Aims. As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. Methods. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). Results. A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Conclusion. Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated. Cite this article: Bone Joint J 2024;106-B(3):293–302

Introduction. We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy. Materials & Methods. A systematic review of the literature was conducted searching EMBASE, MEDLINE and Cochrane library for all articles discussing infected bone regenerate- a paucity of information was found. Abstracts were independently reviewed by 2 authors (LH and LT). In total, there were 16 papers, and then subsequently analysed we identified two case reports regarding infected regenerate. Results. Developing an infection in a regenerate is highly rare with very few reported cases within the published literature. The literature identified risk factors for an infected regenerate, with open fracture and smoking being the two consistent factors. The open fracture deep infection rate is cited at 10% in most publications, this is at the site of the open fracture and not within the regenerate. Conclusions. Infection within the regenerate during distraction osteogenesis is highly unusual, with only two other published papers in the literature to the best of our knowledge. This should be borne in mind when managing patients with infection of unknown sources in cases of distraction osteogenesis

Aims. Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences. Methods. A single-centre 2:1 matched-pair retrospective analysis of 42 patients treated with the STRYDE and 82 patients treated with the PRECICE nail between May 2013 and November 2020 was conducted. Clinical and lengthening parameters were compared while focusing radiological assessment on osseous alterations related to the nail’s telescopic junction and locking bolts at four different stages. Results. Osteolysis next to the telescopic junction was observed in 31/48 segments (65%) lengthened with the STRYDE nail before implant removal compared to 1/91 segment (1%) in the PRECICE cohort. In the STRYDE cohort, osteolysis initially increased, but decreased or resolved in almost all lengthened segments (86%) after implant removal. Implant failure was observed in 9/48 STRYDE (19%) and in 8/92 PRECICE nails (9%). Breakage of the distal locking bolts was found in 5/48 STRYDE nails (10%) compared to none in the PRECICE cohort. Treatment-associated pain was generally recorded as mild and found in 30/48 patients (63%) and 39/92 (42%) in the STRYDE and PRECICE cohorts, respectively. Temporary range of motion (ROM) limitations under distraction were registered in 17/48 (35%) segments treated with the STRYDE and 35/92 segments (38%) treated with the PRECICE nail. Conclusion. Osteolysis and periosteal reaction, implant breakage, and pain during lengthening and consolidation is more likely in patients treated with the STRYDE nail compared to the PRECICE nail. Temporary ROM limitations during lengthening occurred independent of the applied device. Implant-related osseous alterations seem to remodel after implant removal. Cite this article: Bone Joint J 2023;105-B(1):88–96

Percutaneous EndoProsthetic Osseointegration for Limbs (PEPOL) facilitates improved quality of life (QOL) and objective mobility for most amputee's discontent with their traditional socket prosthesis (TSP) experience. Some amputees desiring PEPOL have residual bone much shorter than the currently marketed press-fit implant lengths of 14-16 cm, potentially a risk for failure to integrate. We report on the techniques used, complications experienced, the management of those complications, and the overall mobility outcomes of seven patients who had femur distraction osteogenesis (DO) with a Freedom nail followed by PEPOL. Retrospective evaluation of a prospectively maintained database identified nine patients (5 females) who had transfemoral DO in preparation for PEPOL with two years of follow-up after PEPOL. Six patients had traumatic causes of amputation, one had perinatal complications, one was performed to manage necrotizing fasciitis and one was performed as a result of osteosarcoma. The residual femurs on average started at 102.2±39.7 mm and were lengthened 58.1±20.7 mm, 98±45% of goal (99±161% of the original bone length). Five patients (56%) had a complication requiring additional surgery. At a mean of 3.4±0.6 (2.6-4.4) years following osseointegration six patients had K-level >2. The 6 Minute Walk Test remained unchanged (267±56 vs 308 ± 117 meters). Patient self-rating of prosthesis function, problems, and amputee situation did not significantly change from before DO to after osseointegration. Six patients required additional surgery following osseointegration: six to remove fixation plates placed to maintain distraction osteogenesis length at osseointegration; two required irritation and debridement for infection. Extremely short residual femurs which make TSP use troublesome can be lengthening with externally controlled telescoping nails, and successfully achieve osseointegration. However, it is imperative to counsel patients that additional surgery to address inadequate regenerate or to remove painful hardware used to maintain fixation may be necessary. This may improve the amputee's expectations before beginning on a potentially arduous process

