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   Table of Contents - Current issue
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January-June 2020
Volume 6 | Issue 1
Page Nos. 1-91

Online since Tuesday, June 30, 2020

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EDITORIAL  

Shortening: The orthopedic theory of relativity Highly accessed article p. 1
Dror Paley
DOI:10.4103/2455-3719.288573  
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Evolution of tibial lengthening techniques: Two steps forward, one step back? p. 5
Sanjeev Sabharwal
DOI:10.4103/jllr.jllr_14_20  
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REVIEW ARTICLE Top

The effect of fixation dynamization on fracture healing: A systematic review Highly accessed article p. 7
Nando Ferreira, Yashwant Singh Tanwar, Marilize Burger
DOI:10.4103/jllr.jllr_11_20  
Dynamization of fixation has long been used as a strategy to promote fracture healing. Which clinical scenarios would benefit from dynamization, how and when to introduce it and its effectiveness remains to be elucidated. A systematic review of the literature reporting on the use of dynamization in fracture healing using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis was conducted. The primary outcome was time to union and union rate of fractures across all anatomical sites, including adult and pediatric populations. A total of 19 studies fulfilled the inclusion criteria of which 14 studies evaluated the use of dynamization using intramedullary nails, while five studies evaluated external fixator dynamization. The diversity of dynamization strategies, variation in timing of dynamization and contradictory results precludes definitive conclusions. Further research is needed before recommendations for the use of dynamization to improve fracture healing can be considered.
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ORIGINAL ARTICLES Top

Tibial lengthening evolution: Classic ilizarov, lengthening and then nailing, motorized internal lengthening nail p. 13
Austin T Fragomen, Thomas D Falls, Jaehee Suh, Nathan Khabyeh-Hasbani, S Robert Rozbruch
DOI:10.4103/jllr.jllr_3_20  
Introduction: Distraction osteogenesis is an effective method for the treatment of congenital and acquired limb length discrepancy. Lengthening and then nailing (LATN) was developed to decrease the time in external fixation. With the advent of motorized internal lengthening nails (MILN), external fixation has been eliminated and lengthening of the tibia has become a less burdensome process for patients. Methods: We performed a retrospective review of three groups of patients: Twenty-four patients (27 tibiae) using MILN, 20 patients (32 tibiae) using LATN and 24 patients (34 tibiae) using a classic Ilizarov technique. Results: In the MILN group, the average bone healing index (BHI) was 1.5 months/cm, with an average BHI of 0.9 months/cm for LATN patients and 1.9 months/cm for classic patients. There was a statistically significant difference among the three groups (P < 0.001). There were no deep infections in the internal lengthening nail group. There were no nonunions, persistent joint contractures, or significant unintended changes in alignment in any of the groups. Discussion: Applied appropriately, all three techniques are effective and lead to healing without any significant deformity. Conclusion: Motorized internal lengthening of the tibia is an effective treatment option. The LATN technique still allows for longer lengthenings and faster healing than MILN, however, it does require an additional surgery and the need to wear an external fixator.
