Humans Functions (locomotion, protection of organs, reproduction) require a strong support system (bones). The ‘Osteostasis’ is the ability of maintaining the bone structure, its mechanical characteristics and function. Five principles are required for an efficient bone system: Basic Requirements: 1) Stability and 2) Function. Repair System (like house building in desert or sea): 3) Roads (vessels), 4) Materials (calories, proteins), 5) Workers (bone cells). Analysis of bone problems through these principles bring to optimised treatments. Measurements (>700 lengthening, 32-year follow-up, Full WB Albizzia/G-Nails FWBAG): Bone-DEXA, WB conditions, muscle, fat, etc.
Introduction
Materials & Methods
A 6cm femoral gain requires 5-Y during normal growth, but only 6–8-W surgically (x30–40 faster). In lengthening surgery, losses of muscle force (MF) and circumferences (MC) are major. Recovery is long, preventing sports till bone fusion. Can we maintain MC and strength throughout the entire lengthening and how? We monitored for over 30 years patients for muscle force (isokinetic), circumferences, activities (including sports) and food intake, and acted on the 5 principles of the Osteostasis. Over 750 femoral lengthening with Full WB Nails (FWBN) got Isokinetic testing (≧1991), circumferences measurements (≧2012; 20-15-10-5-0cm above patella, max-calf, mini/max-ankle), food intake (≧2012), using MyFitnessPal App (≧2016), gradually enforced. Preoperative training along with a daily post-operative training are supervised by our trainers. Recommendations for food intake and activities were provided. Patients noted on a specific App all parameters. Compliance was noted.Introduction
Materials & Methods
Frame HI is the #Days for device removal/cm. IM Nail HI is less relevant (31–45 D/cm). Albizzia HI was 33 D/cm (1991–2003). Patients felt fine approximately 1M after end of lengthening (EoL), resuming normal life and sports. This sometimes resulted in implants fractures (e.g. skying before bone fusion). Ideally, the full fusion should occur at the EoL. We decided to shorten the HI to reach this target, optimising all parameters. The evolution of care has been monitored over a 32-year clinical experience with a fully weight-bearing nails (Albizzia then G-nail). Monitoring was with X-rays, DEXA, blood bone activity, and in London with special 5G CBCT Scans. We implemented several changes in the Care of patients and measured them according to the ‘Five Principles’ (stability, function, ‘Roads-vascular supply’, ‘Materials-calories’ and ‘Workers-BFC’, with actions on food intake, activity levels and on muscle and bone vascular growths.Introduction
Materials & Methods
The Patient's Dream is not to stay in hospital even overnight, including in limb lengthening. We developed the ‘Hyper Fast Track Protocol’ (HFTP) in 2015 to fasten recovery and shorten hospital stay. The protocol included surgical stab incisions, use of weight bearing lengthening nails (G-Nail), intramedullary saw, a specific anaesthesia care (blood hypo-pressure, tranexamic acid, low hydration), absence of early anticoagulants, systematic vascular US controls, but early motion (hip and knee Ext/Fle, leg raise, horizontal ‘scissors’), walking, stairs, bike, clicking (maneuvers to lengthen), early discharge, along with other patient's parameters. Timing and exercises reps were registered. Protocols improved over time. Means ± SD are computed.Introduction
Materials and Methods
Cosmetic lengthening is currently growing, raising Ethical concerns. In cosmetic lengthening, the psychological benefit vs process and risks is not quantified in publications. We designed a prospective longitudinal study for evaluating quantitatively the psychological PROMs of patients with cosmetic lengthening and value its interest. Forty five cosmetic patients were operated on with the G-Nail with full weight-bearing, and sports: M/F 34/11, age 29.3±11.5 year-old, Gain 79 mm (range 86–187). All undertook preoperative preparation, psychological tests, post-operating training (lengthening period, twice daily) and a specific psychological program. No patient presented sequels. Questionnaires were provided before and 40.0 month after surgery (scale 0–10) with: Psychological suffering, Happiness in Life (HiL), Quality of Live (QoL), Self-Esteem, Self-Image, Self-Confidence, Professional, Family, Friends and Sexual Relations, Sexual Attraction. Average, SD of changes and T-Test (unequal variances) were computed.Introduction
Materials and Methods
To assess the effect on knee motion of gradual femoral lengthening using an intramedullary nail, between 1994 and 2003, 27 non-achondroplastic patients had bilateral femoral lengthening using the Albizzia nail. Vigorous post-operative physiotherapy was the norm. Knee motion recorded at various stages pre and post-operatively was compared. For an average gain of 6 cm the mean flexion during lengthening was 119. By final follow-up all patients had regained pre-operative range of motion. No tenotomies or joint manipulations were required. Good knee motion can be maintained during femoral lengthening using an intramedullary lengthening device.