Introduction. Osteotomy is a key step in distraction osteogenesis. Various techniques of osteotomy have been described with its own benefits and pitfalls. Percutaneous osteotomy using multiple drill holes is one of the most widely used osteotomy techniques. It still remains a challenge however to keep the drill holes aligned prior to the osteotomy. Moreover, the efficacy of percutaneous irrigation practice to keep the temperature low during drilling with this technique is also debatable. With an aim to overcome these challenges, we are introducing a device called the Double Barrel Drill Sleeve (DBDS) to perform percutaneous osteotomies. We attempted to compare this method to the conventional multiple drill holes technique using laboratory experiments and clinical data. Materials & Methods. DBDS has two adjacent parallel barrels that can fit 3.2 to 3.5 mm diameter drill bits. It has a guide member at the drilling end that can be inserted through a pre drilled hole at the near and far cortices of a bone. This provides a constant rotating point for drilling of holes through the barrels. An osteotomy simulation was performed to compare percutaneous drilling with DBDS vis-a-vis a conventional single drill sleeve (SDS) by qualified orthopaedic surgeons, mainly to assess the drilling patterns of both techniques. Percutaneous drilling was done on PVC pipes wrapped in thick sponge to simulate tubular bone with surrounding soft tissue. We also assessed the effect of indirect irrigation on temperature during drilling using the DBDS against a control group on a cadaveric bone model. Ultimately we reviewed our patients who had undergone osteotomy for distraction osteogenesis with DBDS and the conventional technique, and compared their outcomes. Results. Completion time for the osteotomy simulation in the DBDS group was significantly faster than the conventional drilling group; 74 seconds to 179 seconds. There was significantly less drilling deviation from the midpoint in the DBDS group as compared to the SDS group. Mean bone temperature during drilling with indirect irrigation using DBDS was significantly lower (32.6'C) compared to the control group (48.4'C). There was no significant difference in healing index between patients treated with DBDS and the conventional method. None of these patients developed non union. Conclusions. Percutaneous drilling with DBDS was quicker and more linear compared to the conventional method. Its double-barreled feature allows effective indirect irrigation during drilling. A comparable healing index in both of the techniques shows its clinical efficacy. These attributes make DBDS a usefull tool to overcome some of the pitfalls associated with the conventional multiple drill holes technique

Introduction. Percutaneous EndoProsthetic Osseointegration for Limbs (PEPOL) facilitates improved quality of life (QOL) and objective mobility for most amputees discontent with their traditional socket prosthesis (TSP) experience. Some amputees desiring PEPOL have residual bone much shorter than the currently marketed press-fit implant lengths of 14–16 cm, potentially a risk for failure to integrate. We report on the techniques used, complications experienced, the management of those complications, and the overall mobility outcomes of seven patients who had femur distraction osteogenesis (DO) with a Freedom nail followed by PEPOL. Materials & Methods. Retrospective evaluation of a prospectively maintained database identified nine patients (5 females) who had transfemoral DO in preparation for PEPOL with two years of follow-up after PEPOL. Six patients had traumatic causes of amputation, one had perinatal complications, one was performed to manage necrotizing fasciitis and one was performed as a result of osteosarcoma. Results. The average age at which DO commenced was 39.4±15.9 years, and seven patients had their amputation more than ten years prior (average 25.5±18.8 years). The residual femurs on average started at 102.2±39.7 mm and were lengthened 58.1±20.7 mm, 98±45% of goal (99±161% of the original bone length). Five patients (56%) had a complication requiring additional surgery: four events of inadequate regenerate were managed with continued lengthening to desired goal followed by autograft placement harvested from contralateral femur reaming; one patient had the cerclage wires break which required operative replacement. All patients had osseointegration performed, at 355±123 days after the initial lengthening nail surgery. One patient had K-level >2 before DO, at a mean of 3.4±0.6 (2.6–4.4) years following osseointegration six patients had K-level >2. The 6 Minute Walk Test remained unchanged (267±56 vs 308 ± 117 meters). Patient self-rating of prosthesis function, problems, and amputee situation did not significantly change from before DO to after osseointegration. Six patients required additional surgery following osseointegration: six to remove fixation plates placed to maintain distraction osteogenesis length at osseointegration; two required irritation and debridement for infection. Conclusions. Extremely short residual femurs which make TSP use troublesome can be lengthening with externally controlled telescoping nails, and successfully achieve osseointegration. However, it is imperative to counsel patients that additional surgery to address inadequate regenerate or to remove painful hardware used to maintain fixation may be necessary. This may improve the amputee's expectations before beginning on a potentially arduous process