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Acute deformity correction and lengthening using the PRECICE magnetic intramedullary lengthening nail p. 20
Ahmed I Hammouda, Vivian L Szymczuk, Martin G Gesheff, Nequesha S Mohamed, Janet D Conway, Shawn C Standard, Philip K McClure, John E Herzenberg
DOI:10.4103/jllr.jllr_6_20  
Background: External fixators have been used to treat patients with limb length discrepancy with deformity. Implantable intramedullary (IM) lengthening nails are an attractive alternative achieving accurate results with fewer complications than external fixators. We report on PRECICE™ nail utilization for simultaneous lower limb lengthening and acute deformity correction. Materials and Methods: A retrospective institutional study included a total of 22 segments (13 femurs, 9 tibias; mean age = 17 years) that underwent simultaneous acute deformity correction and lengthening using fixator-assisted nailing and the PRECICE™ IM nail between 2012 and 2015. Results: All segments were corrected with mean final mechanical axis deviation 0.8 cm (0–2.0 cm). Femoral segments achieved frontal plane correction from a preoperative mean lateral distal-femoral angle of 86° to a postoperative mean of 89°; and a sagittal plane correction from a preoperative mean posterior distal femoral angle of 76° to a postoperative mean of 84°. Tibial segments achieved frontal plane correction from a preoperative mean medial proximal tibial angle of 94° to a postoperative mean of 89°; and a sagittal plane correction from a preoperative mean posterior proximal tibial angle of 72° to a postoperative mean of 79°. Rotational malalignment was corrected in all cases based on clinical examination of the rotational profile. The mean length achieved was 4.7 cm. One femoral segment (4.5%) did not achieve the lengthening goal. The mean consolidation index was 42 days/cm. Mean distraction index was 0.7 days/mm. Conclusions: Internal lengthening can permit both lengthening and acute deformity correction, with appropriate preoperative planning, using fixator assisted nailing techniques.
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Psychological and orthopedic outcomes after stature lengthening surgery using intramedullary nails p. 28
Michael Assayag, Joshua R Buksbaum, Nathan Khabyeh-Hasbani, Ellen Katz Westrich, Austin T Fragomen, S Robert Rozbruch
DOI:10.4103/jllr.jllr_4_20  
Introduction: Patients undergo stature-lengthening surgery (SLS) with the hope of improving their psychological health. The presumption is that increased height will improve body-image and self-esteem. The use of motorized internal lengthening nail and lengthening and then nailing techniques has eliminated or minimized time in external fixation increasing interest in the procedure. Material and Methods: Fifteen patients (32 bone segments) who underwent SLS were included in the study. All patients were bilateral, and one patient underwent four-segment treatments in two stages. Psychological assessment was performed with the body image quality of life inventory (BIQLI), the situational inventory of body-image dysphoria (SIBID), and the multidimensional body-self relations questionnaire before surgery and at latest follow-up. Orthopedic data included length obtained, bone healing index (BHI), adjacent joint range of motion, and Association for the Study and Application of Methods of Ilizarov (ASAMI). bone and functional scores. Results: The mean magnitude of lengthening was 64 ± 9.3 mm (48–77) (P < 0.001), resulting in an average increase from 161 cm to 167.4 cm. Mean BHI was 0.86 month/cm. ASAMI bone and functional results were all excellent after average follow-up of 37 months, with no loss of adjacent joint range of motion. BIQLI score significantly increased from 0.62 ± 1.26 (range −1.6–1.9) to 1.67 ± 0.85 (range −0.16–2.6) (P = 0.02). SIBID score significantly improved from 1.3 ± 0.81 (range 0.4–2.5) to 1.02 ± 0.68 (range 0.42–2.1) (P = 0.03). Discussion: Patients' significant increase in BIQLI score postoperatively, when compared to their scores preoperatively, demonstrate higher satisfaction in their body-image following SLS. Significant improvement in patients' SIBID score demonstrate a decrease in the impact of stature dysphoria in patients' everyday life following SLS. Conclusion: SLS is a safe and effective treatment to increase height. In patients, psychological health, including body-image and self-esteem, is improved.
