Introduction: Internal lengthening nails have enhanced the patient experience in limb lengthening, but soft-tissue complications such as neuropathies and joint contractures continue to limit the degree of correction achievable in a single procedure. In progressive conditions like congenital limb deficiencies, limb length discrepancy (LLD) may recur over time, necessitating repeat interventions. This study evaluated outcomes in patients who underwent two consecutive internal femoral lengthening procedures. Materials and Methods: Seven patients who had sequential internal femoral lengthenings were retrospectively reviewed. Diagnoses included congenital femoral deficiency (n = 4), fibular hemimelia (n = 1), and physeal growth arrest from trauma (n = 1) or infection (n = 1). Data collected included demographics, total length gained, bone healing index (BHI), and the interval between procedures. Results: The cohort comprised four males and three females, with a mean age of 9.9 ± 5.1 years at the first lengthening. The left femur was lengthened in five cases. The median interval between procedures was 46 months (interquartile range: 25 months). The BHI was generally higher during the second lengthening than during the first (median 28.2 vs. 25.6 days/cm), although the direction and magnitude of the change differed between patients. However, bone regenerate maturation after the second lengthening was less predictable, showing a wider BHI range (12.5–42.8 days/cm). Conclusion: Repeat femoral lengthening using an internal lengthening nail is both feasible and safe, with comparable bone healing to the initial procedure. Increased variability in healing during the second lengthening warrants further study to identify factors influencing bone regeneration consistency.
High-energy Gustilo–Anderson Grade IIIB open tibial fractures with massive segmental bone loss (>10 cm) present a major reconstructive challenge. We report a 49-year-old female with a 15 cm tibial defect and extensive soft tissue loss. A sequential orthoplastic approach was utilized. Initial debridement and spanning fixation were followed by a robust, large-volume latissimus dorsi (LD) free flap for definitive soft tissue coverage. Six weeks later, a mono-focal Ilizarov bone transport was initiated. The stable LD flap permitted safe pin placement and distraction. The transport successfully bridged the 15 cm defect, achieving full consolidation at 18 months. This staged strategy – prioritizing stable free flap coverage before delayed ilizarov bone transport – is a highly effective limb salvage alternative for massive defects, resulting in a high likelihood of union with excellent functional outcome and amputation avoidance.
Context: Hemiepiphysiodesis has been a successful approach for the management of lower extremity coronal malalignment around the knee. This procedure has reportedly been effective in correcting deformity caused by different pathologies. Aims: This study examines the effect of underlying pathology on the rate of correction following temporary hemiepiphysiodesis. Settings and Design: Records of skeletally immature patients who underwent temporary hemiepiphysiodesis with at least 1-year radiographic follow-up were retrospectively reviewed. Subjects and Methods: Lower extremity mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were measured preoperatively and on the final radiograph obtained before implant removal or before a second procedure was performed on the same limb. Statistical Analysis Used: Rate of change of MAD, LDFA, and MPTA was examined as a function of pathology, deformity direction, age, and body mass index using linear mixed models. Results: One hundred and forty-five patients (257 limbs) were included. The mean ± standard deviation age at surgery was 11.9 ± 3.5 years. The mean rate of correction was 1.48 ± 1.00 mm per month and did not differ based on direction of the initial deformity (P = 0.55). The mean rate of change in LDFA was 0.29° ± 0.27° per month and MPTA was 0.28° ± 0.26° per month. A faster rate of correction of LFDA and MPTA was noted for younger children (P < 0.001) and those with rickets (P < 0.03). A faster rate of correction of MAD showed a trend toward significance for younger children (P = 0.069). Conclusions: In children with coronal plane deformities treated with guided growth hemiepiphysiodesis, faster correction is expected for children with rickets and younger children.
Background: Circular external fixation constructs are increasingly designed to be more compact while maintaining mechanical stability. In hexapod systems, limited ring space and strut clearance constrain fixation placement, making fixation cube-hole position (offset) and half-pin divergence key design variables. However, limited guidance exists on how these factors should be balanced when a constant bone-capture (excursion) distance must be maintained. This study evaluated the stiffness–footprint trade-off across five fixation cube-hole configurations under a constant excursion constraint. Methods: A benchtop circular external fixation construct was assembled using a 150-mm reference ring and a 38-mm Delrin cylinder as a bone surrogate. A 5.0-mm half-pin was mounted via a five-hole fixation cube. Five configurations were tested while maintaining a constant excursion of 65.52 mm. As cube-hole position moved proximally, ring–block offset decreased (65.52–17.52 mm) and required divergence increased (0°–30°). Axial compression testing was performed, and stiffness was calculated from the slope of the load–displacement response within the 2–10 lb linear region (peak load 12–15 lb). Three repeat trials of a single construct assembly were performed per configuration. Configuration-depentdent mechanical behaviors were compared using one-way Analysis of Variance ANOVA with Tukey post-hoc testing. Results: Axial stiffness varied markedly across configurations. One-way ANOVA demonstrated large between-configuration differences (F[4,10] =5540.4, P < 0.001; η2 = 0.999). Post hoc comparisons showed clear separation between all configurations (Tukey HSD, all P < 0.001), with minimal overlap in measured stiffness values. The orthogonal configuration (0°) was least stiff (293.6 ± 0.8 lb/in). Stiffness increased with divergence, peaking at 20° (486.7 ± 0.1 lb/in; +65.7% vs. baseline). Further divergence to 30° reduced stiffness but remained above baseline (+43.5%). All pairwise comparisons were significant (P < 0.001). Footprint decreased progressively from 2025.0 mm2 to 788.6 mm2 (−61%). Conclusions: While the tested comparisons represent technical repeats rather than independent construct replicates, these results indicate consistency in the measurements within each configuration and the separation between configurations. Moderate half-pin divergence (≈20°) maximized axial stiffness, while greater divergence (30°) minimized footprint with preserved rigidity. These findings support configuration optimization in circular and hexapod fixation.
Limb lengthening is a well-established surgical procedure used to address congenital and acquired limb length discrepancies. Despite advancements in external and internal fixation techniques, the process remains physically and psychologically demanding, with prolonged recovery and a risk of complications. Clinically applicable rehabilitation guidance remains limited and fragmented within the literature. This narrative review provides a structured and practical overview of rehabilitation in lower limb lengthening, integrating current evidence with clinically relevant strategies across the preoperative, intraoperative, and postoperative phases. Key components of care include patient education, prehabilitation, structured rehabilitation protocols, and early identification and management of complications. These elements are essential for optimizing functional recovery and reducing complication risk. A structured, phase-based rehabilitation approach may improve clinical outcomes following limb lengthening.