Introduction. Metabolic bone disease encompasses disorders of bone mineralization, abnormal matrix formation or deposition and alteration in osteoblastic and osteoclastic activity. In the paediatric cohort, patients with metabolic bone disease present with pain, fractures and deformities. The aim was to evaluate the use of lateral entry rigid intramedullary nailing in lower limbs in children and adolescents. Materials and Methods. Retrospective review was performed for an 11-year period. Lower limb rigid intramedullary nailing was performed in 27 patients with a total of 63 segments (57 femora, 6 tibiae). Majority of patients had underlying diagnoses of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright disease). Mean age at surgery was 14 years. Indications for surgery included acute fractures, prophylactic stabilisation, previous nonunion and malunion, deformity correction and lengthening via distraction osteogenesis. Results. All fractures healed. Correction of deformity was successfully achieved in all segments. Delayed union occurred in 4 segments in 1 patient and was successfully treated with nail dynamization. Other complications included prominence, cortical penetrance and loosening of locking screws. One patient who had lengthening performed had nonunion and was managed with exchange nailing and adjunctive measures. Conclusions. Rigid intramedullary nailing is very effective in stabilisation and deformity correction of long bones in adolescent patients with pathological bone disease. The technique has low complication rates. We recommend the use of this technique in paediatric units with experience in managing metabolic bone conditions

Introduction. Infected big gap non-union of femur and tibia are difficult to treatment because of infection, bone loss, shortening, poor sift tissue over and deformity. Step by step management and definitive treatment by Ilizarov fixator was achieved in our cases. Materials and Methods. A long defect which is more than 10cm in femur and tibia because of infection and gap, tumor resection, traumatic loss, which is very difficult to treat by conventional method and that's why we treated that type defect by Tibialization of fibula with Ilizarov technique. Management of infected big gap non-union of the femur include debridement and bone transport by Ilizarov technique by using Ilizarov fixator we can correct deformities, regenerate new bone without bone grafting, correct LLD and patient can weight bear during the course of treatment. We retrospectively reviewed records of 246 consecutive patients who underwent distraction osteogenesis using Ilizarov compression-distraction device for infected big gap INU of femur and tibia from 2000 to 2020. Results. All healed with the application of Ilizarov fixator, 5 needed reapplications of Ilizarov to achieve 100% union. 210 were excellent, 25 good and 6 were fair by ASAMI criteria. Mean Ilizarov duration was 366 days (130–250). Mean 8.2 cm length was achieved in the regenerate. Conclusions. A well plan step by step Ilizarov technique to cover infected gap non-union of femur and tibia is an excellent method in challenging cases. Excellent results cannot be achieved with conventional methods but can be easily achieved with Ilizarov technique within 1–2 years

Introduction. Fibula contributes to weight bearing and serves as a lateral buttress to the talus. Fibular shortening leads to ankle valgus, distal tibial epiphyseal wedging and ankle instability. Trauma, infection and skeletal dyplasias are the common causes of fibular shortening in children. Aim was to review this cohort who underwent fibular lengthening and ankle reconstruction. Materials and Methods. Retrospective review from a prospective database of clinical and radiographic data of all children who underwent fibular lengthening for correction of ankle valgus. Distraction osteogenesis with external fixator was performed for all cases. Results. Eight children with 10 fibulae (average age: 10 years) were followed up for an average of 75.6 months. In older children, corrective tibial osteotomy was performed in addition to fibular lengthening. TSF frame mounted with mini-rail fixator was used in seven children who required adjuvant tibial correction and mini-rail was used for bilateral fibular lengthening in one. Remodelling of the wedged distal tibial epiphysis was noted in 75%. Talar tilt and mLDTA improved in 66.7% and fibular station in 85.7% limbs. Seven year old girl required re-lengthening. Two children developed fibular non-union. Proximal fibular migration was observed in one child, in whom the tibial wire did not engage the fibula. Conclusions. Restoration of tibial mechanical axis and lateral talar buttress is necessary to correct ankle valgus. Stabilisation of fibula to the tibia is prudent during distraction. Younger children may require re-lengthening. Remodelling of the triangular tibial epiphysis can be achieved when done early

