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   Table of Contents - Current issue
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January-June 2021
Volume 7 | Issue 1
Page Nos. 1-81

Online since Wednesday, June 30, 2021

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ORIGINAL ARTICLES  

Circular external fixation as an alternative method of stabilization for extra-articular tibia fractures in the elderly p. 1
Giovanni Lovisetti, Ettore Vulcano, Lorenzo Bettella, Ralph Cook, Francesco Sala, John D Muelle, Tazio Talamonti
DOI:10.4103/jllr.jllr_30_20  
Background: Recent epidemiologic reports from national fracture registries demonstrate an increase in the incidence of tibia fractures in the elderlies. Objectives: the objective of this retrospective study is to evaluate Circular External Fixation (CEF) for primary and definitive fixation of tibia extra-articular fractures (TEF) in the elderly treated at a level I trauma center. Materials and Methods: we evaluated a subset of 31 elderly patients (over 70 years) with 31 TEF (mean age 76 years, range 70-89) of which six (19.4%) were open treated with CEF between 2010 and 2017. 29 (93.5%) fractures underwent definitive fixation with traditional Ilizarov, 2 were treated with Sheffield and Taylor Spatial frames and evaluated clinically and radiologically accordingly to ASAMI bone and functional scores. Results: All fractures consolidated without additional procedures at an average of 21.3 weeks (range 9-42). No deep infections were observed. Four malunions within 8° occurred. ASAMI bone results were excellent in 93.6% of patients and revealed an excellent result in 21 (67.7%) of patients, eight patients (25.8%) had a good result, and 2 (6.5%) a fair result. Conclusions: CEF gave excellent results in the treatment of a variety of tibial shaft fractures in an elderly population, in terms of early return to ambulation, with average time to union, rate of delayed union, and misalignment rate comparable or superior to intramedullary nail and plate osteosynthesis, that represent the options more frequently proposed in clinical practice and literature. Advantages of circular external fixation in osteosynthesis of extra-articular tibia fractures in these patients are the minimal impact on soft tissues and the stability of the construct, that allows immediate weight bearing and early return to ambulation.
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Patient perspectives in the choice of management of leg length discrepancy p. 8
Christopher A Iobst, Anirejuoritse Bafor
DOI:10.4103/jllr.jllr_18_21  
Background: The traditional limb length discrepancy management algorithm dictates that patients with less than 5 centimeters (cm) of leg length discrepancy should not be offered lengthening surgery as a treatment option. With the development of intramedullary lengthening nails, the procedure for limb lengthening has become more patient friendly and reliable. This study investigated current patient preferences for management when faced with a projected final length discrepancy of less than 5 cm. Materials and Methods: Following IRB approval, a retrospective chart review of a single surgeon's experience with patients presenting with clinical and radiological evidence of limb length discrepancy between 2017 and 2020 was performed. Patients were excluded from the study if the final discrepancy or projected discrepancy was more than 5 cm. The same management options for the LLD were presented to each patient and their family: 1) Observation, 2) Shoe lift, 3) Epiphysiodesis/Acute shortening of the longer limb, 4) Limb lengthening of the shorter limb. Results: Sixty-two (62) patients met the inclusion criteria. This was comprised of 45 skeletally immature patients and 17 skeletally mature patients. Forty-four (44) patients (71% of the entire group) preferred to have the shorter limb lengthened. This represents 27 (60%) of the skeletally immature patients and all 17 (100%) of the skeletally mature patients. No patients chose acute shortening or a shoe lift as definitive management. Conclusion: With 71% of patients opting for a lengthening procedure, this study demonstrates that patients prefer limb lengthening over limb shortening for discrepancies less than 5 cm. With improvements in the knowledge and techniques of limb lengthening as well as better patient experience particularly with the intramedullary lengthening nails, surgeons should not feel obligated to only offer lengthening to patients with LLD > 5 cm.
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Femur deformity correction planning in sagittal plane using mechanical axis p. 13
Victor A Vilenskiy, Leonid Nikolaevich Solomin, Alexander Igorevitch Utekhin
DOI:10.4103/jllr.jllr_14_21  
Recently, deformity correction planning using reference lines and angles is a standard procedure. At the same time, both anatomical and mechanical axes are used for the frontal plane. However, until nowadays, there was no algorithm for planning femoral deformity correction in the sagittal plane based on the mechanical axes of the bone fragments. The aim of this study was to develop a method of femur deformity correction planning in the sagittal plane based on mechanical axes. Materials and Methods: On the basis of computer tomography data of 23 adults with nondeformed femurs, we measured the angular relationships between the anatomical axis of the proximal femur in sagittal plane and mechanical axis (∠maj) and the angular relationships between the femoral neck axis and mechanical axis in sagittal plane (∠laj). Results: It was found that ∠maj was 16.0° ±7.6°, and ∠laj was 10.2° ±2.4°. Based on the data obtained, we developed a method for planning the correction of femoral deformities in the sagittal plane. According to this method, the mechanical axis of the proximal bone fragment can be determined using any of three options: (1) “Joint line based.” In this method, the proximal joint line of the femur is drawn, then from the center of