 1983 (from home and abroad) till today I faced lot of problems and difficulties with very interesting, challenging and complex cases. Results: Today I would like to share my experiences with these following diseases:. 1. Popliteal pterygium syndrome with 8 cm shortening. 2. Post traumatic right disorganized knee, bad scar in the leg with ankle valgus, 14 cm LLD. 3. Reconstruction vs. Amputation. 4. Bilateral relapse CTEV with Bilateral genu valgum. 5. AMC total body involvement. 6. Sequalae of meningo myocele and so on. 7. Relapsed CTEV of an adolescent girl. 8. Untreated bilateral DDH of a 25 years old girl who could not walk since birth. Conclusions: Acknowledgements:


  EP 29: Orthopedic Hexapod Ortho-SUV Frame (OSF) For Specific Cases (Multilevel Deformitie, LON, Knee, Foot) Top


Leonid N. Solomin1, Victor A. Vilenskiy2, Elena A. Shchepkina3, Fanil K. Sabirov4, Konstantin A. Ukhanov5

1. 1. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia

2. St. Petersburg State University, St. Petersburg, Russia

3. St.Petersburg, St.Petersburg, Russia

4. Russia, St.Petersburg, Russia

5. The Turner Scientific and Research Institute for Children's orthopedics, St. Petersburg, Russia

Background: Nowadays are known 8 different hexapod frames for long-bone deformity correction. All of them proved their efficiency in long bone deformity correction. Ortho-SUV Frame (OSF; www.ortho-suv.org) is actually not a frame, but universal unit that can be applied to different types of ring and has no strict places for struts fixation. That is a basic for its use in specific cases. Methods: We analyzed 8 cases of multilevel deformity correction using “Spring Technique” (ST); 5 cases of lengthening and rotation correction over the nail (LON); 25 cases of knee joint stiffness (KJS); 13 cases of midfoot,11 - of hindfoot and 19 cases of complex foot deformities correction. The results in group of ST were evaluated on the following parameters. a period of deformity correction (DCP), time in frame (TIF). In group LON we estimated the value of lengthening, time in frame. In foot deformity correction group, we analyzed accuracy of deformity correction, TIF, number and character of complications. Results: In all cases of ST we achieved excellent accuracy of alignment. We faced with the following complications. one case of equines deformity in ankle treated by achilles tendon tenotomy and foot support. In one case, we had to make reosteotomy due to premature consolidation at one osteotomy level. In LON group, the average lengthening that we achieved was 40.2+16 mm. The TIF was 60.7+24.5. We had no complications in this group. In KJS group we received average knee joint flexion after frame removal 95 degrees, extension - 0. We faced with following complications. 1 pin-hole femur fracture, 1 posterior subluxation of lower leg, 1 skin necrosis, 1 instability of the frame, 1 deep infection. In all cases, except one, the secondary surgery on complication was successful and brought good results. In one case, we couldn't reach normal ROM due we had to stop correction and preliminary remove the frame due to patient's request. In cases of foot deformity correction, the achieved accuracy of deformity correction for ankle was 87%, for midfoot – 91 %, for hindfoot – 90%, for complex foot deformities- 89%. We faced with the following complications. 1 case of wire breakage, 3 cases of skin necrosis, 2 cases of pin-tract infection, 3 cases of preliminary consolidation. Conclusions: OSF is highly effective tool for deformity correction in such specific fields of external fixation as. flexion and extension knee stiffness, foot deformities, multilevel deformities of the long bones, LON. Acknowledgements: to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, The Turner Scientific and Research Institute for Children's orthopedics, Pavlov First Saint Petersburg State Medical University and Ortho-SUV Ltd.


  EP 30: New 3D Technology For Planning Of Long Bones Deformity Correction - Ortho-SUV Planner (OSP) Top


Leonid N. Solomin1, Alexander I. Utekhin2, Victor A. Vilensky3

1. 1. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia

2. St. Petersburg State University, St. Petersburg, Russia

3. St.Petersburg, St.Petersburg, Russia

Background: In cases of complex deformities which have torsion component, determination of CORA on 2D planners (BoneNinja, Traumacad etc.) looks to be improper due to the reason that we never see simultaneously both joints on one long leg film properly – only one. The solution of this problem seems to be 3D planning, but no instrument for it (software) was available in the world market till nowadays. The aim of the study was to compare traditional planning using long leg x-ray films, and 3D planning. Methods: 3D Ortho-SUV Planner (OSP) - is a new solution in the field of long-leg deformities 3d-planning. The software works with converted data of CT scans into a virtual 3D model. The tools of the software are created specially for orthopedic purposes. determination of anatomical, mechanical axes, lines the joints according to the traditionally used landmarks. As far as we can turn the 3D model in any direction while determination of the axes and joint lines the axes (anatomical and mechanical as well) are true and correspondingly we have true CORA. In the study, we compared the level of CORA (the distance from the knee joint line) in 3D-planning (in OSP) and the traditional planning (on long-leg x-ray films) in the same complex multiplanar deformities of femur (in 10 cases). All the analyzed cases had torsion component of the deformity. Results: In all the cases of deformity correction planning the level of CORA found in the analyzed groups varied with average difference that was 62+15 mm. That means that following the traditional planning, the osteotomy was to be performed 62 mm above or below the true CORA, which could become evident only in the elimination of torsion and all the angular values of the deformity. Also in SUV-planner we had imitated the osteotomy at level that we had received in 2D planning and imitated 3D deformity correction. In all the cases, we received translation that in average was 36+14 mm. This would have led to the need for restoration of the mechanical angles and mechanical axis of the limb to perform additional translation of fragments for 36 mm in width, which could negatively affect on the fusion of fragments and cosmetic result. Conclusions: Deformity correction planning using 3D Ortho-SUV Planner (OSP) is very effective because it allows to determine “true” CORA even in cases of complex deformities accompanied by torsion. 3D deformity correction planning looks to become the golden standard in the nearest future. Acknowledgements: to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University and Ortho-SUV Ltd.


  EP 31: Multilevel Deformities Correction Using “Spring Technique” (ST) Of Ortho-SUV Frame Assembly Top


Leonid N. Solomin1, Fanil C. Sabirov2, Konstantin L. Korchagin1, Irina V. Orlova3, Elena A. Shchepkina1

1. Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia

2. St. Petersburg State University, St. Petersburg, Russia

3. , St.Petersburg, Russia

Background: Orthopedic hexapods are needed for complex long bone deformity correction. This requirement is particularly relevant in the presence of multilevel deformities, having two or more deformity apexes. Methods: We have developed a method of correction of multilevel d long bone deformities, which is based on ST of orthopedic hexapod Ortho-SUV Frame (OSF, www.ortho-suv.org) assembly. For this purpose, struts are attached only to the proximal and distal rings. Intermediate rings are fixed to the adjacent rings by means of springs. Only axes of proximal and distal bone fragments are taken into consideration while software using. During deformity correction, the position of intermediate fragment(s) takes proper position automatically. We used ST for treatment of 9 patients with 10 segments multilevel deformities. femur (3) and lower leg (7). MAD values for patients in this group were. with valgus deformity - 12-75 mm (2 patients); with varus deformity - 0.7-6.3 mm (7 patients), limb length discrepancy - 20-110 mm. Antekurvation deformity ranged from 5 to 28 (3 patients), rekurvation deformity - 8 degrees (1 patient). Torsion was identified in two patients. 9 and 30 deg. In the treatment of patients with femur deformity mLPFA was 93-110, mLDFA - 87-95, mPPFA - 48-60, mPDFA - 68-80. At tibia deformations mMPTA was 60-123, mLDTA - 72-110, mPPTA - 68-80, mADTA - 72-80. Results: Correction period was 49+11.7 days (33-63), the period of fixation – 291+17.5 days (224-339). Accuracy of deformity correction in all cases corresponded to preoperative planning. Complications of category I (according Caton, 1991) occurred in 3 cases (2 – pin-tract infection, 1 - neuropathy of the peroneal nerve); category II - in one case. the lag in the correction at the level of distal osteotomy. Re-osteotomy was done. Complications of category III were not identified. Conclusions: (preliminary) The use of Spring Technique (ST) provides the performance of multilevel deformity correction simultaneously at each CORA level using a single orthopedic hexapod. This simplifies the procedure, increases the comfort of the treatment and doesn't have specific complications. Acknowledgements: to Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg State University, Ortho-SUV Ltd.


  EP 32: High Tibial Osteotomy Using Mini External Fixation Top


Ghassan Salameh1, Michael Schmidt2

1. Salamehfix Limb Lengthening Center, Tartous, Syria

2. Waldhof Praxis, Frankfurt, Germany

Background: 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 angulation 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. Methods: 52 Patients treated with various severities 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 overcorrection from 3 to 5 degrees valgus, the external fixation device was used is Salamehfix , which consist of two arcs deferent 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. Conclusions: 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. Acknowledgements: Small size fixation, stability, possibility of correction of varus deformity with bone translation and early Wight bearing gives the system more advantages in treatment of gonarthroses.


