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   Table of Contents - Current issue
Coverpage
January-June 2018
Volume 4 | Issue 1
Page Nos. 1-62

Online since Thursday, May 3, 2018

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EDITORIALS  

Editorial: The Janusian issue p. 1
Milind M Chaudhary
DOI:10.4103/jllr.jllr_10_18  
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Biological reconstruction after tumor resection p. 3
Hiroyuki Tsuchiya
DOI:10.4103/jllr.jllr_9_18  
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ORIGINAL ARTICLES Top

Activities of a large limb lengthening and reconstruction center in the 21st century p. 6
Alexander V Gubin, Dmitry Y Borzunov, Tatiana A Malkova, Natalia S Belokon
DOI:10.4103/jllr.jllr_26_17  
Background: Limb lengthening and reconstruction surgery (LLRS) is a relatively new orthopedic subspecialty. It started to develop in the 1980s when the Ilizarov method became known to the world orthopedic community. Purpose: We evaluated the caseload dynamics and compared the use of the Ilizarov techniques against the total of annual surgical interventions performed at our center. Materials and Methods: We retrospectively examined archival data on the admissions and surgical activities since the center's inception and in several years separately. The total of admissions, surgical activity, and the total of external fixation operations was calculated. We also reviewed all consecutive LLRS cases for a sample period of 2015, assessing admission patterns and surgical categories. Academic activity was reviewed using available databases of medical publications. Results: The total of admissions throughout 45 years was 185,839. The number of admissions reached 12,451 in 2016, almost six times more than in 1986. In 1996, the surgical volume significantly decreased and started to grow significantly from 2011. LLRS reduced relative to the total of operations performed though its absolute number grew by 52.6% in 2016 as compared with 1986. It comprised only 30% in 2016 while other orthopedic and joint pathology techniques were employed in 70% of operations. The number of operations with the Ilizarov method for osteomyelitis increased >4.45-fold in 2016 as compared to 1986. According to the Scopus database, the most productive years were 2015 and 2016 with 50 and 54 articles, respectively, published in the national and international journals. Conclusions: The scope of the center's activities has expanded beyond the Ilizarov method. Many newer technologies for the management of musculoskeletal diseases are employed to meet the needs of the market. Due to growth of musculoskeletal diseases and above mentioned factors, LLRS activity has been constantly growing. Its main concepts are the Ilizarov philosophy, age, and technical continuity.
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Accordion maneuver: A bloodless tool in ilizarov p. 11
Ranjit Kumar Baruah, Sourav Patowary
DOI:10.4103/jllr.jllr_25_17  
Purpose: Accordion maneuver (AM) is a “Bloodless Tool” to stimulate bone healing as described by Professor Ilizarov by a mechanism called transformation osteogenesis. It has been underdescribed in literature. Furthermore, there is lack of standard protocol for AM. We report our cases where this Bloodless Tool was used and discuss the strategies for its use in various conditions. Materials and Methods: We reviewed our cases that underwent AM during 1994−2015, through this retrospective study. In nonunion, initial compression or distraction was decided by the status of nonunion. In hypertrophic (stiff) nonunion, the first maneuver was distraction followed by compression in one cycle and the sequence was reversed in atrophic (mobile) nonunion. In hyporegenerate, distraction was discontinued, stability restored, and AM was performed with compression first. Results: Twenty-three patients were included. In 15 cases monofocal, 7 cases bifocal, and in 1 case trifocal osteosynthesis was done with Ilizarov. AM was done for hypertrophic nonunion in 6 cases, atrophic nonunion in 15 cases, and hyporegenerate in 5 cases. In 3 cases, AM was done for both hyporegenerate and docking site nonunion. In all the cases of nonunion, union was achieved and in all the cases of hyporegenerate, bone formation improved. Conclusions: Transformation osteogenesis with AM is a bloodless tool in Ilizarov. To achieve desired results, protocol for the maneuver should be based on type of pathology between the fragments.
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Effectiveness of the management of bony articular collapse with bony defects in tibial plateau fractures with the use of genex: An absorbable calcium composite synthetic bone graft p. 20
Kathryn Lowery, Abishek Chatuverdi, Mark Blomfield, Hemant Sharma
DOI:10.4103/jllr.jllr_9_17  
Background: Synthetic grafts containing calcium sulfate and calcium phosphate are used to manage defects and support the articular surface in the management of periarticular fractures. GeneX is a synthetic graft that contains beta-tricalcium phosphate and calcium sulfate. Objectives: This study's aim was to assess the maintenance of elevated articular segments in tibial plateau fractures grafted with a synthetic calcium composite graft. Methods: Patients who received a single synthetic calcium composite graft intraoperatively at a single Level 1 Major Trauma Centre were identified. Case notes and radiographic images were reviewed to assess articular collapse, mode of fixation, maintenance of the articular surface, and reoperation rates. All intra-articular segments were elevated, graft applied, and combination of implant (circular frame/plate) were used for definitive fixation along with raft screws. There were forty tibial plateau with average preoperative collapse of 13.12 mm (2.2−50). Modes of definitive fixation: frame and raft screw technique 19, plate 18, and screws alone 3. Results: Two (5%) had postoperative collapse after anatomical reduction intraoperatively (one plate and one circular frame). Five demonstrated inadequate reduction intraoperatively, three circular frames, and 2 plates as definitive mode of stabilization. Four maintained inadequate reduction at final X-ray but one collapsed postoperatively. Of those with collapse, final average was 4.2 mm (3−5.3). Five patients required secondary surgery and none directly attributable to the synthetic graft. Conclusions: The use of the synthetic graft GeneX with subchondral raft screws along with circular frame or plate appears to be safe and effective in providing support to elevated intra-articular fractures and provides satisfactory outcomes in tibial plateau fractures.
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Inter- and Intra-observer reliability of the pixel value ratio, Ru Li's and Donnan's classifications of regenerate quality in pediatric limb lengthening p. 26
Lori Anne Archer, Ashlee M Dobbe, Harpreet Chhina, Héctor A Velásquez García, Anthony Cooper
DOI:10.4103/jllr.jllr_11_17  
Objective: The objective of this study is to determine the inter- and intra-observer reliabilities of three regenerate classifications (pixel value ratio [PVR], Ru Li and Donnan) in pediatric patients undergoing femoral or tibial distraction osteogenesis (DO). Methods: One hundred and forty regenerate radiographs (12 consecutive patients) were analyzed by using two observers using each classification system at two-time points. Inter and intra-observer reliabilities were calculated. Results: PVR and Ru Li demonstrated good, and Donnan demonstrated moderate to good inter- and intra-observer reliability. Two regenerate fractures occurred. Conclusion: Each classification can be reliably applied to pediatric DO. The PVR method of regenerate evaluation is ideal as it is simple and objective and can be used with readily available imaging software. The regenerate fractures identified in this study occurred in patients with longitudinal limb deficiency.