the femur head with the angle 85° (mean value of mPPFA) to this line is drawn a line that is mechanical axis; (2) “Femoral neck based.” The neck axis is drawn first, then from the center of the femur head with the angle 16° (mean value ∠maj) to this line is drawn a line that is mechanical axis; and (3) “Anatomical axis based.” First, the anatomical axis of the proximal femur is drawn, then a line parallel to the anatomical axis from the center of the femoral head is drawn, then a line at an angle of 10° (mean value ∠laj) to it is drawn, that is the mechanical axis. Determination of the mechanical axis of the distal fragment in sagittal plane is made by the following: the distal joint line is drawn and divided into five equal segments. Then, the point located on the border of the front 2/5 and the rear 3/5 of the segment is found. From that point, at an angle of 81° (mean mPDFA), a mechanical axis of the distal femur fragment is drawn. The intersection of the mechanical axes of the proximal and distal fragments defines the apex of the deformity. Conclusion: The proposed method for planning deformity correction based on mechanical axes for the sagittal plane complements the existing planning methods for the frontal plane and improves the quality, namely the accuracy of preoperative planning.
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Risk factors for focal osteolysis in a stainless-steel limb-lengthening device p. 19
Oliver Charles Sax, Janet D Conway, Shawn C Standard, Michael Assayag, John E Herzenberg, Philip Kraus McClure
DOI:10.4103/jllr.jllr_17_21  
Background: Magnetic, telescoping intramedullary lengthening devices are widely used for treatment of limb length discrepancies. However, a routine radiographic review of a stainless-steel device demonstrated soft tissue and bony changes suggestive of osteolysis. Therefore, we sought to examine all patients implanted with a stainless-steel limb-lengthening nail. We specifically asked: (1) what is the incidence of periosteal reaction osteolysis? (2) Is a new biologic reaction classification system valid and reliable? and (3) Are there predictive factors for the development of osteolysis? We hypothesized that higher patient weight and femoral insertion would be risk factors for lysis, due to increased bending moments on the implants. Materials and Methods: A retrospective review of all patients implanted with a stainless-steel limb-lengthening nail between December 2018 and December 2020 was conducted at a single institution. A total of 57 nails in 44 patients were radiographically examined with an average follow-up of 6.2 months (range: 1–21 months). The incidence of osteolysis was calculated through review of patient radiographs. These were then classified according to a novel system by five fellowship-trained orthopedic surgeons with agreement assessed using an intraclass correlation coefficient (ICC). Logistic regression measured predictive factors for this phenomenon. A separate histologic analysis of two bone/soft-tissue biopsies at the time of routine explantation was conducted by an independent pathologist. Results: The incidence of periosteal reaction and osteolysis was 36.8% and 17.5%, respectively. Nails with progression to osteolysis increased to 34.6% (9/26) when examining nails with at least a 6-month follow-up. ICC testing yielded good inter-rater agreement for the novel classification system (average measure: 0.860, 95% confidence interval 0.828–0.888). Age >16 years (P = 0.024) and body weight >150 pounds (P = 0.038) were predictors of osteolysis. Histologic analysis of the biopsies demonstrated an abundance of particulate debris suggestive of chromium reaction. Conclusions: The modular junction of a stainless-steel lengthening device is susceptible to osteolytic changes, and this appears to be associated with increased age and weight. This phenomenon has an apparent time dependence: osteolysis increases with greater follow-up.
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A re-examination of the patterns of foot and ankle deformities in congenital limb deficiencies p. 26
Alpesh Kothari, Simon P Kelley, Maryse Bouchard
DOI:10.4103/jllr.jllr_13_21  
Purpose: The aim of this study is to evaluate foot deformities and anomalies present in congenital limb deficiencies (CLDs). We sought to define the relationship between the type of limb deficiency and foot posture, patterns of ray deficiencies, and association between tarsal coalition (TC) and ball-and-socket ankle. Materials and Methods: This is a single institution, retrospective radiograph, and medical record review of patients with CLD, comprising congenital femoral deficiency (CFD), tibial hemimelia (TH), and fibular hemimelia (FH) from January 2000 to January 2019. Data extracted included patient demographics, predicted leg length discrepancy, associated deformities and anomalies, and specifics of the foot deformity. Surgical procedures were recorded. Data were reported using descriptive statistics. Fisher's exact test analyses of contingency tables were used for the exploratory components of this study. Results: Eighty-one patients with 97 limb deficiencies were identified (16 – CFD, 18 – TH, and 63 – FH). Isolated CFD was not associated with foot and ankle deformity and TH was associated with an equinocavovarus foot in all limbs. In FH, an equinocavovarus deformity was present in 15/63 (24%) feet, most requiring foot surgery. Of 48 patients with FH and absent rays, two lacked lateral rays, whereas the remainder missed one or more intermediate rays. TC was unrelated to the presence of ball-and-socket ankle. Conclusions: This study demonstrates heterogeneity in the spectrum of foot and ankle deformity in CLD, particularly in FH. Recognition of this phenotypic variation is critical for surgeons to formulate a comprehensive treatment plan and ensure optimal functional outcomes. Level of Evidence: IV.
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Evaluating the accuracy of the SMART taylor spatial frame software – Comparison with manual radiographic analysis methods p. 31