  EP 33: Allogenic Bone Marrow Derived Mesenchymal Stem Cells In Promoting Bone Fracture Healing: They Do Work! Top


Gang Li

The Chinese University of Hong Kong, Shatin, Hong Kong SAR

Background: Mesenchymal stem cells (MSCs) are immune-privileged and a cell source for tissue repair. Previous studies showed that there is systemic mobilization of osteoblastic precursors to the fracture site, we hypothesized that both systemic and local administration of allogeneic MSCs may promote fracture healing. Methods: Bone marrow derived MSCs and skin fibroblasts were isolated from the GFP- Sprague-Dawley rats, cultured and characterized. Closed transverse femoral fracture with internal fixation was established in 48 adult male Sprague-Dawley rats, whom were randomly assigned into 4 groups receiving. PBS injection; MSCs systemic injection; Fibroblasts systemic injection and MSCs fracture site injection. 2 million cells were injected at 4 days after fracture. All animals were terminated at 5 weeks after fracture; examinations included weekly radiograph; Micro-CT; mechanical testing; histology, immunohistochemistry and double immunofluorescence. Results: The callus size of MSCs injection groups were significant larger among all the groups. Radiographs and 3D-reconstruction images showed that the fracture gaps united in the MSCs injected groups, while gaps were still seen in the fibroblast and PBS injection groups. The mechanical properties were significantly higher in the MSCs injection groups than those in the fibroblast and PBS groups, but no difference was found between the MSCs local and systemic injection groups. Immunohistochemistry and double immunofluorescence demonstrated that GFP-positive MSCs were present in the callus in the MSCs injection groups at 5 weeks after fracture, and some have differentiated into osteoblasts. Quantitative analysis revealed the number of GFP-positive cells in the callus in the MSCs systemic injection group was significantly lower than that of the MSCs local injection group. The proportion of GFP-osteoblasts in GFP-positive cells in the MSCs systemic injection group was significantly lower than that of the MSCs local injection group. Conclusions: These findings provide critical insight that allogeneic MSCs may be a novel treatment method for promoting fracture repair. Allogenic MSCs are safe and reliable cell source which can be prepared and banked, and used when needed. They promoted bone formation in fracture healing and without any noticeable adverse effect. Acknowledgements: The work was partially supported by grants from National Natural Science Foundation of China (NSFC No.81371946 to Gang Li). Hong Kong Government Research Grant Council, General Research Fund (CUHK470813 and 14119115) and a project grant from China Shenzhen City Science and Technology Bureau (GJHZ20140419120051680) to Gang Li.


  EP 34: Joint Distraction Attenuates Osteoarthritis By Reducing Cartilage Degeneration, Subchondral Bone Aberrant Change And Secondary Inflammation Top


Gang Li1, Yuanfeng Chen2, Xiaohua Pan3

1. Department of Orthopaedics and Traumatology, Shatin, Hong Kong SAR

2. The Chinese University of Hong Kong, Shatin, Hong Kong SAR

3. Department of Orthopaedics and Traumatology, Shenzhen, China

Background: 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 imaging techniques. Methods: 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-1β 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-1β 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. Conclusions: 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, slowing down the onset and progress of OA. Acknowledgements: The work was partially supported by grants from National Natural Science Foundation of China (NSFC No.81371946, 81374568) to Gang Li. Hong Kong Government Research Grant Council, General Research Fund (CUHK470813 and 14119115) and a project grant from China Shenzhen City Science and Technology Bureau (JGJHZ20140419120051680 and JCYJ20150630165236960) to Gang Li are gratefully acknowledged. This study was also partly supported by SMART program, Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong.


  Other subjects Top



  EP 35: Is static measure of frontal plane knee alignment reliable in deciding about surgical realignment in young active women with varus knee? Top


Anna Fryzowicz1, Pawel Koczewski2, Michal Murawa1, Jaroslaw Kabacinski1, Lechoslaw Dworak3

1. Department of Biomechanics, University of Physical Education, Poznan, Poland

2. Department of Paediatric Orthopaedics and Traumatology University of Medical Sciences of Poznan, Poznan, Poland

3. Chair of Bionics, University of Arts, Poznan, Poland

Background: Varus knee malalignment is one of the risk factors of the development and progress of degenerative changes in the medial knee joint. In gait analysis, the external knee adduction moment (EKAM) and EKAM impulse have become the substitute dynamic measures for medial knee loading. The aim of the study was to examine the relationship of EKAM and EKAM impulse with frontal plane knee alignment in young, active women. Methods: The experimental group included 40 women aged 17-32 years. All subjects completed the International Physical Activity Questionnaire (IPAQ) as well as Sport and Recreational Activities subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-SR). The frontal plane knee alignment was measured in standardized position with photometric method by determining the pelvis-knee-ankle (PKA) angle. Higher values indicate varus alignment. Kinematic data were collected using an 8-camera BTS SMART D motion capture system. Two AMTI force plates were used to collect kinetic data. The data of interest was determined with Smart Tracker and Smart Analyzer software and involved. maximum external knee adduction moment in loading response (EKAMmax1) and terminal stance (EKAMmax2) as well as EKAM impulse during stance phase (IEKAM). Data were analyzed using STATISTICA 12.0. Spearman's rank correlation coefficients were used to examine bivariate relationships between PKA and variables of interest. The significance level was set at p<0.05. Results: PKA ranged from 174.5o to 186.1o (on average:178.6 ±2.4o). On average, the magnitude of EKAMmax1 was 0.35 ±0.09 Nm/(kg·m), EKAMmax2 was 0.31 ±0.09 Nm/(kg·m) and EKAM impulse was 0.13 ±0.03 Nms/(kg·m). All subjects were physically active according to IPAQ outcome. 84% on high and 16% on moderate level. The mean KOOS-RS outcome was 87.6%. There was no significant correlation between PKA and EKAM or EKAM impulse. There was significant correlation between PKA and KOOS-RS (r=-0.398, p<0.05), indicating more difficulties during activity with more varus alignment. Conclusions: Although more varus alignment was related to more difficulties during activity all women in studied group were physically active, most of them on high level. Since there was no relationship between PKA and dynamic measures of medial knee loading, it is concluded that frontal plane knee alignment measured with photometric method alone is not reliable in deciding about surgical realignment in young, active women with varus knee. Acknowledgements: Authors declare no conflict of interest.


  EP 36: Ilizarov applications to benign bone tumors Top


Prof Md. Mofakhkharul Bari

Bari Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Background: The usefulness of Ilizarov external fixator was investigated 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 females 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. Conclusions: Preservation and bone regeneration 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 forthese methods. Acknowledgements: Dr. Md. Shahidul Islam, Prof. MD; FCPS, Bari-Ilizarov Orthopaedic Centre. Dr. Nazmul Huda Shetu, M.S (Ortho), Consultant, Bari-Ilizarov Orthopaedic Centre. Dr. Md. Mahfuzer Rahman, D. Ortho- Consultant, Bari-Ilizarov Orthopaedic Centre.


  EP 37: Severe Knee Anquilosys In 150 Degrees After Femur Fracture In The Childhood- Correction With Ilizarov Frame- Case Presentation Top


Hilario Boatto, Carlos Luiz Engelen, Robinson Toshimitsu Kyiohara, Marcelo Fumio Utsunomyia, Jose Lucarelli, Jose Roberto Zagatti Hernandes

Federal University of Sao Paulo, Sao Paulo, Brazil

Background: 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. Methods: To correct this severe deformity it was necessary to perform an osteotomy and gradual correction with an Ilizarov external fixator. The external fixator had a femur and tibial frame. At the femur was placed an arch and one ring and two rings at the tibia. The frames were connected by two hinges placed at the convex side of the deformity and two posterior distraction rods. Results: The full extension was obtained and the limb lengthening was performed. There was no knee motion but the patient was able to walk without using any clutches. The external fixator device was used for 20 months and the total lengthening was 20 centimeters. Conclusions: The Ilizarov External Fixator Device Provides a safe correction of severe knee flexion deformities without neurological or vascular complications. Acknowledgements: No disclosure


  EP 38: Leg length discrepancies after pertrochanteric fractures in young patients – A single center experience Top


Thomas M. Tiefenboeck, Nikolaus Lang, Géraldine Désirée Sturz, Thomas Haider, Gerald E. Wozasek

Medical University of Vienna, Department of Trauma Surgery, Vienna, Austria

Background: Bony healing in general is associated with resorption at the fracture site and accompanying shortening of the affected bone. Pertrochanteric fractures occur typically in geriatric patients, however, can be found in younger patients after high-energy trauma. In elderly patients, leg length discrepancy after bony healing of pertrochanteric fractures is usually neglected, however, in young patients it may become a serious complication. Thus, the aim of this study was to evaluate the amount of leg-length discrepancy after surgical treatment of pertrochanteric fractures in young patients. Methods: This study was performed as a retrospective single centre data analysis of a level one-trauma-centre. Included were all patients (age 18-65) suffering from pertrochanteric fractures surgically treated at our Department between 2007 and 2015. Results: A total number of 69 patients with pertrochanteric fractures, age 18 – 65 years were found. In 11 patients (16%) a leg length discrepancy of more than 1cm was found. In three patients (4%) even a leg length discrepancy of over 2cm was found. Conclusions: According to our presented data leg length discrepancies are common even in non-geriatric patients after osteosynthesis of pertrochanteric fractures. However, severe leg length discrepancy was only detected in 4% of our patients. This collective, however, might suffer from late complications. Therefore, early treatment need to be discussed. Acknowledgements: There were no conflicts of interest for all authors regarding this study.


  EP 39: Accuracy Of Medial Cutting Guide Compared To Anterior Cutting Guide In Distal Femoral Osteotomy Of Total Knee Arthroplasty Top


Khanin - Iamthanaporn, Varah - Yuenyongviwat, Teeranan - Laohawiriyakamol, Pramot - Tanutit

Prince of Songkla University, Hatyai, Thailand

Background: Minimally invasive surgery (MIS) in total knee arthroplasty has the benefits of less postoperative pain and faster recovery time. A MIS instrument was designed to help surgeons perform this task in the reduced visualization approach. A medial cutting guide of the distal femur is used for distal femoral bone cut without patella subluxation. This study was conducted to compare the accuracy of the distal femoral bone cut between the medial and standard anterior cutting guides. Methods: Two orthopedic surgeons who specialize in total knee arthroplasty and are familiar with both types of cutting guides performed the procedures. Forty-eight plastic saw bones were used. Five-degree valgus medial and anterior cutting guides were randomly assigned to the surgeon. After the osteotomies were performed, the plastic saw bones were sent for plain radiographs. Two independent radiologists measured the medial distal femoral angle (MDFA) and posterior distal femoral angle (PDFA). Results: The MDFA from the medial cutting group was statistically significantly different from the anterior cutting group (P = 0.041). The PDFA was not different between the groups. The number of outliers was not different between the groups when a 2-degree error was defined as an outlier (P = 0.609 for MDFA and P = 0.359 for PDFA). A high degree of reliability was found in both MDFA and PDFA measurements (intraclass correlation coefficients = 0.813 and 0.824, respectively). Conclusions: A MIS medial cutting guide had less accuracy than the standard cutting guide in distal femoral cut. Acknowledgements:


  EP 40: Rheumatoid Arthritis - A Challenge For Knee Replacement Surgery Top


Pedro Teixeira Mota1, António Lemos Lopes2, Marta Maio2, Rita Sapage2, Carlos Pintado1

1. Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal

2. Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal

Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by progressive damage of synovial-lined joints and variable extra-articular manifestations. RA can affect any joint and is a common cause of secondary knee osteoarthritis. Total knee arthroplasties can be categorized according to mechanical stability into. non-constrained, semi-constrained and constrained (or hinged).The use of a hinged implant in a primary arthroplasty is rare and is usually reserved to patients with severe ligamentous insufficiency, severe flexion or extension gap mismatch, recurvatum deformity, neuromuscular disease and limb salvage procedures. Methods: We describe the case of a 36 years old male patient, with RA, evaluated by an orthopedic surgeon for severe pain in both knees. Results: The clinical examination showed an important bilateral deformity and decreased range of motion. X-rays were positive for grade IV bilateral knee osteoarthritis with a great amount of bone destruction and evident collateral ligamentous insufficiency. The patient was submitted to a bilateral total knee arthroplasty, with an eight-year gap between surgeries. A constrained (hinged) implant was used in both knees. No intra or post-operatively complications were observed. After nine years of the procedure for the left knee and one year for the right knee, the patient has occasional pain. The KSS is 72 for the left knee and 75 for the right knee. Conclusions: Total knee arthroplasty is one of the most common orthopedic procedures worldwide and is associated with high rates of success. Although constrained implants are associated with a tendency for worse outcomes and higher rates of complication, in severe cases as the one we present, these implants are the most likely way of achieving a pain free, stable knee. Acknowledgements: The authors have nothing to disclose


  EP 41: The Management And The Treatement Of Haglund'S Disease: About 13 Cases And A Review Of The Literature Top


Karim Latrach Tlemsani1, Hamza Kefi2, Khalil Amri2

1. Military Hospital of Tunis, Rades, Tunisia

2. Military Hospital of Tunis, Tunis, Tunisia

Background: Haglund's disease consist in a painful swelling of the rearfoot causing discomfort in footwear caused by the prominence of the superior posterior tuberosity of the calcaneum or Haglund's deformity. Methods: The present study was conducted in the department of orthopaedic and traumatology of Military Hospital of tunis and included 13 feet in 13 patients followed for disabling talalgia including 3 women and 6 men with a mean age of 51 years (36 to 61 years). The diagnosis was clinical. The radiography confirmed this by showing the existence of a conflict between the Achilles tendon and the posterior-superior angle of the calcaneus. Results: All patients were operated after failure of the medical treatment. The treatment consists of resecting the calcaneal spur and the bursa followed by a complete central split of the tendon. All patients were satisfied with the postoperative result after a 14 month mean follow-up. The evaluation was carried out by the AOFA scale. Conclusions: Haglund disease is one of the causes of posterior talalgia leading to disability in everyday life. A well-conducted medical treatment has proved in some cases its efficiency. But most often, the management of the tendinopathies of Achilles belongs to the surgery. Acknowledgements: None


  EP 42: Treatment Of The Thalamic Calcaneal Fracture By REFF : About 30 Cases and A Review Of The Literature Top


Hamza Kefi, Karim Latrach Tlemsani, Maher Teka

Mahdia Hospital, Tunis, Tunisia

Background: Thalamic calcaneal fractures are common injuries that the management still challenge the surgeons, because their prognosis less favorable than extra articular fractures and their treatment based on variety of therapeutic methods which remained today controversial. Methods: A retrospective study was conducted in the department of orthopaedic and traumatology of taher sfar hospital, over a period of 17 years (1997- 2003). The material in the present research included 30 observations of patients treated for thalamic calcaneal fractures by the recovery method. Age of the samples ranged from 18 to 56 years old. Results: The operative technique was based on a reduction by a Steinmann pin and stabilization by kirchner pins. The postoperative hospitalisation was estimated to 2 days .no skin or severe septic complications were noted. Radiological and functional outcomes were evaluated over a mean of 4. 62 years. According to the criteria kataoka, the reduction was very good or good in 18 cases (60%). The mean score of AOFAS Hindfoot was 75.96/100. 80% of cases get back to work with a satisfaction. Conclusions: Comparing to open surgery, we concluded through our study that the REFF allows a good functional and anatomical results with a low risk of serious skin and septic complications if properly indicated and executed. Sander's Type 2 and Duparc Type 3 are the proper indication of chirurgical treatment by REFF. Acknowledgements: None


  EP 43: Treatment Of Lower Limb Deformities After Cerebral Palsy By External Fixation Technique By Analyzing 2890 Cases Top


Zhang * Li

National rehabilitation hospital, Beijing, China

Background: Spastic cerebral palsy is the most common type of cerebral palsy, with the performance of children hypoevolutism in motor development, and obviously increased skeletal muscle tension, especially lower limb. Older patients with cerebral palsy, due to long-term muscle spasms and muscle imbalances, often develop secondary stationarity deformity of different level or even bone deformities. Due to uneven regional economic development in our country, many patients lose the optimal timing of treatment, leave severe joint deformity of double lower limbs, disable to stand up, lose independent ability in life and activities. For limb deformities after cerebral palsy, there are various treatments and their main purpose was to amputate muscle spasm, balance muscle strength, rectify deformity, adjust limb weight line, improve motion function. With the development of the external fixation technology, fixed orthodontic treatment of cerebral palsy has entered a new stage of development. Methods: ince 1990, professor Qin Sihe's orthopaedic surgery team has treated more than 4100 patients with cerebral palsy. Through retrospectively analyzing all follow-up cases, there are 2890 cases of cerebral palsy patients treated by external fixation of orthopaedic surgery, including 1760 male cases and 1130 female cases. Results: good treatment effect of 2710 cases, excellence rate 93.8%; Other 180 patients had not obtained good effect or treatment effect with recurrence of deformities, older age or economic reasons. Conclusions: By analyzing external fixation treatment efficacy of 2890 patients with cerebral palsy for 26 years, Qin Sihe's orthopaedic surgery team has found that external fixation orthopaedic surgery is mainly suitable for spastic type. Appropriate surgical method should be chosen according to the patient's age, type, and the characteristics of the illness. The patients with complex condition should be treated to by optimizing the combination of different surgical methods with reasonable postoperative rehabilitation to improve the effect of surgical treatment. Acknowledgements:


  EP 44: The Enlightenment Of Qin Sihe's 33,160 Limb Deformity Correction Surgeries To International Orthotics In 38 Years Top


Zhang * Li

National rehabilitation hospita, Beijing, China

Background: Professor Qin Sihe has dedicated himself to technical study of orthopaedic surgery transmission for 38 years. During these years, he has successively implemented 33,160 orthopaedic deformity surgeries, including limb deformity after polio heritage, central paralysis, rachischisis, trauma and various limb deformities caused by congenital disorders, which has undoubtedly provided useful database for the causes of world orthopaedic surgery, orthopaedics and even human health. Methods: Analyzing the database will provide great wealth for human health. Results: Analyzing the database will provide great wealth for human health cause in limb deformity disease classification, disease development, treatment, disease prevention and control. Conclusions: Analyzing the database will provide great wealth for human health cause in limb deformity disease classification, disease development, treatment, disease prevention and control, and meanwhile will lay a substantial clinical basis for professor Qin Sihe's limb reconstruction theory. Acknowledgements:


  EP 45: Surgical Management Of Severe Deformities Of Foot And Ankle By External Circular Fixation, About 15 Cases. Top


Javier Martínez Ros, Cesar Salcedo Canovas, Jose Molina González, Francisco Javier Carrillo Piñero, Juan Pedro García Paños, Pedro Antonio Martínez Victorio

Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain

Background: Deformities of the foot and ankle can be the result of different etiologies. congenital, traumatic, neurological.. These lesions are usually associated with important structured deformities and / or joint contractures in the foot that makes difficult, per se, a surgical treatment traditional as is the reduction open by traditional incisions with complications derived from precarious vascularization, difficult healing after extensive approaches and deep infections. For this reason, a non-aggressive technique has been introduced by external circular fixation for its resolution. The present paper describes the different procedures applied to a series of 15 patients for the treatment of foot deformities by external circular fixation associated with classical osteotomy techniques or soft tissue surgery with the objective of obtaining a non-painful planar position And proper function. Methods: We present a series of heterogeneous etiologies of 15 cases with severe ankle-foot deformities. In all of them, a technique of circular external fixation was applied, which allows gradual elongation of the joint and correction of most aspects of the deformity. Gestures such as Achilles tendon enlargement, U-shaped or “V” retropéteal osteotomies, midotarsal and subtalar arthrodesis were added if indicated. The results obtained after a minimum follow-up period of 24 months are analyzed. Results: In 14 of the 15 cases a planitic foot was obtained, a fundamental objective of the treatment, with correction, in addition, of deformities such as supination and adduct of the antepie. They resumed their march without external support and resolved chronic planar ulcers due to poor support. Conclusions: This technique allows correction of deformities of the foot by traction on the affected articular blocks (tibio-astragalocalcaneum, madiotarsis) allowing its realignment with distraction of soft parts as well as after performing osteotomies. We obtained less stiffness by the smaller approaches and avoided to alter the precarious healing of the soft parts of these patients. In these patients, the Ilizarov technique should be considered an alternative to classical surgery. These are cases of difficult planning but, despite this, succesifull results can be obtained. Acknowledgements: I would like to thank the work done by all the Traumatology Service of the Virgen de la Arrixaca University Hospital for the preparation of this work, especially Dr. Salcedo, without which this would not have been possible.