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Sonographic evaluation of distraction osteogenesis in patients undergoing lengthening of tibia for increase in stature p. 33
Konstantin Igorevich Novikov, Tatyana Ivanovna Menshikova, Koushik Narayan Subramanyam, Olga Stepanovna Novikova, Abhishek Vasant Mundargi
DOI:10.4103/jllr.jllr_14_17  
Context: Limb lengthening demands constant monitoring of the regenerate bone by frequent radiological examinations. Aims: The aim of the study was to explore if sonography can be used in place of radiography for monitoring distraction osteogenesis. Settings and Design: This study was a prospective and observational study. Subjects and Methods: Thirty-five consecutive patients with a mean age of 24, where tibia was monofocally lengthened by mean of 5.5 cm ± 0.5 cm were included in the study. Along with all radiological assessments (every 2 weeks during Distraction Phase [DP] and 4 weeks during Maturation Phase [MP]), concurrent sonographic assessment was done and findings compared. Statistical Analysis Used: Descriptive methods. Results: Reparative granulation tissue in the distraction gap and endosteal reaction at both ends were visualized sonographically at 2 weeks before any radiological evidence of regeneration. The echolucent gap increased as distraction progressed with the internal hyperechoic signals getting organized to linear structures at 4 weeks when first radiological evidence was noted. This echopositive portion of the regenerate bone narrowed down by 6−8 weeks when radiographs showed bony trabeculae, more so in MP. By 14−16 weeks of MP, there was a significant reduction of echopositive zone, where more of regenerate got converted to hyperechogenic cortical bone. Sonography was poor in measuring distraction gap and assessing mechanical axis alignment. Sonographic findings correlated well with the findings of accelerated and poor regeneration on radiographs during DP and aided modification of distraction. Conclusions: Sonography is a valuable tool in DP and first half of MP and many radiographic examinations during these phases may be replaced by sonography. Judicious and combined application of sonography and radiography must be explored for superior characterization and monitoring during limb lengthening, with lesser radiation exposure.
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Radiological and clinical findings following distraction osteogenesis of the lower limb in children with or without botox injection: A preliminary report p. 41
Maryse Fortin, Noémi Dahan-Oliel, Kathleen Montpetit, Unni Narayanan, Christine Saint-Martin, Reggie C Hamdy
DOI:10.4103/jllr.jllr_16_17  
Context: Limb lengthening correction according to Ilizarov distraction osteogenesis (DO) usually yields excellent results. While pediatric orthopedic surgeons anecdotally report that botulinum toxin A (Botox) alleviates spasm and pain during DO, no study has examined the effects of this surgery and Botox injection on muscle morphology in children. Aims: (1) To evaluate the clinical and radiological effects of lower limb lengthening in children and (2) the effects of adjunctive Botox muscle injection. Setting and Design: This was a center and randomized control trial. Methods: Seven children underwent tibial (n = 3) or femoral lengthening (n = 4) and were randomized to receive either a Botox or sterile saline solution. Quality of life and functional mobility outcomes, muscle testing, and magnetic resonance imaging examination were obtained at baseline, 12-, and 24-month postoperative. Muscle measurements were acquired on axial T1-weighted images and included: (1) total cross-sectional area (TCSA), (2) functional cross-sectional area (FCSA, fat-free area), (3) ratio of FCSA to TCSA, and (4) asymmetry between sides. Results: Physical performance improved at 12- and 24-month postoperative. Muscle strength remained functional across the three time points. A decrease in TCSA and FCSA was observed at 12-month follow-up in the operated thigh of patients undergoing femur lengthening, but muscle mass was regained at 24 months. However, TCSA and FCSA remained lower in the operated femur at 24 months. Similar findings were also observed in patients who underwent tibial lengthening. Patients in the Botox group appeared to have a slightly greater decrease in muscle mass and increase in fatty infiltration in the operated leg. Conclusions: Children undergoing DO preserved their muscle strength and improved physical performance 2-year postoperative. Our results suggest that muscle size and muscle mass remained lower in the operated leg; a finding that was slightly more prominent in children who received a Botox injection.
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How much remodeling is possible in a clubfoot treatment? Magnetic resonance imaging study in a 7-year-old child p. 49
Monica Paschoal Nogueira, Denise Tokechi Amaral
DOI:10.4103/jllr.jllr_18_17  
Background: The Ponseti method for clubfoot treatment was initially described for children up to 6 months. Remodeling of cartilage in infants undergoing treatment by Ponseti method has already been studied with magnetic resonance imaging (MRI). “Neglected” or after walking age clubfeet was also shown to be corrected with the Ponseti method. Remodeling in those patients has not yet been sequentially documented. Questions/Purposes: To document cartilage anlage changes at 2. 5 and 18 weeks during treatment in a 7-year-old child, and verify if those changes are maintained 2.5 years after Ponseti treatment. Does the Achilles tendon also heal and remodel? Materials and Methods: A 7-year-old with bilateral clubfeet is treated with Ponseti method with ten casts, followed by complete percutaneous tenotomy and anterior tibial transfer to the third cuneiform. Cartilage and bone remodeling are studied through MRI sequences at the beginning of treatment, 5, 18 weeks and 2.5 years after Ponseti clubfoot treatment. Results: Images before treatment show severe tibiotalar plantar flexion, plantar talar neck inclination, and inferior talonavicular subluxation. After 5 weeks images show the correction of hindfoot equinus. After 18 weeks images demonstrate correction of the tibiotalar plantar flexion, normal congruency of the talonavicular and subtalar and complete healing of Achilles tendon. These cartilage/bone changes are maintained after 2.5 years, and the foot is plantigrade. MRI studies after treatment show good congruency, and reduction of talonavicular, talocalcaneal, and calcaneocuboid joints. Healing of Achilles tendon is documented after 8 weeks of complete tenotomy, and anterior tibial tendon transfer can be identified inserted to the third cuneiform. Conclusions: The observed changes can justify application of Ponseti Method for children with clubfeet after walking age. Clinical Relevance: Ponseti treatment can be applied to children over walking age resulting in correction of clubfeet due to cartilage remodeling.
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CASE REPORT Top