Nando Ferreira, Christopher Arkell, Franklin Fortuin, Aaron Kumar Saini
DOI:10.4103/jllr.jllr_5_21  
Background: The accuracy of hexapod circular external fixator deformity correction is contingent on the precision of radiographic analysis during the planning stage. The aim of this study was to compare the SMART Taylor spatial frame (TSF) in suite radiographic analysis methods with the traditional manual deformity analysis methods in terms of accuracy of correction. Methods: Sawbones models were used to simulate two commonly encountered clinical scenarios. Traditional manual radiographic analysis and digital SMART TSF analysis methods were used to correct the simulated deformities. Results: The final outcomes of all six analysis methods across both simulated scenarios were satisfactory. Any differences in residual deformity between the analysis methods are unlikely to be clinically relevant. All three SMART TSF digital analyses were faster to complete than manual radiographic analyses. Conclusion: With experience and a good understanding of the software, manual radiographic analysis can be extremely accurate and remains the gold standard for deformity analysis. In suite SMART TSF radiographic analysis is fast and precise to within clinically relevant parameters. Surgeons can with confidence trust the SMART TSF software to provide analysis and corrections that are clinically acceptable.
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Effect of axial dynamization in circular external fixation on bone segment vertical and lateral displacements p. 37
Erin M Honcharuk, Alexander M Cherkashin, William A Pierce, Chanhee Jo, David A Podeszwa, Mikhail L Samchukov
DOI:10.4103/jllr.jllr_15_21  
Context: The field of deformity correction with external fixation has continued to advance since with the addition of half-pins, even though they can act to stiffen the construct and undermine healing. Dynamization increases axial motion at the fracture site and improves fracture and osteotomy healing in the experimental and clinical studies. No study compares the lateral and vertical displacements of bone segment in dynamized versus nondynamized frames. Aims: The purpose of this study was to compare the segmentary motion in the axial, coronal, and sagittal planes using nondynamized and dynamized circular external fixation frames. Subjects and Methods: Seven frame models were tested including classic Ilizarov three-wire construct and two frame configurations representing the most common modern half-pin and wire combinations. These models were either nondynamized or dynamized with two types of dynamization modules. Each model underwent axial loading up to 50 kg for 11 cycles. Statistical Analysis Used: One-way analysis of variance testing followed by post hoc Tukey's test. Results: The addition of each half pin sequentially decreased axial motion while increased sagittal motion. Dynamization had a limited effect on the sagittal motion but significantly improved axial motion. The sagittal to axial motion ratio increased with half pins in nondynamized frames but decreased equal to or beyond the Ilizarov three-wire fixation frame with dynamization. At the limit of the dynamizers' motion, there was change in the rate of displacement, suggesting that subsequent motion was strictly from the wires and half-pins. Overall, there was minimal coronal motion. Conclusions: While half pins decrease axial micromotion and increase detrimental sagittal motion, dynamization restores.
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Orthopedic implant design from concept to final tested product: A design surgeon's experience p. 45
Henry Sean Pretorius, Nando Ferreira
DOI:10.4103/jllr.jllr_2_21  
Background: Orthopedic surgeons are invariably faced with situations where contemporary surgical techniques and implants are not satisfactory for a specific clinical scenario. One such scenario frequently arises around the lack of implant choice for intramedullary fixation of radius and ulna fractures. We will describe our experience designing and testing a new radius and ulna nail, inclusive of protecting the underlying intellectual property. Design Process: Phase 1: Identifying a need: Current intramedullary forearm devices have abandoned the ability to place interlocking screws at the nondriving end and are therefore not length stable. As current nails only come in 20 mm length increments, this may pose challenges in attaining accurate anatomical length restoration. Phase 2: Concept: (1) Anatomically designed in terms of length, diameter, and radius of curvature. (2) Nail inventory that has the optimal choice of implants to manage the majority of forearm injuries. (3) Locking system at the nondriving end that is easily targeted and has an acceptable radiation exposure for freehand locking. Phase 3: Anatomical study: Multiplanar reconstruction of upper limb computer tomography angiography scans were used to analyze the forearm osteology of 98 individuals. Primary measurements included the lengths of both radius and ulna shafts, the minimum canal diameter size, the proximal shaft angle of the ulna, and the radius of curvature of the radius. The size of the proximal ulna and distal radius were also measured for design parameters of the nondriving end of the nail. Phase 4A: Prototype design: To improve the usability of these nails, the design priorities were set as: (1) Locking hole design. (2) Jig and instrument design for insertion and removal. (3) Pressure release during insertion. Phase 4B: Prototype testing: Prototype testing consisted of nail insertion into human cadaver forearm bones using the initial prototype and instruments. The design aspects of the implant such as the locking holes with X-ray-assisted screw insertion or the radius of curvature were also evaluated. Mechanical testing will also be done.
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CASE REPORTS Top