  EP 46: Accuracy of acute - Correction and intramedullary fixation of complex deformities of the lower limb. Top


Mahmoud Abdel-Monem El-Rosasy1, Ashraf Atef Mahmoud2, Osama Ali El-Gebaly1, Wael Abdel-Latif Azzam2

1. Tanta University, Tanta, Egypt

2. Faculty of Medicine, Tanta, Egypt

Background: complex deformities of the diaphysis of long bones of the lower limb have been successfully corrected by using circular external fixators with the advantages of ability to gradually correct the deformity, correction of limb length and possible fine tuning of deformity correction. Major disadvantage of external fixators are inconvenience to the patient, pin tract infections and joint contractures. Objective. to evaluate the accuracy of deformity correction and the shortcoming and complications of acute correction of diaphyseal deformities of the lower limb and subsequent intramedullary fixation. Methods: the cases of 28 patients were retrospectively evaluated. All patients had multidirectional deformities of the diaphysis of the femur (no. 19 cases) or the tibia (no. nine cases). The mean age of the patients at the time of surgery was 18 years (range; 16–49 years). Preoperative planning included properly projected radiographs for deformity analysis. Postoperative radiographs were obtained for evaluation of accuracy of deformity correction, residual deformity and quality of fixation. Results: the goal of deformity correction was achieved in 26 cases (93%). Acute palsy of posterior tibial nerve occurred in one case of lower third tibial deformity correction and resolved after urgent decompression of the tarsal tunnel. No cases of deep infection or implant failure were encountered. Conclusions: multidirectional diaphyseal deformities of the lower limb could be precisely corrected in carefully selected cases, however, proper preoperative planning and attention to the technical details are necessary for good results. Acknowledgements: The authors have no conflict of interest


  Reconstruction after articular lesions Top



  EP 47: Pelvic Support Osteotomy A Reconstruction Technique In Failed Hip Prostheses Or Severe Deep Infection Top


León Gonzalo Mora H. Md.

CORA Group - Clínica El Rosario, Medellín, Colombia

Background: Technique described for the treatment of irreparable damage of the hip in children, used and perfected by Ilizarov, modernized with monolateral tutors, application of pins with hydroxyapatite, techniques of early replacement to internal fixation. In Adults, Indicated for rescue and reconstruction of irreparable damage of the hip, Hip arthroplasties failed or complex infections. The monolateral external fixators is applied with angular correction clamps, Swibling micrometric, two low energy osteotomies in the proximal and distal femur. It offers significant advantages over Girleston or arthrodesis. Biomechanically better than arthrodiastasis and ankylosis of the hip, it corrects the mechanical axis and support of loads. Methods: We apply to 20 patients. (20-85 years); Double femoral osteotomy, valguizing and proximal extensor and distal derotation and varus, Stabilized with Monolateral Riel with micrometric Swibling, are stabilized with 6.0 mm pins coated with Hydroxyapatite. Cement, infected tissue and foreign bodies from previous joint replacements, canal rimming, culture taking, antibiotic therapy, were removed and osteogenesis by distraction of the 1mm distal segment. per day. Once the time of distraction is completed at 20-30 days, the external guardian is replaced by a system of LCP plates for early rehabilitation and to avoid complications of external fixation. Results: The technique is applied to 20 adult patients with irreparable damage of the hip by failed arthroplasties, significant bone loss and infection. Patients undergoing more than 6 surgeries (6-18), failed revisions of hip arthroplasty, osteomyelitis, non-candidates for joint replacement, acetabular destruction. Significantly improve functional limitation, Harris score, increase from 30 preoperative to 84 postoperative, allows functional walking in 100% of patients, with a 40% aid (Walker or Staff). Corrected the discrepancy in average of 62mm. At an average of 14mm. At the end of treatment, the Trendelenburg gait improves, and 95% of patients express great satisfaction with the procedure. There was no recurrence of infection, analogous scale of pain between 0-3. The mechanical axis of the limb and knee joint alignment are corrected. They required additional surgeries such as Judeth's 40% Cuadriceplasty for knee contracture, 45% osteosynthesis material removal, 15% additional elongation. Average treatment time 4.5 months (3-6). Conclusions: Recommended for salvage of complications of hip arthroplasty. Acknowledgements: CORA Group


  EP 48: Deformity Correction In Patients With Large Joint Replacement Using An External Fixator. Is This A Safe Procedure Considering The Theoric Risks? Top


Daniele D. Pili, Murizioa A. Catagni, Andrea A. Poli

Ilizarov Centre Lecco, Lecco, Italy

Background: Is deformity correction using external fixator possible and safe on a limb carrying a joint replacement?. We present a series of 8 limbs in 8 patients with large joint replacement that undergo limb lengthening and /or deformity correction with an external fixator on the same limb. Methods: We present a series of 8 patient that undergo limb lengthening and /or deformity correction using an external fixator on the same limb. Results: All patient achieved full consolidation and a goof result. No serious complication have been noted. No deep infection at the joint replacement was noted. One case suffered low grade DVT treated with short term anticoagulant. Conclusions: Deformity correction and limb lengthening on patients caring a large joint replacement is possible and safe. Despite the small series, no risk of in faction is been noted. DVT is a possible complication and prophylaxis should be considered. Acknowledgements: Deformity correction and limb lengthening with an external fixator on patients caring a large joint replacement can be carried out considering the risk factors. No serious compliances have been noted in our series.


  EP 49: Juvenile Osteochondritis Dissecans - Arthroscopic Treatment Top


Pedro Teixeira Mota1, António Lemos Lopes2, Marta Maio2, Rita Sapage2, Carlos Mota Pintado3

1. Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal

2. Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal

3. Centro Hospitalar de Trás-os-Montes e Alto Dour, Chaves, Portugal

Background: Osteochondritis dissecans (OCD) is a pathological process in which a portion of subchondral bone and its overlying carti¬lage become damaged. There are two forms of the disease. juvenile OCD (open physes) and adult OCD (closed physes). It usually presents with nonspecific symptoms, ranging from mild pain to joint effusion or locking. The true cause of OCD still remains unclear. Methods: We report the case of a patient with JOCD, submitted to surgical treatment. Results: We present the case of a 14-year-old adolescent, who presented with right knee pain after trauma, while playing soccer. The pain was mostly restricted to the lateral compartment and he presented knee swelling. The radiography showed an osteochondral lesion on the lateral femoral condyle. MRI confirmed the presence of an osteochondral lesion in situ, with 1.5 cm and the presence of liquid between the bony bed and the fragment, making it unstable. The patient was submitted to arthroscopic treatment. The lesion was levered and both surfaces were shaved. Microfractures were performed on the subchondral bed. The fragment was reduced and fixed with two absorbable screws. With 24 months of follow-up, the patient is painless, has total knee range of motion and plays soccer without limitations. MRI shows integration of the fragment. Conclusions: JOCD lesions tend to show greater healing rates than adult OCD lesions. Treatment depends on the stage of the disease. Usually, conservative treatment is reserved to patients with JOCD stage I or II, but in unstable lesions, surgical treatment is recommended. The purpose of surgical treatment is to ensure anatomical reduction and stable fixation of the lesion, because unhealed lesions is associated with early onset of osteoarthritis. As shown in this case, arthroscopic treatment is the gold-standard for unstable JOCD lesions. The surgical aggression is minimal and it is usually associated with good to excellent results. Acknowledgements: The authors have nothing to disclose.


  EP 50: Experience In Surgical Treatment By External Fixation To Perform Knee Arthrodesis After Septic Failure. Top


Javier Martínez Ros, Cesar Salcedo Canovas, Jose Molina González, Francisco Javier Carrillo Piñero, Juan José López Martínez, Francisco De Prado Campos

Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain

Background: Knee arthrodesis is a rescue procedure after the failure of the arthroplasty. There are several techniques available to achieve femoro-tibial fusion, such as internal fixation using intramedullary nails, plaques or a combination of both; Or external fixation (FE). In the case of septic defects, FE is the optimal treatment, since the absence of a foreign body reduces the risk of relapse, in addition to being able to perform it in a single phase. In this communication, we present our experience in the use of FE in different configurations, from monopolar, biplanar fixation to circular, in order to achieve femoral-tibial fusion after septic failure, analyzing its results and the times used. Methods: We present 16 patients on whom knee arthrodesis was performed by FE due to repeated septic failure of knee arthroplasty. The results obtained are analyzed in terms of. epidemiology, FE configuration used, the attainment of arthrodesis, complementary tests used, associated reconstruction techniques, arthrodesis attainment times, local and systemic complications. Results: There are 12 patients, 7 males and 5 females. Monopolar fixation was used in 6 cases, biplane in 3 and circular in 7 of them. The referring results to the previous items were collected. Conclusions: The FE has important advantages over internal fixation systems, since in addition to this, not implanting permanent material that can act as a nest for infection of the future relapse, it allows axial compression at the level of arthrodesis and provides versatility at the time of applying reconstructive techniques in a context where major bone loss is frequent with subsequent associated dysmetria. The different configurations allow us to customize the case, depending on the particularities of the patient regarding previous history, bone loss, stability.. Thanks to the arthrodesis the patient gets a stable and painless extremity, but with difficulty climbing stairs, sitting in cinemas .. but in spite of everything a fused member is more efficient and functional than an amputation above the knee in all The population groups. Acknowledgements: I would like to thank the work done by all the Traumatology Service of the Virgen de la Arrixaca University Hospital for the preparation of this work, especially Dr. Salcedo, without which this would not have been possible.


  Reconstruction after lower limb trauma Top



  EP 51: Bone replacement after extensive segmental loss - Case report Glauber K Linhares, Ivonir Fagundes Alves Junior, Thiago Amorim Bastos, Ricardo Krikor Dejehizian, Hilario Boatto Top


UNIFESP, São Paulo, Brazil

Background: The authors present the case of a 33-year-old motorcycle accident victim who presented loss of the middle and distal third of the left tibia at the accident site. In cases of great bone loss the surgeon is left with the difficult decision to amputate or preserve the limb. There is little description in the literature of the best treatment option. This case illustrates that the possibility of reimplantation of a large bone segment is possible, with good results for the patient. Methods: Patient was submitted to bone reimplantation and external fixation as damage control. Subsequently, he was submitted to external circular fixation and evolved to consolidate the segment after 11 months of use of the fixator. After removal of the fixator, the patient was submitted to ankle arthrodesis. Results: Although patient presents decreased limb function he was able to maintain his lower limb and satisfied with the result, as the amputation was avoided. Conclusions: In cases of extended bone loss, the reimplation should be considered. Taking into consideration that in this case, this technique was successful and patient was satisfied with the result. More cases need to be studied in order to stablish a standard of care. Acknowledgements: Author refers no conflits of interest.


