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PubMed2003

Early failure mechanisms of constrained tripolar acetabular sockets used in revision total hip arthroplasty.

Fifty-eight patients received an Osteonics constrained acetabular implant for recurrent instability (46), girdlestone reimplant (8), correction of leg lengthening (3), and periprosthetic fracture (1). The constrained liner was inserted into a cementless shell (49), cemented into a pre-existing cementless shell (6), cemented into a cage (2), and cemented directly into the acetabular bone (1). Eight patients (13.8%) required reoperation for failure of the constrained implant. Type I failure (bone-prosthesis interface) occurred in 3 cases. Two cementless shells became loose, and in 1 patient, the constrained liner was cemented into an acetabular cage, which then failed by pivoting laterally about the superior fixation screws. Type II failure (liner locking mechanism) occurred in 2 cases. Type III failure (femoral head locking mechanism) occurred in 3 patients. Seven of the 8 failures occurred in patients with recurrent instability. Constrained liners are an effective method for treatment during revision total hip arthroplasty but should be used in select cases only.

Acetabulum↗
PubMedDate not supplied

[Characteristics of the learning curve in total hip endoprosthesis exemplified by the BiContact prosthesis].

AIM: Total hip arthroplasty is a common operation but there are few data describing the learning curve of this operation. The aim of the presented study is to prove and describe the learning curve in total hip arthroplasty. METHOD: Between 1991 and 1993, 168 patients were included in this prospective study, operated by three surgeons having different experiences in operating total hip arthroplasty. Perioperative complications and postoperative X-rays were analysed. Patients were re-examined clinically and radiologically and by a questionnaire 5 years after operation. RESULTS: Radiological complications of the first 84 operated patients were statistically significantly higher than those of the following 84 patients, except for minimal bone fractures and leg lengthening. The learning curve of all surgeons was finished after 20 operations independent of their experience. Clinical results were not influenced by the learning curve at follow-up. CONCLUSIONS: Regardless of the experience of the surgeon, the learning curve in total hip arthroplasty is finished after about 20 operations for each surgeon. Intensive preoperative planning and exchange of experience inside and outside every clinic will shorten the length of the learning curve.

Adult↗
PubMedDate not supplied

Ilizarov technique in the treatment of congenital pseudarthrosis of the tibia.

This study analyzes the risks and benefits of Ilizarov's technique in congenital pseudarthrosis of the tibia (CPT). This was a retrospective review of 14 patients treated between 1985 and 1993 for CPT, by using Ilizarov's technique. In 12 cases, this technique was used after failure of previous surgical treatment. Realignment, end-to-end compression, and leg lengthening were undertaken in all the cases, without excision of the pseudarthrosis site. The mean fixation duration was 7.8 months. Union was achieved with the initial treatment in seven cases. Bone grafting was used in six of the seven remaining cases and achieved bone healing in three of them. Refracture occurred in one case, and ended with nonunion. At 3.5-year average follow-up, the tibia was united in nine cases. We found that the best indications for Ilizarov's technique in CPT were the normotrophic and hypertrophic types of pseudarthrosis (Apoil II), after the age of 5 years. Secondary massive bone grafting is to be considered in some cases. The major disadvantage of this method is the lack of excision of the pseudarthrosis site. Even after healing is achieved, the bone remains dystrophic and fragile and necessitates a permanent protective orthosis, until the end of bone growth.

Adolescent↗
PubMedDate not supplied

Patellofemoral arthritis in a fused knee with proximal femoral focal deficiency.

A patient with proximal femoral focal deficiency (PFFD) who underwent knee fusion without patella resection and Boyd amputation at age 2.5 years developed severe symptomatic patellofemoral arthritis 10 years later that required excision of her patella. A survey among the 780 members of the Pediatric Orthopaedic Society of North America with a 58% response rate showed that 8 of the 355 pediatric orthopaedists who perform knee fusion without patellar removal in PFFD have experienced problems with patellofemoral degeneration, whereas 57 surgeons excise the patella either routinely or occasionally. Nine respondents reported they use the patella as graft to enhance knee arthrodesis. Twenty-eight surgeons reported no experience in management of patients with PFFD, 3 prefer leg-lengthening procedures as the treatment of choice, and 16 encountered problems related to prosthetic fitting. Patellar resection may be considered when knee fusion and foot amputation are performed in children with PFFD to anticipate for late patellofemoral arthritis.

Adult↗
PubMed2003

The behaviour of the periosteum during callotasis.