Introduction. This study aims to evaluate the effect of using different types of fixator on the quality of callus and complications during distraction osteogenesis in patients with achondroplasia. Materials and Methods. Forty-nine achondroplasia patients with a minimum follow-up of 36 months who underwent limb lengthening between 2005 and 2017 with external fixator only were included. Thirty-three of the patients underwent lengthening using classical Ilizarov frame, while spatial frame used for sixteen. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction. Complications were noted in the follow-up period. Results. The mean age at the time of surgery was 8,6 years. The mean external fixation index (EFI) was 34,3 and 30,1 day/cm for spatial frame and Ilizarov frame respectively. Mean follow-up period of 161,62 months and mean fixator period of 257 days. Amount of lengthening was 7,2 cm for Ilizarov frame, and 7,5 cm for spatial frame. Rate of callus with good morphological quality seen at consolidation was 72,4% and 50% for Ilizarov and spatial frames respectively. Two groups show similar results of complication rates in terms of pin site infection, premature fibular consolidation, regenerate fracture, plastic deformation, knee contracture. However fibular nonunion rates were higher for Ilizarov-type fixator. Conclusions. Although spatial frame with computer assistance brings easier follow-up for deformity correction, Ilizarov-type external fixator show slightly higher rates of good quality callus during consolidation for patients with achondroplasia

Introduction. Bone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique. Methodolgy. Patients were identified through our limb reconstruction database and clinic notes, operative records and radiographs were reviewed. Since 2019, 8 patients (5 male : 3 female) have undergone bone transport via our modified balanced cable transport technique. Average age at time of transport was 39.6 years (range 21–58 years) with all surgeries performed by the senior author. Patients were followed up until radiological union. We recorded the length of bone transport achieved as well as any problems, obstacles or complications encountered during treatment. We evaluated outcomes of full weight bearing and return to function as well as radiological union. Results. 4/8 bone defects were due to severely comminuted open fractures requiring extensive debridement. All other cases had previously undergone fixation of tibial fractures which had failed due to infection, soft tissue defects or mal-reduction. The mean tibial defect treated with bone transport was 41mm (range 37–78mm). From the start of cable transport to removal of external fixator our patients spent an average of 201 days in frame. 7/8 patients underwent a 2-week pin-site holiday and subsequent insertion of intramedullary nail 2 weeks later. One patient had sufficient bony union to not require further internal fixation after frame removal. 10 problems were identified during treatment. These included 4 superficial infections treated with antibiotics alone and 5 issues with hardware, which could be resolved in the outpatient clinic. 1 patient had their rate of transport slowed due to poor skin quality over the site of the regenerate. 4 obstacles resulted in a return to theatre for additional procedures. 1 patient had a re-do corticotomy and 3 had revision of their internal cable transport constructs due to decoupling or screw pull out. 1 patient had residual ankle joint equinus following treatment which required an Achilles tendon lengthening procedure. Another patient underwent treatment for DVT. There were no deep infections identified and no significant limb length discrepancies or deformities. Conclusions. Overall, we have found that our modified balanced cable transport technique has allowed for successful bone transport for significant defects of the tibia. We have learned from the obstacles encountered during this case series to avoid unnecessary return trips to theatre for our future transport patients. The internal cable system allowed all patients to complete their planned transport without excessive pin tract scarring or pain. Early conversion to intramedullary nail allowed for a shorter time in frame with continued full weight bearing as the regenerate consolidated. No metalwork failure or deformity has occurred in relation to docking site union. All patients have made a good return to pre-operative function during their follow-up period with no evidence of late complications such as deep infection