  EP 52: Fractures Of The Distal Femur. A New AO Subtype Classification For Type 33C3 Requires Validation And Planning Treatment Of These Fractures.Case Report Top


Bernard Prakash Devadasan

Mawar Medical Centre, Seremban, Malaysia

Background: A classification is useful only if it considers the severity of the bone lesion and serves as a basis for treatment and for evaluation of the results. Fractures of the distal femur are divided into three types, which are subdivided into three groups, hierarchical organization in triads. Since the articular injury is the most important for treatment and prognosis. Adult articular cartilage tends to tear at the junction between calcified and uncalcified cartilage, leaving the osteochondral junction undisturbed. The adolescent in contrast does not have a tide mark because he has less calcified cartilage and the shearing forces are transmitted deep to the osteochondral junction. This is in contrast are fixed with bioabsorbable smart nails. Methods: We describe a very distal femur articular fracture in an 18-year boy motorcyclist who had an axial loading fracture when his left knee hit against a divider. He sustained an open grade 3 distal femur fracture with lateral subluxation of the patella and medial retinacula ligament tear. Wound debridement, and bone fragments were fixed with cancellous screw before host area begins to fill in and the free fragment will not fit back. Stabilization of the joint was done with Ilizarov fixation. Results: The patient was started on full weight bearing with the aid of a walking frame. Manipulation of the joint was done and Ilizarov fixation at the joint interphase was converted to a hinge and physiotherapy was started. The patient developed poor knee extension due to deficient medial quadriceps with scarring fibrosis. He underwent a fascia lata graft with anchor sutures and Krackow suture plication. The patient regained full function with union of the fracture and knee range of motion. Conclusions: The dread complication is stiffness of the joint. Ilizarov fixation allows early weight bearing and hinge fixation prevents flexion contracture of the joint. Type 33C3 should be sub classified as 33-C3-1 lateral condyle articular, 33-C3-2 medial condyle articular 33-C3-3 articular multi-fragmentary as it relates to techniques/implants that require interfragmentary compression. A validation should be conducted via a prospective clinical study to assess fractures of the distal femur and allow communication of a classification for treatment and outcomes. After completion of this phase this sub type classification may be officially validated as there is no other method of fixation of these types of fractures other then screw fixation with Ilizarov stabilization. Acknowledgements: Prof Maurizio Catagni


  EP 53: Gradual reduction of post traumatic chronic knee dislocation using Ortho-Suv Hexapod: A case series of 2 patients Top


Zamri Ab Rahman1, Johan Abdul Kahar2, Rohaman Tasarib1, Ashraf Hakim Abdul Halim2, Prasad Paramasivam1

1. Hospital Serdang, Kajang, Malaysia

2. Universiti Putra Malaysia, Upm Serdang, Malaysia

Background: Chronic knee dislocation is a rare condition. The best treatment for this problem is still debatable. Only limited amount of publications is available regarding the strategies of treatment; most of which are case reports. One of the ways to reduce a chronically dislocated knee is by gradual reduction using a hexapod frame. We wish to report on 2 cases of chronic knee dislocation that we have successfully reduced with gradual correction using the Ortho-SUV hexapod system and share their outcome. Methods: 2 male patients, aged 21 and 17 respectively, suffered from post-traumatic chronic left knee dislocation. Gradual reduction of the knee joints was carried out for both patients using the Ortho-SUV hexapod frame (13 months post trauma for the first patient, and 4 months post trauma for the second patient), and full reductions were achieved after 5 weeks and 8 weeks respectively. A period of programmed passive range of motion exercises was then commenced. Next, modification into hinge construct was done to allow the start of active range of motion exercises in a controlled manner. Knee functions were assessed after removal of all hardware. Results: Good reductions of their knee joints were obtained as per radiographic evidence. Resulting knee functions were graded “fair” for the first patient (72/100) and “good” for the second patient (87/100) based on Lysholm Knee Scoring Scale. The entire treatment process using the hexapod frames were well tolerated by both patients. Apart from mild pin tract infections, no other complications occurred during their course of treatment. Conclusions: Based on our experience with these 2 patients, we conclude that gradual correction using a hexapod frame is a good treatment option for chronic knee dislocation. This is a valuable option in cases which we wish to avoid open reduction or in cases of failed acute open reduction. Hexapod frames also have other advantages such as performing simultaneous multi-axial deformity correction hence cutting short the time on external fixator. Hexapod frames also can provide 2 modes of correction in knee dislocation; after gradual reduction is done it can be followed by gradual passive range of motion training mode. Acknowledgements: The authors declared no potential conflict of interest with respect to the study authorship and/or publication of this article. None of the authors has commercial affiliation with the product named in the study.


  EP 54: Infected Tibial Fracture With Diaphyseal Bone Sequestrum: Treatment By The Ilizarov Method And Assembly. Top


Manuel Azevedo

Venerável Ordem da Lapa, Porto, Portugal

Background: Case study presentation. The patient was involved in a car accident abroad, with fracture of the leg bones, nail reduction with skin necrosis and bone sequestrum. Repatriation with indication for amputation. Methods: Was treated by the Ilizarov's method and assembly. Sequestrectomy, acute shortening with fibula osteotomy and corticotomy of the distal 1/3 tibia. As the fibula consolidated, it was necessary to make another assembly to traction the external maleollus after osteotomy. Results: The goal to maintain the leg and resolve the infectious problem was obtained. Conclusions: Using the Ilizarov's method and assembly is the best instrument for the resolution of complex traumatic lesions, both concerning methodology and materials. Acknowledgements:


  EP 55: Treatment Of Coxa Vara In A Patient Allergic To Synthesis Material. Treatment With Ilizarov'S Method And Assembly. Top


Manuel Azevedo

Venerável Ordem da Lapa, Porto, Portugal

Background: Case study presentation. Clinical case of femur fracture in coxa vara in a car accident. Besides the fracture's curve, the patient was also allergic to synthesis materials. Methods: The treatment approach was with Ilizarov's method and apparatus, with a femur assembly to correct the axis and fracture consolidation. Results: In this case, the objective was of the consolidation and it wasn't necessary to extend the assembly above and below to protect the articular surfaces. Conclusions: It is stated that the objectives were obtained. fracture consolidation, axis correction and no allergic complication concerning the used material. Acknowledgements


  EP 56: Leg Bone Fracture With Compartment Syndrome And Foot Ischemia After 48 Hours: Treatment By The Ilizarov Method And Assembly. Top


Manuel Azevedo

Venerável Ordem da Lapa, Porto, Portugal

Background: Case study presentation. The patient had a height fall with bone leg fracture, presenting compartment syndrome and foot ischemia after 48 hours. Methods: The Ilizarov's assembly was made and the patient was sent to vascular surgery that issued the following opinion. “Serious ischemia with signs of irreversibility – fixed cyanosis. Reduced mobility and no sensibility. Indication of hypocoagulation to restrain the ischemia level with possible future indication for amputation below the knee”. The plastic surgery made a radiusvascular bone graft. As it did not work, corticotomy of the superior tibia and bone transport was made. Results: The consequences were distal amputation of Hallux's F2 and from F1 to F2 of the second toe. Conclusions: The process' resolution was obtained with the maintenance of the leg. Acknowledgements:


  EP 57: Treatment Of Comminuted Exposed Fracture Of The 1/3 Leg Distal With Extensive Loss Of Soft Tissues Treated With Ilizarov'S Method And Assembly Top


Manuel Azevedo

Venerável Ordem da Lapa, Porto, Portugal

Background: Case study presentation:. Clinical case of comminuted exposed fracture with soft tissue loss. Transferred from other hospital with single tube osteotaxis. It should be noted that this case was with a patient with chronic cannabis addiction. Methods: Single tube osteotaxis was removed and the Ilizarov apparatus was attached to the leg and foot, with the external Ilizarov fixator. All infected bone was removed and the wound closed; the top-to-top fracture was reduced through acute shortening with wound suture. A proximal corticothomy was made to correct the dysmetria. Results: The objective was to control the foot, obtaining fracture consolidation and regaining length. This traumatic situation was treated by the Ilizarov method and apparatus, obtaining the correction of all problems. Conclusions: The assembly was extended to the foot; maintaining the foot in a functional position, with higher stability to ease the soft tissues healing process. The infeccious process was solved and total recovery were obtained. Acknowledgements


  EP 58: Treatment Of Acquired Deformity In Ankle's Equinus (Sequelae Of Infected Ankle's Fracture) By The Ilizarov Method. Top


Manuel Azevedo

Venerável Ordem da Lapa, Porto, Portugal

Background: Case study presentation. Clinical case of correction of deformity in ankle's equinus in the sequence of a distal tibial fracture. Surgically treated in Belgium with plaque and screws, worsen with infection. Methods: With appropriate treatment resulted in an equinus deformity, dysesthesia, algoneurodistrophy and tibial osteomyelitis. Patient was repatriated, and begun the treatment with Ilizarov's method and apparatus, with full resolution of the problems. Results: The intervention consisted in assembling the apparatus to correct the deformity, regaining control at finger level and other articulations and in the promotion of the patient's march. Conclusions: It's highlighted the importance of a correct assembly, with the use of articulations to the correction of the deformity for the protection of the articular surfaces and preventing the emergence of new deformities (for example, at finger level). The ligament distraction is of high importance to impede the suffering of the articular surfaces in order to obtain articular mobility. It is also a surplus to the physiatric recovery after the removal of the external fixator. Acknowledgements:


  EP 59: Exposed Superior Tibial Fracture With Bone And Skin Loss Treated By The Ilizarov Method And Assembly. Top


Manuel Azevedo

Venerável Ordem da Lapa, Porto, Portugal

Background: Case study presentation. Traffic accident, transferred from another hospital with osteotaxis with bone and skin loss. Methods: Treatment with the Ilizarov method and apparatus. Assembly with fracture reduction by acute shortening with associated fibula osteotomy. Results: Assembly with fracture reduction by acute shortening with associated fibula osteotomy, which allowed wound closure and exposure resolution. At 3 weeks, the process of distraction to correct the dysmetria was started. Conclusions: During the process there was a period of patient's non-collaboration (athrophic pseudarthrosis) which, after resolution, allowed the fracture's consolidation and resolution of the infectious process. Acknowledgements:


  EP 60: Ilizarov Technique For Correcting Flexion Deformity Of The Knee Of Arthrogryposis Multiplex Congenita Top


Qin Sihe

national research center of rehabilitation technique aids, Beijing, China

Background: To study the methods and effects of Ilizarov distraction technique in treatingthe flexion deformity of the knee caused byarthmgryposis multiplex congenita. Methods: Between August 1998and February 2003, 6 patients(10 knees)with the arthrogryposis multiplex congenita were treated, 4 patientsin double knees, 5 males, 1 female, mean age 8 years and 2 months, ranged from 3 years and 7 months to 13. years.The preoperative flexion degree was averagely 51°. Thepatients accompanied 13 other partsmalformation of limbs. The modffied Ilizarov distraction apparatus of the knee was used. Whileinstalling theapparatus in the operation, the knees should be kept in the location of maximum extension, the center ofjoint hinges on the apparatus should be placed towards the rotatory center of the knee, two groups of 2 mm Kwireswere passed through the femur and tibia around the knee. who were fixed on the proximal and distalrings, Distraction Was started after the surgical procedure 5 days via rotating the threaded rods at the posteriorof the knee, at an average of 2 to 3 mm per day, at the first week, after 2 weeks with tlle rate modified to 2mm per day, up to the knee extended to 0°. The accompanied deformities of the hip and/or the foot might becorrected at the sametime or next time. The average duration of the distraction Was 37 days(23-48 days). During the correction all limbs might undergo weight. After 2 weeks at the end of distraction the fixator wasremoved and the patients could walk by a long—leg brace. Results: Ten knees with the flexion contracturewere suffieienfly corrected without severe complications. Nine knees of all were followed upat an averagetime of 1 years and 3 mouths. no recurrence of the deformity Was seen in all patients,their function of walk. Was significantly improved. Conclusions: Ilizarov technique is a simply. safe and effective method formanaging the flexion deformity of the knee of the arthrogryposis multiplex congentia. The procedure isconformable to the biological theories and microsurgieal principles. Acknowledgements: Key words: Orthotie devices, Knee joint, Foot deformities, Congenital, Arthrogryopsis multiplex congentia


  EP 61: Mini-Invasive Distraction Technique For Treatment Of Severe Ankle And Foot Deformities Secondary To Ischemic Contracture Of The Leg Top


Qin Sihe

national research center of rehabilitation technique aids, Beijing, China

Background: To explore the Ilizarov mini-invasive distraction technique for treatment of severer ankle and foot deformities secondary to ischemic contracture of the leg . Methods: Based on the tension-stress low of Ilizarov, a serial of adjustable three dimensions external distractive instrument was developed in our department . From April 2002 to March 2004, eight patients with ankle and foot deformities secondary to ischemic contracture of the leg induced by trauma and fracture were treated with the distractive instrument. Of them, 4 patients were male and 4 females, aged from 13 to 31 years with an average of 23 years. Five affected leg were in the left and 3 in the right. Preoperative abnormal style included talipes equines in 6 feet and equinovarus in 2 feet, with extensive scar contracture in the legs .Five patients suffer from failure of soft tissue release before, two patients with severe bony deformity of the feet were underwent limited foot triple osteotomy in this department before the distractive correction .Preoperatively ,the distractive framework was set up to meet special condition in each patient, in surgery, pins were placed according to Ilizarov's principle, then fixed with the three dimensions framework .Begin to distract from 7 days after operation and distractive time from 29 to 60 days with an average 46 days, the turnbackles in the framework were revolved slowly, distractive force was applied on the contracture tissue, therefore, talipes equines or equinovarus were corrected gradually. During the distractive period, proper loading walking was encouraged. Results: All of the 8 patients were followed up from 10 months to 2 years and 5months, with an average of 13 months. All of deformities in the feet were corrected satisfactorily, full feet contact with the ground in stand or walking and were achieved with good function .No complication, such as pin tract infection, skin necrosis and neurovascular injury was occurred in this group. Conclusions: Mini-invasive distraction technique for treatment of severe ankle and foot deformity secondary to ischemic contracture of the leg is safe and mini-injury means with satisfactory outcome ,it is also an effective approach for treatment of various kinds of rigid foot anomaly. Acknowledgements: Key words Ischemic contracture of the leg Foot anomaly Corrective instrument Ilizarov technique Min invasion


  EP 62: Clinical Analysis Of 107 Fatients With Foot And Ankle Deformities Caused By Spina Bifida Top


Qin Sihe

national research center of rehabilitation technique aids, Beijing, China

Background: To analyze the incidence, clinical features, deformity categories and orthopedic treatment of foot and ankle deformities caused by spinal bifida. Methods: Methods. The charts of the patients received surgical treatmentbetween January 1990 and July 2009 were studied retrospectively, and the data were analyzed. Results: One hundred and aeven cases of foot and ankle deformities caused by spinal bifida received surgical treatment and were included. There were 44 males and 63 female patients. The average age was 17.7 years (range,1.3-52.0 years).and 50.5 %(54/107) of cases were over 18 years old and had spinal bifida occulta, and the other 49.5% had spinal bifida manifesta. There was only one case with thoracic spinal bifida (T3-8), while the other 106 cases had lumbosacral vertebrae cleft (mainly L3to Sacrum). Among a total of 165 feet unilateral involvement was found in 49 cases (22 cases on the left side, 27 cases on the right side), bilateral involvement in 58 cases. Combined ankle-foot deformities included 76 varus talipes, 23 talipes valgus, 15 flail feet, and 51 other foot deformities. Other site deformities, as a result of spinal bifida, included knee flexion or hyperextension deformity in 4 cases, hip deformity (hip adduction, flexion, or hip dislocation, pelvic tilt,lower extremity discrepancy,etc.)in 17 cases, and urination dysfunction and defecation in 30 cases.Twenty-nine of 54 cases with spinal bifida occulta failed to be diagnosed in other hospitals and the misdiagnosed rate reached 53.7%(29/54). Corrective surgery was performed in only 26 patients. And 50.5%(54/107) of patients (over 18 years old) had severe foot and ankle deformities due to a failure of prior surgical treatment. Conclusions: Spinal bifida is the most commonly found in the lumbosacral vertebrae. Although the main pathogenesis is developmental abnormalities of spinal cord and nerve, the secondary deformity is usually located on the foot and ankle. Some young orthopedic surgeons may not have enough awareness and treatment experience about this disease due to over-specialty of the orthopaedics, so the delay of early diagnosis and treatment is often found and many severe foot and ankle deformities occur. Acknowledgements: Key words. Spinaldysraphism; Foot deformities; Statistical analysis; Orthopedic surgery;


  EP 63: Ilizarov LTS And Limited Osteotomy Of Triple Joint For Correction Of The Severe Adult Talipes Epuinovarus Top


Qin Sihe

national research center of rehabilitation technique aids, Beijing, China

Background: Objective To explore the application of Ilizarov LTS (the Law of Tension-Stress) in correction of adult severe talipes equinovarus. Methods: There were12 patients (13 feet) with an average age of 26 years, included 9 males and 3 females. Of these patients,3 cases were congenital,6 cases were caused by the polio, and 3 cases resulted from other factors. The Ilizarov distraction apparatuses of the ankle and foot joint were grouped at the preoperation in terms of the diseases. During the operation, the release of inter-posterior soft tissue and the limited osteotomy of triple joints of the clubfoot were performed. According to the principles of Ilizarov's passed wires and installed fixator, the distraction devices of the ankle and foot joint which had corrective function in the three-dimensional directions were placed to the tibia and foot, the telescopic rods on the apparatuses were rotated after the operation 7 days. The foot deformity of talipes varus, internal rotation and forefootptosis were gradually corrected, and the patients could bear weight and walk on the deformity foot in the course of distraction correction. Results The average distraction date was 71 days in the 12 patients after the procedure,. Results: ,all the thirteen clubfeet got satisfactory correction, and all patients didn't have these complications such as incision infection, vascular and neural injury, nonunion of the bone, etc. Postoperative average follow up was 1 year and 3 months, no reoccurrence of the deformities, the feet function was good while loading and walking, all of the patients felt satisfactory. Conclusions: Conclusion Utilizing Ilizarov LTS to correct severe adult talipes equinovarus is a safe, minimally invasive, and effective method. Acknowledgements: [Key words] Ilizarov LTS; Correction; Osteotomy of triple joint; Adult ;Talipes equinovarus


  EP 64: Apparatus Assembly And Clinical Application Of Ilizarov Technique For Correcting Ankle And Foot Deformities Top


Qin Sihe

national research center of rehabilitation technique aids, Beijing, China

Background: According to the basic principle of Ilizarov technique, the apparatus assembly, indications, operation methods and clinical effectiveness of Ilizarov technique in the correction of foot and ankle deformities were explored. Methods: In accordance withpathological changes and requirements for correctioning talipes equinus, cavus, calcaneus and forefoot varus or valgus, four standard external fixators were designed on the basis of Ilizarov apparatus assembly and tested biomechanically to correct the above four-foot deformities. The innovation has expanded Ilizarov technique to correcting scar talipes equinus and severe foot valgus caused by rheumatoid arthritis and congenital fibular deficiency. Results: The clinical applications of the four kinds of external fixators have showed reasonable apparatus structure, convenient installation and adequate adjustment of distraction tension. They had been used in 105 cases and achieved satisfactory correction of deformity and functional recovery without severe complications. Conclusions: The four new assemblies of external fixators showed simple structures, good performance, and practicality. Ilizarov technique has played an irreplaceable role in the correction of severe foot and ankle deformities. Acknowledgements: Key words. external fixators, foot deformities, Ilizarov technique, deformity correction.