Humeral lengthening using a retrograde motorized intramedullary lengthening nail p. 55
Ryan J Hoel, Susan A Novotny, Mark T Dahl
DOI:10.4103/jllr.jllr_28_17  
An elite-level 13-year-old female overhead athlete, with a previous history of bone cyst and fracture at age 8, presented with a humeral length discrepancy of 75 mm which had increased to 81 mm within 1 year. Antegrade correction with a motorized lengthening nail was considered but declined due to risk of shoulder damage and pain. In an off-label manner, a femoral motorized lengthening nail was modified and utilized with retrograde placement. Lengthening instructions were modified weekly to account for rapid humeral growth, to minimize soft-tissue tension, and to maximize regenerate quality. By 11 weeks, humeral length was clinically corrected. Three weeks after ceasing lengthening, full range of motion of the shoulder and elbow returned. Once the site had formed new cortex on all four sides, the nail was removed, and return to full activity occurred 4 months later.
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LETTERS TO THE EDITOR Top

Letter to the editor about article”analysis of strut-to-bone lengthening ratio for hexapod frames using mathematical modeling” by Alex Cherkashin, Mikhail Samchukov, and Christopher A Iobst published in the january-june issue (Vol. 3, Issue 1, pp 45-51) p. 59
Giovanni Lovisetti
DOI:10.4103/jllr.jllr_1_18  
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Respond to the letter to the editor about the article “analysis of strut-to-bone lengthening ratio for hexapod frames using mathematical modeling” p. 60
Alexander Cherkashin
DOI:10.4103/jllr.jllr_8_18  
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