Cases reported "Leg Length Inequality"

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11/27. A 37-year follow-up evaluation of multiple-stage femur and tibia lengthening in dyschondroplasia (enchondromatosis) with a net gain of 23.3 centimeters.

    This case report presents the rare combination of circumstances of a child with (a) dyschondroplasia (enchondromatosis) limited to all the major epiphyseal plates of one lower extremity, (b) unusual capacity to cooperate, and (c) parents who refused permission to treat the limb by amputation but allowed the child to participate in a long-term clinical experiment. In dyschondroplasia (Ollier's disease), the long bones grow in diameter but not in length. In this condition, it was possible (by fasciotomy, osteotomy, and interposition of wedge blocks or hemicylindrical bone implants (stabilized by an intramedullary rod) to lengthen the leg 23.3 cm in ten stages, during the period between five and 14 years of age. With the additional procedure of epiphyseal arrest of the contralateral distal end of the femur at age 11, the eventual correction of discrepancy in leg length was 25.6 cm. Intraoperative and postoperative skin temperature recordings, toe plethysmography, and electromyography show that there were no deleterious changes in the circulatory or neurological functions of the extremity.
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12/27. One-stage surgical procedure for congenital dislocation of the hip in older children. Long-term results.

    The one-stage procedure described in this article, which has been used in children older than three years of age, is the method of choice in the treatment of late-diagnosed congenital dislocation of the hip. The present authors and their patients have been more than satisfied with the results of this procedure. With femoral shortening as the fundamental step, this method can be applied in high dislocations, as well as in cases of subluxation in which a pelvic osteotomy is indicated, to restore the depth of the acetabulum and to prevent undue pressure on the femoral head, which is the main cause of avascular necrosis, joint stiffness, and failures. Evaluation of the results is confusing but should rely on resistance of the hip in daily function, clinical appearance, range of hip motion, and the patient's opinion. Roentgenologic evaluation seems to be even more difficult, because numerous parameters need to be taken into consideration and correlated with the preoperative appearance of the hip. Certainly, it is reasonable to expect the majority of patients to develop osteoarthritic changes eventually, but nearly all patients can live a normal or satisfactory life for a number of years. The present authors are convinced that many patients will remain symptom-free for a long period.
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13/27. Congenital diastasis of the inferior tibiofibular joint: a review of the literature and report of two cases.

    Congenital inferior tibiofibular diastasis is a rare condition of unknown etiology, possibly a form of tibial hypoplasia, marked by a clinical triad of talipes equinovarus, ankle diastasis, and limb length inequality. An analysis of 10 cases reported previously is given with two additional examples. ankle mortise reconstitution and clubfoot correction by surgery have been the basis of treatment. We present two cases in which no ankle reconstruction was done with good results. Syme amputation is considered for cases with severe tibial shortening. prognosis for a plantigrade foot is encouraging if limb length inequality is corrected operatively or non-operatively as indicated.
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14/27. growth disturbance after physial injury of distal femur and proximal tibia studied by roentgen stereophotogrammetry.

    Longitudinal growth determined by roentgen stereophotogrammetry was registered in three patients with physial injuries in distal femur and in two patients with physial injuries in proximal tibia during 18 months. The injuries in distal femur were classified as Type I, Type I kII and Type IV and in proximal tibia as Type I kII and Type IV in the different cases according to Salter and Harris. Markers of tantalum balls were implanted into the metaphysis and bony epiphysis of distal femur and proximal tibia permitting regular determination of longitudinal growth. Significant growth disturbances was registered in four patients. The Salter-Harris classification was difficult to use to predict growth disturbance after physial injuries around the knee. The roentgen stereophotogrammetric method was found useful to determine normal growth rate and after physial injuries to reveal growth disturbance leading to complete or partial growth arrest resulting in leg length discrepancy or angular deformity. This method facilitates preoperative planning if surgery is needed.
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15/27. One stage femoral lengthening in the adult.

    One stage femoral lengthening procedures were performed in 9 adult patients. Eight patients had femoral shortening secondary to femoral fractures. The remaining patient had diffuse left hemiatrophy. The method of one stage lengthening has been modified from that described by Cauchoix. There were 7 males and 2 females with an average age of 23 years. The preoperative femoral shortening averaged 4.5 cm. The average lengthening at surgery measured 4.0 cm and 3.8 cm of this was maintained at follow-up. Complications included one case of serious sciatic and femoral nerve palsy, implant failure in 3 patients, a case of late femoral refracture following plate removal, and a case of acute femoral artery occlusion. There were no postoperative infections. Two cases required additional bone grafting of the osteotomy sites. There was no loss of preoperative hip or knee motion with this technique. One stage femoral lengthening by the method described is a major operative undertaking with several potential complications. The surgical technique is demanding and monitoring of the neurovascular status of the extremity during lengthening is mandatory. When properly executed, results are gratifying.
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16/27. Computer-assisted assembly and correction simulation for complex axis deviations using the Ilizarov fixator.