  EP 65: Application Of Ilizarov Technique For The Treatment Of Stiff Foot Deformity With Skin Scar Top


Qin Sihe

National research certer of rehabilitation technique aids, Beijing, China

Background: To apply the Ilizarov technique in the correction of stiff foot deformity combined with skin scar. Methods: From February 2004 to May 2007, 12 patients were treated with Ilizarov device according to the Ilizarov's principle of tension-stress. There were10cases of talipes equinovarus and 2 cases of talipes equinovalgus. Nine cases underwent limited tarsal osteotomy,3 cases had tendon transfer to restore muscle balance and 1 case had tibial lengthening. The three-dimensional structures of the apparatus were adjusted 5 days after the operation by telescopic rods. In cases of varus deformity,the varus at the forefoot was corrected fist and foot drooping corrected later.The valgus deformity was corrected in the opposite direction. X-ray films were taken regularly to observe the ankle joint and avoid its dislocation. The patients were encouraged to have weight-bearing during the treatment period. The post-operative distraction lasted for an average of 78 days which was followed by a weight-bearing for an average of 69 days and a walking with a foot brace for 2-3 months after the removal of fixators. Results: Twelve patients were followed up for 5 months and 2 years and 4 months. Eight patients had a satisfactory correction of the t deformities with good walking on the whole foot. Four cases had partial recurrence of foot drooping for which 3 cases had a second application of fixators. Finally, 11 cases achieved excellent results. The stiff skin scar became softer and blood circulation improved after the distraction. No infection in the pin sites and incisions, no dislocations in the ankle joint and no damage to nerves and blood vessels occurred. Conclusions: Conclusions Ilizarov technique is a minimally invasive and effective method of correcting stiff foot deformitycombined with skin scar. Limited tarsal osteotomy is needed for bony deformity with a slow distraction. Weight-bearing with a fixator on the foot for more than 8 weeks is necessary for avoiding the recurrence of foot deformity. Distraction may lead to improved blood circulation and regenerated tissue for the skin scar. Acknowledgements: [key words] Distraction osteogenesis; External fixators; Cicatrix; Foot deformities,acquired


  EP 66: Lengthening Over Intramedullary Nail In Case Of Post-Traumatic Femoral Shortening: Interesting Case Report Top


Harshad Mohanlal Shah1, Ravi Varma V. N.2, Rahul P3

1. Ramaiah Medical College & Hospitals, Bengaluru, India

2. J S S Medical College, Mysuru, India

3. Ramaih Medical College, Bengaluru, India

Background: Limb lengthening using Ilizarov external fixation is safe, but the consolidation phase tends to take too long. A method that can safely reduce the time spent in external fixation would help increase patient tolerance and comfort. We report our result of lengthening over nails (LON) method in which an interlocking nail was used along with an Ilizarov external fixator to reduce external fixation duration in limb lengthening. Methods: A 23-year-old male patient with history of trauma and sustained a Type III B compound comminuted intra-articular fracture femur right thigh with bone loss and right tibia shaft fracture. He underwent multiple surgery with wound debridement and plating with External fixator application which was removed after the union of fracture. But patient progressively noticed limp on walking and inequality in limb length. He presented to us with 6cm shortening of the femur and restricted movements of his knee. LON (Lengthening over nail) with Ilizarov external fixation was done. On later date osteoclysis and readjustment of Ilizarov External Fixator was done. The Ilizarov External Fixator was removed after 5 months follow up and distal locking of intramedullary nail was done along with bone marrow infiltration. Results: On latest follow up patient came with thick regenerate with lengthening of femur. He had a residual shortening of less than 2 cms which was negligible. He also had excellent clinical results almost full range of painless movements of his hip and knee joints, very little difficulty for squatting and could sit cross legged and all his activities of daily living were normal. Conclusions: A combination of intramedullary nailing along with external fixation significantly reduces external fixation time while maintaining low rate of complications. Great care needs to be taken to prevent pin track infection. Acknowledgements: No conflict of interest


  EP 67: Going To Great Lengths For The Elderly: Magnetic Limb Lengthening Nails In The Seventh Decade And Beyond Top


Ahmed I. Hammouda1, Vivian L. Szymczuk2, Martin G. Gesheff3, Janet D. Conway3, John E. Herzenberg3

1. Department of Orthopaedic Surgery, Al-Azhar University, Cairo, Egypt

2. University of Illinois College of Medicine at Peoria, Peoria, United States

3. International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, United States

Background: Outcomes with magnetic limb lengthening nails have been reported for the general population. We wanted to determine whether lower limb lengthening using magnetic limb lengthening nails is feasible in older adults. Methods: Retrospective chart and radiographic review was conducted for 5 patients (3 men, 2 women) with a mean age of 67 years (range, 63-72 years). All underwent unilateral lengthening (1 tibia, 4 femora) using magnetic nails. Initial etiology of shortening was trauma (4) and knee fusion (1). Mean lengthening goal was 3.1 cm (range, 2.5-4.0 cm). Results: Mean follow-up after index surgery was 11.9 months (range, 5.7-21.7 months). Mean distraction index was 0.7 mm/day (range, 0.6-0.8 mm/day), and mean consolidation index was 32 days/cm (range, 28-50 days/cm). All healed without requiring bone grafting. Two complications occurred. 1 limb had osteomyelitis (required premature nail removal) and 1 limb was not lengthened for several days (remote controller device malfunction) and was treated by increasing the lengthening rate from 1 mm/day to 1.25 mm/day for 1 week. Conclusions: Lengthening with magnetic nails in older adults resulted in distraction, consolidation, and complication rates that are similar to outcomes reported in the general population. Magnetic limb lengthening nails are a viable option to treat limb length discrepancy in otherwise healthy individuals into the seventh and eighth decades of life . Acknowledgements: AIH, VLS, and MGG have nothing to disclose. JDC is a consultant for Biomet, Cerament, and DePuy Synthes; receives research support from Microbion, CD Diagnostics, and Acelity; receives royalties from the University of Florida; and receives fellowship support from Biocomposites. JEH is a consultant for Orthofix, OrthoPediatrics, NuVasive Specialized Orthopedics, and Smith & Nephew; receives research support from NuVasive Specialized Orthopedics; and is on the editorial board of the World Journal of Orthopaedics. The following companies supported a non-profit organization that is part of Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). CS Medical Supply, Metro Prosthetics, and Stryker. The following organizations supported an annual course for orthopedic surgeons that is held by Rubin Institute for Advanced Orthopedics (Sinai Hospital of Baltimore). Baxter, DePuy Synthes, Merete Technologies, MHE Coalition, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Smith & Nephew, Stryker, and Zimmer Biomet.


  EP 68: Management of a compound proximal femur fracture in a twelve year old child: An interesting case report Top


Harshad Mohanlal Shah1, Naveen Kumar Lokesh1, Abhilash Palla1, Ravi Varma V. N.2

1. Ramaiah Medical College & Hospitals, Bengaluru, India

2. ., ., India

Background: Proximal femur fractures are more prone for complications. Treatment includes internal fixation with I.M. Nail, DHS, 95* blade plate etc., also external fixation with various fixators as other options. Methods: A 12-year-old male child presented with history of fall from moving bus on 14/Feb/2015 sustained open book injury of pelvis with tear of his bladder and left femur. Having sustained a left proximal femur fracture and bladder rupture, he underwent exploratory laparotomy, bladder repair and open reduction internal fixation for femur fracture with DC plate, on the same day. The proximal femur fracture got infected with the same organisms of his urinary infection. It progressed to infected non-union for which he underwent wound debridement, implant removal, antibiotic beads and fixation with Ilizarov external fixator was done on 29/Jun/2015 (4 ½ months after plating). Follow up on 05/Aug/2015 (5 weeks), infection was controlled hence antibiotic bead removal and Ilizarov external fixator was changed to AO tubular External Fixator. The patient was weight bearing in a whole course after external fixator application. The fracture was radiologically united and AO fixator was removed on 26/Nov/2015 (5 months) & above knee POP slab was applied. Results: On last follow up of on 19/Apr/2016 after fixator removal, this patient had . 1. Fracture united. 2. Infection controlled. 3. No deformities. 4. Less than two cms, limb length discrepancy. He also had excellent clinical results almost full range of painless movements of his hip and knee joints, very little difficulty for squatting and could sit cross legged and all his activities of daily living were normal. Thus we were able to achieve an excellent result in this young lad, both radiologically & clinically. Conclusions: Treating compound proximal femur fractures with external fixators gives good results even after complications, particularly infection and nonunion of the fracture after internal fixation. In this patient, external fixation has shown excellent result in treating these conditions. As an afterthought, maybe treating all such patients with external fixation in the first place is safer, even in children. Acknowledgements: No conflict of interest.


  EP 69: Compound fracture sub-trochanter of femur treated by initial Ilizarov & subsequent AO external fixation: A case report Top


Harshad Mohanlal Shah, Rahul Hemant Shah, Sandeep Reddy, Naveen Kumar Lokesh, Rahul P

Ramaiah Medical College & Hospitals, Bengaluru, India

Background: Sub-trochanteric fractures of the femur are usually treated by Internal fixation with DHS (dynamic hip screw) or PFN (proximal femoral nail) or similar implants. This case report is about a successful management of a sub-trochanteric femur fracture with an external fixator, due to a compound fracture. Methods: Mr AKK, male, 48 years, was admitted with a history of RTA on 16/May/2015 with comminuted fracture of the sub-trochanter of the left femur with open wound Type 2. The wound was of 7 cm x 3 cm x 3 cm over left upper thigh. This was surrounded by deep abrasions over left upper thigh of 15 cm x 15 cm. There was swelling & ecchymosis of the thigh antero-laterally. 0n 17/May/2015, wound debridement, closed reduction and Ilizarov External Fixation was done. Wound debridement was done again, four days later. Nine days later, wound debridement & split skin grafting was done. Fourteen days later, he was discharged with the Ilizarov External fixator on. He had pseudomonas infection of the soft tissues and half pins with pain in the knee joint. On 24/Jun/2015, thirty-nine days later, the Ilizarov Fixator was removed and AO External Fixation was done. On 19/Sep/2015, 126 days later (4 1/4 months), dynamization of his AO fixator was done. On 19/Oct/2015, 156 days (22 weeks / 5 ¼ months) later, his AO External Fixator was removed. His fracture had united in 5 ¼ months. Results: On last follow up on 18/Jun/2016, 8 months after fixator removal, he had clinical and radiological excellent results with union of the fracture and healing of all the wounds.He was able to get back to his daily activities like walking, sitting cross legged & squatting but with mild difficulty. Conclusions: Compound sub-trochanteric fractures of the femur can be treated with external fixators giving good results without complications as in this patient, particularly infection of the fracture site which would have occurred if internal fixation was preferred. Acknowledgements: No conflict of interest.