Periosteal behaviour during callotasis has been studied in animals but not in humans. Markers were inserted into the periosteum of seven patients who underwent callotasis. All of them had tibial callotasis, five patients had bone transport procedure and two had leg lengthening due to congenital disorder. They were followed up radiologically at regular intervals and during the distraction the movement of the periosteal markers was recorded. This enabled observation of the way the periosteum elongates during the procedure and also the calculation of periosteal strain at different stages at the points where the periosteum is fixed to bone. The study indicated that in most cases the periosteum acts as an elastic sleeve surrounding the newly formed tissue during lengthening. The site of attachment between sleeve and cortex became established early during lengthening, and hardly changed position at later stages. There was a wide spread of attachment sites and periosteal strains. Attachment sites were not related to pin or wire entry points, and strains were not predictive of callus shape or healing time.

Adolescent↗
PubMedDate not supplied

Knee reconstruction in syndromes with congenital absence of the anterior cruciate ligament.

The authors review their experience with four patients with congenital deficiency of the anterior cruciate ligament (ACL) who underwent surgical treatment of symptomatic knee instability at a mean age of 15.8 years (range 14-17 years). Associated syndromes included fibular hemimelia, congenital short femur, and an unspecified skeletal dysplasia. All patients had undergone multiple previous realignment and leg lengthening procedures and were skeletally mature at the time of the reconstruction. All four patients underwent ACL reconstruction, and one patient underwent concomitant posterolateral corner reconstruction. One patient required an osteochondral autograft transplant procedure in addition to ACL reconstruction. Hypertrophy of the meniscofemoral ligament of Humphrey was a consistent anatomic finding at surgery. The patients were followed for a mean of 38 months (range 26-58 months) after the reconstruction. The mean preoperative Lysholm II score was 38 (range 28-56); the score had improved to a mean of 81 (range 78-93) at the latest follow-up. The authors conclude that reconstructive surgery is a viable option for restoration of knee stability and function in appropriately selected patients with congenital ACL deficiency.

Adolescent↗
PubMed1981

Surgical treatment of partial closure of the growth plate.

During the period from 1965 to 1980, 43 operations for partial closure of a growth plate were performed on 35 patients. Five of the operations were for recurrent partial closure. At operation, the bone bridge connecting epiphysis to metaphysis was removed and replaced with a free fat transplant as described by the author in 1967 and 1975. Of the operations, 18 were on the distal end of the femur and 13 on either end of the tibia. Closure was due to fracture in 28 growth plates and septic osteomyelitis in 8. Benefit from the procedure was questionable after 7 operations. All other operations resulted in restoration of growth and correction or prevention of deformity. The operation prevents deformation of the joint surface, an effect that cannot be achieved by osteotomy or leg lengthening. Deformity present before operation is often reduced by growth to a normal condition after the procedure. Age, location of the bone bridge, and its size influence the indication for the operation and its results. Free fat, as an interposition material, has some advantages compared to solid materials, which may require a second procedure for removal.

Adipose Tissue↗
PubMed1982

Cylindrically modeled bone grafts.

A technique of autogenous grafting for repair of large defects in long bones is presented. Quadrangular grafts, taken from the external table of the posterior ilium, are modeled by bending them into cylindrical form, which has higher mechanical resistance as compared to flat struts. Cancellous chips are added. The original shape of the bone is immediately restored, and heavy internal fixation is avoided. combination of cortical and cancellous bone grafts provides both strength and rapid bone healing. There is no risk of fracture at the donor site. Of eight consecutive cases operated on, seven were successful. One failed because of relapsing infection. The procedure is suitable in children, adolescents, and young adults, for difficult cases of large defects in long bones left after resection of tumors and tumor-like conditions, as well as after diaphyseal distraction for leg lengthening.

Adult↗
PubMedDate not supplied

Treatment of congenital pseudarthrosis of the tibia by the Ilizarov method.

Three cases of congenital pseudarthrosis were treated by the Ilizarov method. Consolidation was obtained by 3.5 months in three patients who had undergone several previous surgical procedures. Although the length of follow-up was short (maximum 3.5 years), consolidation occurred more quickly than by traditional methods. This technique also permitted both simultaneous correction of axial malalignment and leg lengthening. We think that this method has a place as a salvage procedure except where the distal fragment is very thin or dystrophic.

Bone Lengthening↗
PubMedDate not supplied

Pseudomonas osteochondritis complicating puncture wounds in children.