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The impact of radiographic parameters and bone grafting at the docking site on union following bone transport for segmental bone defects of the tibia and the femur: A retrospective cohort pilot study p. 33
Hasan Nahouli, Karim Masrouha, Rima Abdul-Khalek, Asdghig Der-Boghossian, Ali Rteil, Wassim Mourad, Said Saghieh
DOI:10.4103/jllr.jllr_8_20  
Context: In patients with large bone defects, the method of bone transport remains one of the most adopted surgical techniques. Nonunion at the docking site is a critical complication of bone transport procedures. Aims: This study aimed to explore the impact of bone grafting at the docking site as well as radiographic parameters on union rates in patients who underwent bone transport for segmental bone defects of the tibia or femur. Settings and Design: This is a retrospective cohort of a consecutive series of adult patients treated with bone transport by a single surgeon at a single academic medical center. Subjects and Methods: Baseline characteristics of patients, bone transport procedure data, radiographic alignment data, and outcomes of those with bone grafting at the docking site were compared to those that did not. Statistical Analysis Used: Wilcoxon–Mann–Whitney U and Fisher's exact tests were used to analyze the study's data. Results: Thirty-two patients were included. Ten of 11 patients with bone graft at the docking site achieved union. Fifteen of 21 patients with no graft achieved union. Of the group that underwent bone transport without grafting, better alignment in the sagittal plane was significantly associated with achieving union (P = 0.026). The distraction gap of those that went on to unite (m = 9.33) was smaller than those that developed nonunion (m = 15.17) (P = 0.051). Conclusion: Although statistically insignificant, grafting of the docking site seemed to decrease the occurrence of nonunion at the clinical level. Higher distraction gap and translation in the sagittal plane may be the best predictors for nonunion of the docking site among nongrafted patients.
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Correction of multiplanar proximal tibial deformities using the taylor spatial frame p. 40
Ahmed Mohamed Abdelaziz, Hosny A Gamal, Allam S Ahmad, Abdulalim A Abdulsalam
DOI:10.4103/jllr.jllr_5_20  
Context: The management of multiapical and multidirectional deformities of the proximal tibia is still a challenging task with acute correction. The Taylor spatial frame (TSF) enables gradual correction in all planes. Aims: The study investigated the accuracy of correction for multiplanar proximal tibial deformities which had performed with the preassembled TSF. The complications and functional outcome were investigated. Settings and Design: Retrospectively, we compared the parameters of proximal tibial angles before and after using the preassembled TSF frame technique for correction. We used the mechanical axis deviation (MAD), medial proximal tibial angle (MPTA), posterior proximal tibial angle (PPTA), and tibial rotation as reference parameters for accuracy judgment. The deformities were divided into three main planes, each plane subdivided by two directions of angulations. Subjects and Methods: The study included 15 patients (20 tibiae), who underwent a tibial osteotomy surgery after obtaining informed consent for deformity correction using the TSF (Smith and Nephew, Memphis, TN, USA) between June 2016 and May 2018. Results: The three-plane deformities experienced an accurate correction of MAD. MPTA and PPTA were accurately corrected in patients with coronal and sagittal plane deformities, respectively. Rotational deformities were corrected to a satisfactory degree of accuracy in all cases. TSF correction for multiplanar proximal tibial deformities achieved an excellent result regarding functional outcome. Conclusions: Gradual correction for multiplanar proximal tibial deformities with the TSF is accurate, simple and with few complications.
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The use of suspensory fixation for ankle syndesmotic injuries: A modified technique p. 48
Faisal H Zayed, Ahmed I Hammouda, Ismail A Yasseen, Mahmoud M Abo Hashim
DOI:10.4103/jllr.jllr_2_20  
Background: Ankle injuries are a common presentation to the orthopedic clinic and can be just isolated sprains or associated with ankle fractures; most of these involve distal tibiofibular syndesmotic disruptions. Bony or deltoid ligament injuries can critically destabilize the ankle and affect its function. Suspensory repair is a relatively new and accepted surgical treatment for acute ankle syndesmotic injuries. Objective: This study was conducted to evaluate the results of the use of suspensory fixation by modified TightRope (hand-made suture-button system) after acute ankle syndesmotic injury in adults. The American Orthopedic Foot and Ankle Society (AOFAS) score was used as a functional result in this study. Patients and Methods: This prospective study included 20 patients (mean age, 29.5 ± 9.7 years) with acute syndesmotic injuries treated with a suspensory fixation system between the period of January 2017 and December 2017, with a mean follow-up (FU) of 2 years. Variables recorded and analyzed were the age, sex, fracture type, mechanism of injury, associated injuries, FU, complications, and final outcomes. Results: As regarded twenty patients in this study, the median AOFAS score was 97 (range, 90–100). One patient needed implant removal as a result of persistent skin irritation. Conclusion: A modified technique of suture-button fixation is an alternative optimal treatment for acute syndesmotic injuries, resulting in stable functional ankles with less costs. Level IV: Level II.
