Stump Overgrowth after Limb Amputation in Children

Stump overgrowth is the most common complication after limb amputation in children. Its morbidity is relatively high, that required frequent revisions of the stump and prosthesis. The incidence of stump overgrowth varies in the literature; depending on different factors. The exact pathogenesis is unclear, many hypotheses have been suggested. The treatment is a challenge; simple excision of the bone is associated with recurrence and further shorting of the stump. Many options of treatment have been used. This paper is an up-to date literature review that includes the definition, incidence, pathogenesis, clinical presentation, radiographic diagnosis, and treatment options of stump overgrowth in children

Rotational Guided Growth: A Preliminary Study of Its Use in Children

Torsional malalignment of the legs is common in children, and those that do not remodel may benefit from surgical correction. Traditionally, this is corrected with an open osteotomy. Guided growth is the gold standard for minimally invasive angular correction and has been investigated for use in torsional deformities. This study presents our preliminary results of rotationally guided growth in the femur and tibia using a novel technique of peripheral flexible tethers. A total of 8 bones in 5 patients were treated with flexible tethers consisting of separated halves of a hinge plate (Orthopediatrics Pega Medical, Montreal, QC, Canada), which were fixed to the epiphysis and metaphysis at 45° angles to the physis and connected with Fibertape (Arthrex, Naples, FL, USA). The implants are placed medially and laterally in the opposite 45° inclination, determined by the desired direction of rotation. Additionally, the average treatment time was 12 months. All patients corrected the rotational malalignment by clinical evaluation. The average rotational change was 30° in the femurs and 9.5° in the tibias. Further, the average follow-up was 18 months, with no recurrence of the rotational deformity. There was no change in longitudinal growth in the patients who underwent bilateral treatment. Rotational guided growth with flexible tether devices is a novel technique that successfully corrects torsional malalignment without invasive osteotomy surgery

Cross-Union Surgery for Congenital Pseudarthrosis of the Tibia

Congenital Pseudoarthrosis of the Tibia (CPT) is a rare condition with a reputation for recurrent fractures and failure to achieve union. A large variety of surgical procedures have been attempted for the treatment of fractured cases of CPT with an average rate of union without refracture of only 50%. Intentional cross-union between the tibia and fibula has been reported to improve these results to 100% union with no refractures. This is a retrospective study of 39 cases of CPT in 36 patients treated by the Paley cross-union protocol with internal fixation, bone grafting, zoledronic acid infusion and bone morphogenic protein 2 (BMP2) insertion. All 39 cases of CPT united at the tibia and developed a cross-union to the fibula. Two patients had a persistent fibular pseudarthrosis, one that was later treated at the time of planned rod exchange and one that has remained asymptomatic. There were few postoperative complications. There were no refractures during the up to 7-year follow-up period. The most common problem was the Fassier-Duval (FD) rod pulling through the proximal or distal physis into the metaphysis (66.7%). This did not negatively affect the results and was remedied at the time of the planned rod exchange. The Paley Cross-Union Protocol is very technically demanding, but the results have radically changed the prognosis of this once sinister disease

Lengthening Reconstruction Surgery for Fibular Hemimelia: A Review

Fibular hemimelia (FH) presents with foot and ankle deformity and leg length discrepancy. Many historic reconstructions have resulted in poor outcomes. This report reviews modern classification and reconstruction methods. The Paley SHORDT procedure (SHortening Osteotomy Realignment Distal Tibia) is designed to correct dynamic valgus deformity. The Paley SUPERankle procedure (Systematic Utilitarian Procedure for Extremity Reconstruction) is designed to correct fixed equino-valgus foot deformity. The leg length discrepancy in FH is successfully treated with serial lengthening and epiphysiodesis. Implantable intramedullary lengthening devices have led to all internal lengthenings. Recent advancements in techniques and implants in extramedullary implantable limb lengthening (EMILL) have allowed internal lengthenings in younger and smaller patients, who would traditionally require external fixation. These new internal techniques with lengthenings of up to 5 cm can be repeated more easily and frequently than external fixation, reducing the need to achieve larger single-stage lengthenings (e.g., 8 cm). Modern reconstruction methods with lengthening are able to achieve limb length equalization with a plantigrade-stable foot, resulting in excellent functional result comparable or better than a Syme’s amputation with prosthetic fitting