Pseudomonas osteochondritis is an uncommon complication of puncture wounds. It can have a particularly devastating affect in the growing child, often resulting in significant permanent sequelae. To assess the current approach to diagnosis and treatment of this condition in children, 15 such cases seen at the Children's Hospital of Eastern Ontario between 1975 and 1991 were studied retrospectively. Case presentations were similar, with delayed onset of localized pain, swelling, and elevated erythrocyte sedimentation rate following a puncture wound. All patients had previously received oral antibiotics. Initial radiographic changes were rare. All patients were treated with i.v. antibiotics: although most required surgical debridement. Complications including recurrence, chronic pain, and deformities required sequestrectomies, angular osteotomies, and leg-lengthening procedures. A high index of suspicion, coupled with aggressive medical and surgical treatment, is required for a satisfactory outcome.

Anti-Bacterial Agents↗
PubMed1978

A recent development in the treatment of severe compound fractures.

The Wagner leg lengthening device has recently been used successfully as an external fixation device in the stabilization of severe compound fractures. Fixation is rigid, yet adjustable, it does not interfere with the fracture site, and it allows clear access to wounds.

Fracture Fixation↗
PubMed1984

Use of biocompatible orthopaedic polymer for fracture treatment and reconstructive orthopaedic procedures.

For many years attempts have been made to develop materials for use in the surgical treatment of fractures. So far only metal implants have been used. Soviet research has now succeeded in developing a copolymer of polyvinyl-pyrrolidone and methyl methacrylate reinforced by polyamide fibres and calcium gluconate which is reported to have comparable strength of metal implants but superior flexibility. It can be trimmed and shaped at the time of surgery, has no irritative reactions or release of toxic components, and above all is biocompatible. Clinical studies have been going on for 10 years in various Soviet medical centres and the total number of cases treated with the biocompatible polymer implants is well over 1000. In no case was a repeat operation necessary to remove the implant. Control X-rays (as well as animal data) showed that biodestruction of the implants is complete within 1.5 to 3 years depending on their sizes. The first operations outside the Soviet Union have been recently performed in Belgium. In the Soviet Union this material has also been used to treat pathologic fractures and in reconstructive surgical procedures such as leg lengthening.

Adolescent↗
PubMed1983

Knee arthrodesis following prosthesis removal. Use of the Wagner apparatus.

Arthrodesis after the removal of a knee prosthesis is often hampered by the small area of contact of the bony surfaces and by pre-existing infection. Conventional systems of external fixation and compression frequently fail to achieve stability but the addition of the Wagner leg-lengthening apparatus applied anteriorly and adjusted to give compression ensures rigid external fixation. Four knees in four patients were treated using this technique; the treatment followed the removal of infected prostheses in three knees and painful fibrous ankylosis after the removal of the prosthesis in the other. All obtained a sound arthrodesis.

Adult↗
PubMed1984

A new technique for greater trochanteric hip arthroplasty.

This paper describes a new technique for greater trochanteric hip arthroplasty in which the femur is divided at the subtrochanteric level and the upper fragment rotated through 180 degrees to place the greater trochanter deeply in the acetabulum; with the lower limb in the weight-bearing position the fragments are then fixed with a short intramedullary nail. This operation was carried out in a boy aged 4 years 6 months in whom the femoral head and neck had been destroyed by septic arthritis. Ten years later leg-lengthening was performed. When reviewed at the age of 20, he had a stable hip, a satisfactory range of painless movement, and shortening of only 2.5 cm; he could walk and run for long distances with only a slight abductor lunch.

Arthritis, Infectious↗
PubMed1990

The relationship between periosteal division and compression or distraction of the growth plate. An experimental study in the rabbit.

We subjected the proximal tibial growth plates of six-week-old rabbits to either compression or distraction of 1 kg on both legs. On one side the proximal tibial periosteum was divided circumferentially and stripped for 1 cm. After six weeks, growth was measured at both proximal and distal growth plates. Compression inhibited total tibial growth and distraction enhanced it. The compressed growth plate grew less and the distracted growth plate grew more, but there was a reciprocal change at the other end of the bone. Periosteal division enhanced growth at the adjacent growth plate but inhibited it distally; the effect of distraction was enhanced and that of compression reduced. We found reciprocal growth rates at the proximal and distal growth plates. Relatively small amounts of compression or distraction did affect total bone growth. Periosteal division appeared to induce overgrowth at least partly by a mechanical effect; it may be useful as an adjunct to other methods of leg lengthening, though not to epiphyseolysis.