Classification of the Complications was in three grades :
- I : Benign complication without any unexpected surgery or anaesthesia - II : Serious complication with unexpected surgery or anaesthesia - III : Severe complication The complications were recorded in four periods: surgery, elongation, consolidation and late complications
Articular complications do not show any significant difference between the different methods. The main complications are seen in neurological and post infectious diseases. The mean percentage of lengthening in these complications is not different of the mean percentage of the series.
A prospective evaluation comparing functional results in conventional and percutaneous femoral nailing techniques was performed. 4 patients (8 nails) were operated on with a conventional IM nailing technique (CT), and 4 (8 nails) with the percutaneous technique (PT). Limited trochanteric approach was performed, allowing the setting up of the sighting device for the nail. Patient was positioned on the lateral side, hip at 60° flexion. A long k-wire was passed through the skin, along the axis of the medullary canal in the anterior-lateral part of the Piriformis fossa, into the medullary canal. A small skin incision was performed, and then a cannulated drill introduced over the k wire. The reamer guide was pushed down to the distal femoral metaphysis. Percutaneous flexible reaming was then performed in a conventional manner, taking care to introduce the reamer through the gluteus medius with no torque. Section was performed through the same incision with a modified intramedullary saw. The nail was inserted, fixed on a modified sighting device. The continuous passive machine was set up in the recovery room or in the intensive care unit. Physiotherapy was directed towards maintaining knee range of motion. Patients were evaluated for scar size, muscle function, leg raise and range of motion (ROM). Follow-up averaged 30 (CT) and 11 (PT) months. Gain averaged 61 mm (CT) and 79 mm (PT). Scar size for nail insertion ranged from 6 to 11 cm (CT) and 1.1 to 3 cm (PT). Total number of operations from nail insertion to removal, including GA for ratcheting (GAR) and GA for other complications (GAC) was: 18 (CT, all nails removed) 9 (PT, among them 3 removal operations on the waiting list). On postoperative day 1, all patients with PT returned to a subnormal ROM. At one week, Knee flexion averaged 93° (CT) and 131° (PT). For CT, it increased gradually, passing 100° at 8 weeks, and 130° at 20 weeks. In PT, the minimum obtained was 126° at 10 weeks, passing 130° at 13 weeks. In CT, the decreased knee flexion was 90° (5 knees) and 80° (1 knee), while in PT; only 2 knees went below 110° (85 and 95°). Trendelenburg sign was negative in all PT by 3 months. Percutaneous IM nailing, along with a good physiotherapy programme, seems to improve tremendously the outcome and decrease the complication rate, even in large limb lengthenings, which are considered as major surgery and often are associated with numerous complications.
Anteriorly displaced fractures of the wrist can be treated by the Kapandji technique of percutaneous intrafocal pinning with pins inserted through an anterior approach to give good reduction and stabilisation of the fracture. We have modified this technique by placing the pins through a posterior approach which decreases the risks of neurovascular damage. We have used this method to treat six children with distal radial fractures showing anterior displacement or instability. Good anterior stabilisation was achieved. The pins were removed at an average of eight weeks and the patients were then able to return to full activity. This simple technique can be used for unstable fractures after the failure of conservative treatment or in bilateral fractures in adolescents.