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Is bone morphogenetic protein 2 effective, safe and cost-efficient in nonunion surgery of long bones p. 54
Chun Hong Tang, Shah Jehan, Hemant K Sharma
DOI:10.4103/jllr.jllr_9_20  
Background: The prevalence of fracture nonunion surgery is increasing in the general population with greater advancement in trauma surgery. Increasingly complex injuries involving the limbs are now amenable for limb preservation surgery, where in the past amputations would have been common place. Aims and Objectives: We carried out a literature review on the evidence available on the use of Bone Morphogenetic Protein 2 (BMP-2) for long bone nonunion surgery. Methods: This literature review was initially undertaken for a systematic review using PRISMA guidelines, however due to lack of high-quality published literature, we present a narrative review instead. The abstracts of the articles obtained on Medline and Embase database were scrutinised according to the inclusion and exclusion criterions. The primary endpoint was union rates, and secondary end points were time to union, re-operation and post op infection rates. Results: A total of 240 titles were obtained, and after review, 3 articles were selected for final analysis. There were no statistically significant differences noted between the primary and secondary endpoints in the autologous bone graft (ABG) group when compared against the BMP-2 with allograft group. An additional review of the literature suggests that BMP-2 is cost neutral to the healthcare system. Conclusion: Although no firm conclusions can be drawn due to lack of power, the trend suggests no significant difference in union rates between autograft or BMP-2 with allograft, with comparable results to each other in all measurable end-points.
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Insufficiency fracture of the distal femur during ilizarov treatment for congenital pseudarthrosis of the tibia p. 61
Mahmoud A El-Rosasy, Abdullah Ahmed Nada
DOI:10.4103/jllr.jllr_1_20  
Background: Patients with congenital pseudarthrosis of the tibia (CPT) usually have significant limb length discrepancy that requires lengthening. In the presence of generalized osteopenia in CPT patients, insufficiency fractures of distal femur can occur during lengthening. No reports in the literature have described this complication and its management. Patients and Methods: We report three cases of CPT with distal femur insufficiency fracture during the treatment by Ilizarov frame. The fracture was minimally displaced. Under general anesthesia, traction and manipulation for fracture reduction were done. A cast was wrapped around the thigh, then three rods were added to the proximal ring to surround the thigh, and then another cast was used to connect the rods and the first cast. Results: In these three cases, healing of the fracture was achieved within 7 weeks without any complications, and the management of CPT continued as planned. Conclusion: The new technique provides a stable construct based on the already mounted frame; thus, healing of the fracture is achieved in a simple, easy, and cheap way with no documented complications.
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Azhar dome physioclasis: A new surgical technique of treating patients with late presenting blount's disease p. 67
Y Elbatrawy, Ahmed I Hammouda, Mohamed Khaled
DOI:10.4103/jllr.jllr_15_20  
Introduction: Surgical treatment of patients with multi-planar deformity secondary to Late Presenting Blount disease (LPBD). Is there a new method for acute deformity correction of tibial deformity in patients with LPBD? The new method entailed acute deformity correction of the deformity by manual rotation of the deformed limb relative to the CORA in the physis itself. Patients and Methods: A prospective case study performed on two patients. First patient was eleven years old boy with LPBD and bilateral affection. Patient's height was 127cm, and weight was 60 kg; with BMI was 37.2 kg/m2. Both sides were done, left sided correction preceded the right side by 6 weeks. The second patient was twelve years old female. Her height was 145cm, and weight was 67kg with BMI 31.8 kg/ m2. Results: Acute correction of the varus, procurvatum and internal rotation was achieved intraoperatively with corrected mechanical axis. Average follow up was 20 months. No complications encountered in either limb. Conclusion: “Dome Physioclasis” is a new novel surgical technique that allows acute tibial multi-plane deformity correction in patients with LPBD. This method is suitable for selected cases where patients complain from severe deformity and near skeletal maturity. Future more experience in the technique may improve its understanding.