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Introduction. We have previously published limb lengthening using external fixation in pathological bone diseases. We would like to report a case series of femoral lengthening using the PRECICE system in a similar pathological group especially looking at it's feasibility and complications. Materials and Methods. This is a case series of four patients, two patients with osteogenesis imperfecta and two with Ollier's disease, who underwent femoral lengthening via distraction osteogenesis using the PRECICE intramedullary nail system. It was a retrospective study from a prospective database from clinical records and radiographs. Results. The mean age at the time of surgery was 15.5 years, the mean preoperative leg length discrepancy was 30mm, and the mean distraction distance achieved was 28.75mm. Since these patients were of shorter heigh, limb lengthening was considered. All 4 patients had successful insertion of the nail. The outcomes noted from the 4 patients are collated, with several complications occurring including delayed femoral union, fixed flexion deformity of the hip, persisting pain and quadriceps weakness. Those with Ollier's disease underwent an increased rate of distraction to prevent premature healing. The implications of long-term bisphosphonate therapy in OI are discussed with regards to the risk of delayed femoral union and intra-operative fracture. Conclusions. Intramedullary femoral lengthening in pathological bone disease is possible, but the surgeon needs to give attention to certain details. The regenerate formation is based on the background pathology irrespective of the hardware used. There is much more compliance with the nail technique

Aim. Infected segmental defects are one of the most feared complications of open tibial fractures. This may be due to prolonged treatment time, permanent functional deficits and high reinfection and non-union rates. Distraction osteogenesis techniques such as Ilizarov acute shortening with bifocal relengthening (ASR) and bone transport (BT) are effective surgical treatment options in the tibia. The aim of this study was to compare ASL with bone transport in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at surgical resection of the infection. Method. In this single centre series, all patients with a segmental defect (>2cm) of the tibia after excision of infected non-union or osteomyelitis were eligible for inclusion. Based on clinical features, bone reconstruction was achieved with either ASR or BT using an Ilizarov fixator. We recorded the external fixation time (months), the external fixation index (EFI), comorbidities, Cierny-Mader or Weber-Cech classification, follow-up duration, time to union, number of operations and complications. Results. Overall, 43 patients with an infected tibial segmental defect were included. An ASR was performed in 19 patients with a median age of 40 years (range: 19 – 66 years). In this group, the median bone defect size was three cm (range: 2 – 5 cm); and the median frame time eight months (range: 5 – 16 months). BT was performed in 24 patients with a median age of 44 years (range: 21 – 70 years). The median bone defect size was six cm (range: 3 – 10 cm), and the median frame time ten months (range: 7 – 17 months). The EFI in the ASR group and the BT group measured 2.2 months/cm (range: 1.3 – 5.4 months/cm) and 1.9 months/cm (range: 0.8 – 2.8 months/cm), respectively. The comparison between the EFI of the ASL group and the BT group showed no statistically significant difference (p=0.147). Five patients of the ASR group (7 surgeries) and 19 patients of the BT group (23 surgeries) needed further unplanned surgery (p=0.001). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.3% (p=0.0001). Conclusion. Acute shortening/relengthening and bone transport are both safe and effective distraction osteogenesis techniques for the treatment of infected tibial non-unions. They share similar frame times per centimetre of defect. However, ASR demonstrated a statistically significant lower rate of unplanned surgeries