  EP 70: Intra-Articular Corrective Osteotomies Combined With The Ilizarov Technique For Treatment Of Knee Joint Deformities Top


Jia Xu, Qinglin Kang, Yimin Chai

Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China

Background: The aims of the present study were to present our experience of using the combination of intra-articular osteotomy and the Ilizarov method for the treatment of different knee joint deformities. Methods: Six patients (age, 15-50 years) with abnormal hemi joint line convergence angle (HJLCA) and mechanical axis deviation (MAD) were included. Tibial hemiplateau elevation or femoral condylar advancement was performed for all patients. Limb lengthening and residual deformity correction were performed with circular or monolateral external fixators guided by the principles of the Ilizarov technique. Results: The average HJLCA was 15.6° preoperatively and improved to 0.4° at the last follow-up. The average MAD was 70.0 mm preoperatively and improved to 9.1 mm. The average tibiofemoral angle was 31.0° preoperatively and improved to 4.9°. The average follow-up was 2.8 years (range, 1.5–4.1 years). All patients had limb-length discrepancies with an average of 6.3 cm preoperatively, which decreased to 1.1 cm at the last follow-up. All osteotomies and distraction zones healed without complications. Conclusions: Application of intra-articular corrective osteotomies combined with the Ilizarov technique allowed reconstruction of the knee joint with ideal HJLCA and overall mechanical axis. These techniques are beneficial for restoring both the function and cosmetic appearance of the lower limbs. Acknowledgements: The work was partially supported by grant from National Natural Science Foundation of China (NSFC No.81572122).


  EP 71: Minimal Internal Fixation Augmented By The Ilizarov Frame In Simple Diaphyseal Tibial Fractures In Adults. Top


Mohamed El-Sayed, Ashraf Atef

Tanta University, Tanta, Egypt

Background: Although intramedullary fixation of closed simple (type A or B), diaphyseal tibial fractures in adults, provides good tolerance by patients with lower morbidity and better mobility, it is associated with higher complication rates. Methods: This study was designed to evaluate the results of management of these fractures using percutaneous minimal internal fixation by one or more lag screws, and an Ilizarov external fixation. This method was tested to evaluate its efficacy in immediate weight bearing, fracture healing, and prevention of any post-immobilization stiffness of the ankle and knee joints. This is a randomized blinded study, that was performed at a referral, academically-supervised, level III trauma Center. Results: 324 of the initial 351 patients completed this study and were followed for a minimum of 12 months, (12 to 88 months). The age of the patients ranged from 20 to 51 years. Ankle and knee movements were encouraged immediately post-operatively, as well as full weight bearing. Solid union was assessed clinically, and radiographically. Active and passive ankle and knee ranges of motion were measured and compared to the normal side using the Wilcoxon signed rank test for matched pairs. The subjective Olerud and Molander Ankle Score was also used to detect any ankle joint symptoms at the final follow-up. Conclusions: None of the included patients showed delayed or nonunion. All the studied fractures healed within 95 to 129 days. Based on the final clinical and radiographic outcomes, this technique proves to be adequate for the management of simple diaphyseal tibial fractures. On the other hand, it is relatively expensive, technically demanding, necessitate exposure to radiation and the patients are expected to be frame friendly. Acknowledgements: Tanta University Hospitals


  EP 72: TrueLok-Trauma Temporary Circular Fixation And Conversion To Definitive TrueLok Hex Fixation In The Management Of Open Tibial Fractures With Bone Loss Top


Sivan Shankar Sivaloganathan, Jens Brahe, Alex Joel Trompeter

St George's Hospital Trust, London, United Kingdom

Background: The TrueLok (TL) ring fixator is a modern-day variant of the Ilizarov apparatus. TL-Hex is the limb reconstruction hexapod component of the TL system with 6 variable struts allowing 3-D manipulation of bone segments. The rapidly applied TL Trauma system utilises rings from the TL Ilizarov apparatus but with 3-4 adjustable struts. Unlike hexapods, there is no computerised control with the TL Trauma. The rapid struts offer ability to crudely reduce fractures. Unlike monolateral fixators, TL Trauma can be used as a temporary fixator and then be retained / converted to definitive ring fixation. Methods: We present two cases using TL-Trauma in anticipation of reconstruction with TL-Hex frames, in management of open tibial fractures with bone loss. Results: Case 1. 41-year-old male. 3A open distal tibial fracture with compartment syndrome. The non-viable distal tibial block was removed at debridement creating an 8-cm defect. A TL-Trauma fixator plus a cement spacer was applied. After wound management, the TL-Trauma was converted to a TL-Hex frame retaining the original rings, creating a construct for bone transport to ankle fusion. After 9 months, the arthrodesis united and the fixator removed. Case 2. 31-year-old male. 3B open distal tibial fracture. The fracture and soft tissues were debrided, resulting in a 6cm bone defect. The TL-Trauma fixator was applied - the rapid struts biased posteriorly to for access to allow plastic surgeons to perform a free flap synchronously. The TL-Trauma was converted to a bone transport TL-Hex frame subsequently, with retention of the original. Conclusions: In both cases, the TL-Trauma frame allowed for excellent soft tissue management, provided stability, and proved useful as part of the definitive frame. Careful attention to the orientation and inclination of the TL-Trauma rings relative to the tibial axis is required if they are to be used as part of the definitive reconstruction frame. Acknowledgements: St George's Hospital Trust


  EP 73: Is Anterior Internal Subcutaneous Fixation An Effective Minimally Invasive Technique For Unstable Pelvic Fractures Treatment? - Clinical Case Top


Diogo Pascoal1, António Figueiredo2, Jorge Pon3, João Rosa1, Nuno Esteves3, João Esteves1

1. Centro Hospitalar do Porto, Porto, Portugal

2. Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

3. Centro Hospitalar e Universitário Cova da Beira, Covilhã, Portugal

Background: Unstable pelvic fractures are often associated with high energy trauma, and have higher morbidity and mortality rates. The initial surgical treatment includes either external fixation or plate fixation to close the pelvic ring and decrease blood loss. However, in the politrauma patient, both techniques may put the patient at risk of either pintract or deep plate infections and may increase blood loss and operative time. Recently, a minimally invasive surgical approach has been described that allows the pelvic ring to be closed and percutaneously stabilized using spinal implants as an internal fixator. Methods: We introduce a case of a 63-year-old man who suffered high energy pelvic trauma. In emergency setting, the patient was hemodynamically stable, and had no associated lesions. Radiologically, there was an unstable pelvic ring fracture classified as lateral compression type III (Young and Burgess) and Tile C. As an unstable fracture, the patient was proposed to surgical treatment with anterior internal subcutaneous fixation. Intra-operatively closed reduction of the pelvis was achieved with C-Clamp. After reduction, anterior pelvic stabilization was achieved by minimally invasive placement of 4 supra-acetabular iliac poliaxial screws, then, a subcutaneous transfixation rod was inserted and attached to 2 poliaxial pubic symphisis screws. Posterior pelvic stabilization was carried out using two percutaneous screws to the sacroiliac joint. Results: Surgical intervention and postoperative elapsed without complications. He received an early rehabilitation program, and at 6 weeks post operatively resumed walking with crutches. At 3 months the internal fixator was extracted. At 6 months postoperatively, the patient showed satisfaction with the surgical outcome, with good clinical and radiographic evolution, able to walk without crutches and an Harris Hip Score of 87 (Good). Conclusions: The internal subcutaneous fixator represents a novel minimally-invasive procedure for definitive treatment of anterior pelvic ring instability. Has the advantages of soft tissue preservation, increased stability, facilitated patient care due to the subcutaneous location of the implant, and easy access of the abdominal area allowing for emergency procedures. In unstable pelvic fractures, anterior internal subcutaneous fixation is presented as a simplified alternative solution, but effective, allowing the patient to return to satisfactory function and independence in activities of daily living. Acknowledgements: The authors did not receive grants or outside funding in support for preparation of this manuscript.


  EP 74: Calcaneus Ulcer Treated With An Anterolateral Thigh Free Flap - Case Report Top


Pedro Teixeira Mota1, José Miguel Braga2, Isabel Oliveira2

1. Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal

2. Centro Hospitalar de São João, Porto, Portugal

Background: The anterolateral thigh (ALT) flap originally described in 1984, is supplied by the descending branch of the lateral circumflex femoral artery. The artery, a musculocutaneous perforator in 85% of cases, is usually accompanied by two veins. This flap offers the advantages of being pliable with a large cutaneous territory, having a lengthy pedicle with good caliber vessels and possessing multiple components (adipofascial, muscle, fascia, and skin). Methods: We present a case report. The information was obtained by patient interview and examination and by analysis of clinical records. Results: We present the case of a 26 years old male patient, who sustained a work-related accident which resulted in open dislocation of the left ankle with extensive soft tissue injury and fracture of the right calcaneus and metatarsals. The left lower limb was treated accordingly and the right calcaneal and metatarsal fractures were addressed conservatively. An ulcer developed in the right calcaneal area and evolved unfavourably to an extensive necrotic area. After multiple debridements, the defect was reconstructed with a contra lateral ALT free flap with terminal-terminal anastomosis to posterior tibial artery and two concomitant veins. Four months after the surgery, the flap is well vascularised and the surgical wound has no signs of dehiscence. Conclusions: ALT flap is very versatile and the types of tissue to be included in the flap can be selected according to the defect to be reconstructed, as a suprafascial flap, fasciocutaneous flap or musculocutaneous flap. Although its use has been extensively described in head and neck reconstruction, its versatility makes it a good option for reconstruction of other anatomical areas, as it could be seen in this case,. Acknowledgements: The authors has nothing to disclose.


  EP 75: Two-stage reconstruction with external fixation of a bone defect after open distal shaft tibia and fibula fracture – Case report Top


José Simões Monteiro, Ricardo Alves, Ju