    In axis correction with the Ilizarov ring fixator, the correction results are often insufficient or there are unexpected translation effects, which can be causally attributed to wrong preoperative planning or inaccurate assembly. To avoid such results, computerised simulation was developed. Via digitalisation of the bone outlines traced from X-radiographs with an additional scale, preoperative correction planning can be performed, simulated with normal software. This can be used while constructing the apparatus and positioning the joints. In addition, the translation effect of the bone fragments can be simulated by arbitrarily choosing the pivot of the correction. In transferring the X-radiograph true to scale, one can compare the ring planes before and after correction. It is possible to estimate the necessary distraction as well as compression and thus the postoperative distraction mode. Using computerised planning, the apparatus construction can be optimised and complications caused by misplanning avoided. Not only the inexperienced user can benefit from this aid.
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17/27. Toxic shock syndrome as a complication of orthopaedic surgery.

    Toxic shock syndrome (TSS) was initially described by Todd et al. in 1978. TSS as a complication of orthopaedic surgery was reported in 1984. There have been previously a total of nine cases of TSS reported in orthopaedic patients. These patients presented at an average of 13 days postoperatively compared to 2 days for general surgical patients. patients with external fixators, however, presented an average of 25 days postoperatively. Menstrual TSS and nonmenstrual TSS present similarly; however, the fatality rate is reported as 10 and 50%, respectively. There was a 27% case fatality rate in orthopaedic patients. Because TSS is not a septicemia but a toxemia, the treatment depends on aggressive hemodynamic stabilization rather than antibiotic therapy. The classical presentation of TSS is not often seen in patients with TSS complicating orthopaedic surgery. Wounds rarely have any signs of infection. This presentation may be even more difficult to identify due to the occasionally long latency period between surgery and the development of TSS. It appears that external fixators may be left in place if there are no signs of infection. This requires further study.
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18/27. One-stage release of congenital circumferential constriction bands.

    A one-stage release of circumferential congenital constriction bands was performed in four extremities (three patients). No wound problems occurred, even when there had been marked swelling of the extremity distal to the band. The one-stage release facilitated postoperative care, and there was no need for additional periods of anesthesia or for additional operations, which are necessary when this problem is treated with a release performed in two or three stages.
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19/27. Treatment of deformity of the lower limb in adults who have osteogenesis imperfecta.

    The Ilizarov method of lengthening was used to correct deformities of the lower extremity in six patients who had type-1 osteogenesis imperfecta, as categorized by Silence et al. The average age was thirty-one years (range, fourteen to fifty-one years). The deformities included shortening of four tibiae and three femora as well as an angular malalignment (average, 28 degrees; range, 20 to 40 degrees) of all four tibiae and one femur. One patient also had a non-union of the right femur. The average angular correction was 23 degrees (range, 20 to 30 degrees). The seven limb segments gained an average of 6.6 centimeters (range, two to eleven centimeters) in length. All limb-length discrepancies were corrected to within two centimeters of the length of the contralateral limb. At an average of three years and four months (range, one year and seven months to six years), the roentgenographic appearance of the fully matured bone was comparable with that of the original bone. There was no fractures or increases in the angulation of the segment of new bone. Two patients had pain when walking; it was related to a chronic pin-track infection in one and to osteoarthrosis of the ankle in the other. The functional status of four patients was improved and that of the other two patients was unchanged. All six patients were pleased with the outcome of the procedure. There was eighteen complications: stiffness of the knee in two patients; a peroneal nerve palsy in two; a superficial pin-track infection in three; and a deep pin-track infection, greater-than-normal loss of blood intraoperatively, loosening of two pins, worsening of the instability of the knee, and an infection in the knee in one patient each. In another patient, a Rush rod that had been placed before correction of the deformity migrated proximally and had to be removed after completion of the correction. There were five fractures.
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20/27. Intraoperative SSEP monitoring during external fixation procedures in the lower extremities.

    The efficacy of somatosensory evoked potentials (SSEPs) to detect acute peripheral nerve injury during external-fixator application in the lower extremities was evaluated in 40 children with 42 Ilizarov surgical procedures. The study included patients who were either clinically normal or who had preexisting neuropathy but consistent and reliable SSEP responses preoperatively. SSEPs were recorded from the popliteal fossa and lumbar regions after alternating stimulation of the peroneal and posterior tibial nerves at the ankle. SSEP changes due to anesthesia, Ilizarov apparatus application, and other intraoperative variables are described. Significant deterioration or total loss of SSEP response during surgery occurred in four cases. Two of these patients were normal preoperatively and had symptoms of neurologic deficit postoperatively; the other two had exacerbations of pre-existing neuropathy. In general, the peroneal nerve was at greater risk for injury during surgery. SSEP monitoring proved to be technically feasible in external-fixation procedures on the lower extremities and may be a practical tool for detection of intraoperative nerve compromise.
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