Sclerostin is a negative regulator of osteoblast differentiation and bone formation. Expressed by osteocytes, it acts through antagonising the Wnt/â-catenin pathway and/or BMP activity. Distraction osteogenesis, used for limb lengthening and reconstruction, can be complicated by disuse osteopenia and poor healing response, both of which would benefit from pro anabolic therapy. We examined the effects of Sclerostin Antibody (Scl-AbIII, Amgen Inc.,) in a rat model of distraction osteogenesis. A femoral osteotomy was stabilized with an external fixator in male Sprague Dawley rats. After a week of latency, the gap was distracted twice daily for 14 days to a total of 7 mm. Saline or Scl-Ab was administered twice weekly throughout the distraction period and up to 4, 6 or 8 weeks post commencement of distraction. Three groups were examined: Saline, Continuous Scl-Ab throughout the study (C Scl-Ab), and Delayed Scl-Ab with commencement of Scl-Ab after distraction (D Scl-Ab). Regenerate bone mineral content (BMC), determined by DEXA, was increased 36% at 4 weeks and 86% at 6 weeks with C Scl-Ab, resulting in a 65% increase in bone mineral density (BMD) at 6 weeks, compared with Saline (p<0.01). D Scl-Ab treatment showed a 41% increase in BMC and a 31% increase in BMD compared with Saline at 6 weeks (p<0.05). At 8 weeks, C Scl-Ab remained significantly increased over Saline (72% in BMC; 60% in BMD). Micro-CT scans of the regenerate revealed increases in bone volume of 88% with C Scl Ab and 65% with D Scl-Ab compared with Saline at 6 weeks (p<0.05). By 8 weeks, these increases were 36% for C Scl-Ab (p<0.05) and 37% for D Scl-Ab compared with Saline (p<0.01). Importantly, mean moment of inertia was increased over two-fold in both Scl-Ab groups at 6 weeks compared with Saline (p<0.05). Histology at 6 weeks confirmed micro-CT data with 85–88% increases in bone volume/tissue volume (BV/TV) in the regenerate with both C Scl-Ab and D Scl-Ab compared with Saline (p<0.05). Analysis of bone formation at 6 weeks revealed increases in mineral apposition rate of 56% in C Scl-Ab and 52% in D Scl-Ab compared with Saline (p<0.05). Scl-Ab treatment increased bone formation in this model of distraction osteogenesis, resulting in a larger regenerate callus (increased BMC and BV/TV). We expect further studies to reveal increases in mechanical strength. Scl-Ab may hold promise as a therapeutic to accelerate regenerate formation and consolidation in distraction osteogenesis for limb reconstruction

The purpose of this study is to provide a systematic review of the literature and assess outcome of our experience of Ilizarov Bone Transport in reconstruction for primary malignant tumours of bone (PMTB). A systematic review of the literature for reported cases of primary reconstruction of PMTB using distraction osteogenesis was performed. All cases of distraction osteogenesis for primary reconstruction of PMTB in our institution were reviewed. Outcome was determined from retrospective review of case notes and radiology. Patients were contacted to define final status. There are few cases of primary reconstruction of PMTB using Ilizarov method in the literature. Most reports relate to benign tumours or reconstruction of secondary deformities or non-union after tumour resection. At our institution we have treated 7 patients with bone defects resulting from excision of a PMTB. Mean age was 42.1 years (23–48). Tumours occurred in the tibia in 4 cases and the femur in 3 cases. Histologic diagnosis was chondrosarcoma in 3, malignant fibrous histiocytoma in 2, adamantinoma in 1 and malignant intraosseous nerve sheath tumour in 1. All patients were assessed through the hospital sarcoma board and shown to have isolated bone lesions without metastases. Mean bone defect after resection was 13.1 cm (10–17). Mean frame time was 13.6 months (5–23). Mean follow-up was 46 months (15–137). Complications included pin infection, docking site non-union, premature fusion of corticotomy, soft tissue infection and minor varus deformity. There was one local recurrence of tumour at five months after resection, resulting in a through hip disarticulation. The other cases remain tumour-free with united, well-aligned bones and acceptable long-term function. PMTB is rare and poses a major reconstructive dilemma. Distraction osteogenesis provides an effective method of biologic reconstruction in selected cases, and good outcomes can be achieved

The aim of this study was to assess the incidence of fibula non-union in patients undergoing distraction osteogenesis, and the incidence of symptoms following this. A consecutive series of 58 patients undergoing distraction osteogenesis at a tertiary centre under a single surgeon were included. Data was collected prospectively. Plain radiographs were reviewed retrospectively by a blinded reviewer. Union was defined as the presence of bridging callous on two views. There were 58 distraction procedures performed. The mean age was 37.2 years (range 16.0 to 80.6). There were 36 males and 22 females. The mean follow-up was 23.4 months (4–70 months). 9 (15.5%) went onto non-union at frame removal. 3 (33.3%) of the 9 fibulas that did not unite developed symptoms. 2 (66.7%) of these required surgery in the form of fibula plating. Both of these patient's symptoms resolved following surgery. 3 (33.3%) of the 9 non-united fibulas also had tibial non-union compared to 1 of the 49 where the fibula united. There was no association between location of fibula osteotomy and development of non-union. 35 fibula osteotomies were performed in the third quarter. Of the fibulas that united, the mean fibula lengthening was 9.25 mm (range 1.2–27.8 mm). In the fibulas that went onto non-union the mean lengthening was 23.66 mm (range 5.1–51.5 mm) (P = 0.004). 54 (93.1%) of the tibias united following osteotomy and distraction, whilst 4 (6.9%) went onto non-union requiring operative treatment. Of the 4 tibias that did not unite, 3 (75%) also had fibula non-union (P = 0.01). Fibula non-union is a relatively common complication following osteotomy in distraction osteogenesis. The length of fibula distraction and tibia non-union are significant risk factors for the development of a fibula non-union. We recommend surgical intervention for those patients who have symptomatic fibula non-unions