Treatment of tibial hemimelia jones type 4 by ankle-sparing reconstruction (from birth to skeletal maturity) p. 52
Mark Eidelman, Pavel Kotlarsky
DOI:10.4103/jllr.jllr_11_21  
Tibial hemimelia is a relatively rare congenital preaxial longitudinal deficiency. The focus of this report is on Jones Type 4 (also called ankle diastasis). Treatment options range from amputation to tibiotalar arthrodesis with subsequent lengthening procedures. We present a case report of a patient with tibial hemimelia Jones Type 4 treated by ankle-sparing reconstruction with serial tibial- and fibular-lengthening procedures. To the best of our knowledge, this is the first report of ankle-sparing reconstruction followed until maturity.
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Deformity correction with the ifixation system: A new era of six-axis correction frames p. 57
Yasser Elbatrawy, Mohamed Khaled, Mohamed Yahya Hassanein, Ehlimana Agovic, Elvir Bazdar
DOI:10.4103/jllr.jllr_10_21  
The technology of computer-assisted six-axis frames is rapidly evolving. In this case report, we describe two cases of pediatric lower limb deformities treated by a novel hexapod device, the iFIXation system. For our knowledge, this is the first report in literature for its usage. The first case was a 14-years-old girl with posttraumatic shortening, varus and external rotation deformities of her lower limb around the ankle. All the deformities and shortening were corrected simultaneously with the iFIXation system. The second case was an 8-years-old girl with postinfection valgus and external rotation of the knee as well as shortening of the femur. Distal femoral deformities and shortening were simultaneously corrected by the iFIXation system and growth modulation to prevent recurrence of the deformity was done. The reported cases represent our earliest experience with the iFIXation system.
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LETTERS TO THE EDITOR Top

Use of cable ties in ilizarov frame assembly: A simple method to prevent wire-related injuries during postoperative care p. 62
B Prashanth, Pritish Singh, Anubhav Vichitra, Vinod Kumar
DOI:10.4103/jllr.jllr_1_21  
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EXPERT OPINION Top

Expert opinion: Using of antiplatelet agents in surgery with external fixators p. 64
Maurizio A Catagni, Daniele Pili
DOI:10.4103/2455-3719.320061  
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BIRTH CENTENARY CELEBRATIONS OF PROF G.A. ILIZAROV Top

G. A. ilizarov. How i remember him p. 68
Kirienko Alexander
DOI:10.4103/2455-3719.320062  
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Ilizarov – The teacher p. 70
A Cherkashin
DOI:10.4103/2455-3719.320064  
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Beyond the Urals: Kurgan p. 75
Maurizio A Catagni
DOI:10.4103/2455-3719.320065  
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Reminiscences of professor G. A. ilizarov visit to America p. 78
Stuart A Green
DOI:10.4103/2455-3719.320066  
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ERRATUM Top

Erratum: One-week accelerated PONSETI method in the management of idiopathic clubfeet p. 81

DOI:10.4103/2455-3719.320067  
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