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CASE REPORTS Top

Tibial lengthening with a motorized magnetic intramedullary nail after combined plating and titanium mesh cage for distal femur periprosthetic fracture nonunion p. 73
Rami Khalifa, Christopher Gerzina, Amr Abdelgawad, Ahmed M Thabet
DOI:10.4103/jllr.jllr_12_20  
Fifty-seven years old female presented with resistant nonunion and limb length discrepancy (LLD) following distal periprosthetic fracture. The report described the experiences treating these conditions and literature review about the topic. Nonunion in periprosthetic distal femoral fractures can be challenging to the orthopedic surgeon and can result in a significant LLD. With the patient described herein, a combined technique with plating and titanium mesh cage and subsequent tibial lengthening with a motorized lengthening nail was used to address these conditions.
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Knee Arthrodesis Using Ilizarov Method with Autogenous Bone Graft Application in a Second-Stage Surgery: A Case Report of a Morbidly Obese and Diabetic Patient with a Septic Failure of Total Knee Arthroplasty p. 77
Ricardo Marta, Luís Maia, Carlos Vilela, João Carvalho
DOI:10.4103/jllr.jllr_7_20  
Currently, the main indication for knee arthrodesis is septic failure of a total knee arthroplasty (TKA). Circular external fixation has shown good results, and it is a good option to treat these cases. We present a case of a morbidly obese female, 55 years old, with a chronic septic failure of TKA, submitted to a knee arthrodesis using the Ilizarov technique. In a second-stage surgery, the remaining bone defect was filled with autogenous iliac crest graft. A radiographic and clinical fusion was verified 3 and 5 months, respectively, after the primary surgery. Twelve months later, she is very satisfied with the surgery results, presenting a Visual Analog Scale score 1 and a stable and pain-free lower limb. The residual limb length discrepancy was 3 cm, and she walks with a shoe lift without external support. Our case emphasizes the importance of autogenous bone graft application in a second-stage surgery to a successful and fast knee arthrodesis using the Ilizarov method in patients with chronic septic failure of TKA and severe comorbidities.
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A case of personalized limb salvage of the distal femur by three-stage distal femoral replacement p. 81
Androniki Drakou, Konstantinos Zygogiannis, Markos Psifis, Aristides Mitrou
DOI:10.4103/jllr.jllr_10_20  
Major distal femur defects involving the knee with underlying osteomyelitis and joint destruction require a staged surgical plan. We describe a case of a 21-year-old patient who suffered high-energy open diaphyseal and articular trauma of his right distal femur. Following radical debridement of bone and soft tissues, we implanted a cement spacer covered by a musculocutaneous flap. Previous tissue scarring did not permit knee function; therefore, we used a 250 ml soft tissue expander to create extra skin cover and we shortened the leg. A custom-made lengthening distal femoral replacement prosthesis was implanted, and the length was gained gradually followed by an intensive full range of motion exercises (0–125). We introduce the combination of first shortening and then lengthening a limb combined with the use of tissue expanders to create a soft tissue functional envelop for a knee prosthesis to work.
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HISTORY Top

Ilizarov p. 84
Galina Victorovna Diachkova
DOI:10.4103/2455-3719.288557  
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Introduction to Galina victorovna diachkova p. 90
Dror Paley
DOI:10.4103/2455-3719.288558  
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