Introduction. Lower limb mal-alignment as a result of fracture malunion can result in knee degenerative arthritis or predispose to early arthroplasty failure due to the altered mechanical axis. The choice of corrective osteotomy is often determined by potential complications. Opening wedge osteotomy is associated with poor bone healing especially in adult diaphyseal bone. Distraction osteogenesis enables gradual deformity correction with the gap filled by regenerate bone. Bone formation however is formed less favourably in the diaphysis and metaphyseal osteotomy is advised. We present a consecutive series of adult tibial diaphyseal correction using the Taylor Spatial Frame utilising the method of distraction osteogenesis. Method. 15 adults, 11 male and 3 female, underwent tibial deformity correction. A mid diaphyseal osteotomy was made using minimal soft tissue dissection and an osteotome. The site was determined by the centre of rotation of angulation (CORA). After a 6 day latency period distraction was undertaken by the Taylor Spatial Frame. Patients were encouraged to fully weight bear throughout the treatment process. Following regenerate consolidation the frame was removed and a below knee weight bearing cast applied for 4 weeks. Result. A mean correction of 11 degrees (4∼19) was undertaken. Correction time was a mean 13.5 days (6∼22). All osteotomies consolidated and frame removal was after a mean 136 days (92–192). All patients had at least one superficial pin site infection which responded to oral antibiotics. There were no deep infections or significant complications. Conclusion. Deformity correction at the CORA produces realignment without translation. The Taylor Spatial Frame allows accurate virtual hinge placement and stable correction of adult bone. Concern over diaphyseal osteotomy in adult bone has been previously raised but our study confirms that tibial diaphyseal correction using distraction osteogenesis is successful with minimal morbidity and rapid return to function. We believe that this should be considered as the optimal technique when undertaking tibial diaphyseal deformity correction

Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with mean age 15 years (9 to 23) and mean follow-up 21 months (8 to 51). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with torticollis, congenital myopathy and Noonans syndrome and obstetric brachial plexus injury. Mean length gained was 31 mm (15 to 41) which represens an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263) and mean external fixation index was 56 days/cm. Two patients required internal fixation following fixator removal to consolidate union and one required additional internal fixation for atrophic regenerate. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin site infections. Clavicular lengthening by distraction osteogenesis for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury following acute correction. It has the potential to improve shoulder pain, function, range of movement and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union

Purposes of the study. To assess safety, lengths gained, frame time and perform cost analysis of the technique of submuscular plating to the femur and tibia following distraction osteogenesis. Introduction. Since 2005 we have performed submuscular plating to the femur and tibia after distraction osteogenesis in order to shorten time in external fixator. Aim. To assess safety, lengths gained, frame time and perform cost analysis. Methods. Retrospective analysis using notes and digital radiographs, with cost codes for 2011 prices. Patients. 23 patients (14 male), mean age 11 (range 4 to 17). 14 diagnosed as congenital longitudinal deficiency. Total 37 bones lengthened (14 femur and tibia, 7 tibia only, 2 femur only). Ilizarov fixator most commonly used for tibia, LRS fixator for femur. Results. Mean length gained 68 mm per patient, 43 mm per bone. Mean frame time 121 days. Fixator index 0.59 months/cm per patient, 0.90 months/cm per bone. Mean cost £20100 per patient, £12500 per bone, £2800 per cm length. Cost attributable to plating £5100 per patient, £3300 per bone. Complications: 5/24 had pinsite infections, 2/24 required tendon releases, 1/24 had deformity, 1/24 sustained a fracture proximal to femoral plate. No deep infections. Conclusions. Plating after lengthening is a safe procedure with no deep infections. The frame time is low (0.6 months/cm per patient) but increases overall costs by an extra £5000