Animals↗
PubMed2005

Trying to do my best as a mother: decision-making in families of children undergoing elective surgical treatment for short stature.

OBJECTIVES: To explore how families make decisions about elective leg-lengthening surgical treatment. DESIGN: Interviews were conducted and analysed using Interpretative Phenomeno logical Analysis (Smith, 1995). METHODS: Data were gathered using semi-structured interviews with nine mothers of children who had recently decided to undergo treatment. RESULTS: Overall, the decision process was guided by the mothers' central concern to act responsibly as a parent. Thematic analysis indicated that the decision was taken in a social context where short stature could lead to discrimination and disability. The decision-making process evolved gradually over several years as mothers and children gathered information about treatment. While mothers emphasized that ultimately it was their child's decision, they monitored the decision process and filtered the information available in an attempt to ensure that the child made a well-informed and wise choice. CONCLUSIONS: The decision was presented as an ongoing process by the mothers, their concerns representing their desire to do their best as parents for their children. Theoretically, the mothers' description of the process can be understood in terms of their attempts to resolve an ethical dilemma. Clinical implications include recognition of the role of the psychologist in supporting mothers in their decision making and thus indirectly helping children.

Adolescent↗
PubMed2001

Present status of the use of growth hormone in short children with bone diseases (diseases of the skeleton).

Skeletal dysplasias are genetic disorders of bone and cartilage development, mainly characterized by disproportionate short stature. Achondroplasia is the commonest and best described form of skeletal dysplasia, leading to a mean final height of 131+/-5.6 cm for males and 124+/-5.9 cm for females. Growth hormone (GH) has been used in different studies in patients with achondroplasia in order to ameliorate their height, and short term results range from rather positive to moderate. However, disproportionate advancement of bone age has been observed that can compromise the positive effect of such treatment. Furthermore, concern exists about the aggravation of body disproportion necessitating a later leg lengthening procedure in order to achieve proportionate adult stature. In hypochondroplasia, GH treatment seems to give better results when administered at puberty. No data on final height yet exist, however, so that more studies with greater numbers of patients need to be performed before a consensus on GH use in achondroplasia and hypochondroplasia can be reached. Other forms of skeletal dysplasias are quite rare, so that no conclusion on GH use in such patients can be drawn. Finally, in osteogenesis imperfecta, GH administration significantly ameliorates bone density but does not clearly seem to affect final height positively.

Achondroplasia↗
PubMed1997

Longitudinal growth rate following slow physeal distraction. The proximal tibial growth plate studied in rabbits.

Studies in animals by de Bastiani et al. (1986) on leg lengthening by physeal (growth plate) distraction have shown that the integrity of the growth plate can be preserved intact if slow rates of distraction are employed. Clinically, however, this technique has been restricted to the period shortly before skeletal maturity, due to uncertainty about the behavior of the growth plate following distraction. We conducted 2 studies. 11 immature rabbits used in a study on the normal growth at the proximal tibial physis established that the growth rate was unchanged with transfixing K-wires in the epiphysis. The normal growth rate of the proximal physis of the tibia decreased with age and was expressed as a quadratic function, Gn (mm/day) = 0.44-0.002 age (days). At 6 weeks of age, the growth rate was 0.33 mm/day, slowly decelerating to a rate of 0.15 mm/ day by the 16th week. In the lengthening study, to determine whether the growth plate would maintain a normal rate of growth following slow distraction, a custom-made bilateral distraction device was applied to the proximal tibial epiphysis of 32 immature rabbits aged 6 weeks and weighing approximately 500 gm. The growth behavior of the growth plate following 2, 3 and 4 weeks of distraction was studied. The rate of distraction was set at 0.5 mm/ day. The mean amount of distraction achieved was 8.5 mm, 11.3 mm and 14.6 mm resulting in a mean 'net' increase in length as compared to the experimental control after the distractor was removed amounting to 3.0 mm (55% of the control growth), 3.6 mm (47%) and 4.2 mm (40%), respectively. Subsequent serial measurements, up to 13 weeks postdistraction, showed no significant change in the discrepancy between the length of the tibia and the growth rate at the proximal tibial epiphysis and between the distracted and the contralateral controls in all 3 groups. Our findings suggest that the proximal tibial growth plate in the rabbit would maintain a normal growth rate after slow physeal distraction for periods up to 4 weeks.

Animals↗