Submuscular plating after distraction osteogenesis in children

Abstract

Although distraction osteogenesis has solved limb length discrepancies, many complications are inevitable from long duration of external fixation. Use of intramedullary nails for early removal of fixators has its own challenges especially in pediatric age group. To facilitate early removal of external fixators in children, we tried a novel method of submuscular plating over the distraction callus, which is described, and the results and complications of this technique are presented. In eight children (four girls and four boys), of limb lengthening (four cases) and bone transport (four cases) done in three femurs and five tibiae with external fixators (five Ilizarov ring fixators and three monofixators), submuscular plating was done over the distraction callus. The causes of limb length discrepancy included traumatic and septic growth arrest, congenital pseudoarthrosis of tibia, fibular hemimelia, tumor salvage, and Perthes' disease. The purpose of plating was to remove the external fixator earlier after achieving the target length. Mean age of plating procedure was 11.62 years, and mean amount of distraction was 5.47 cm. In all patients, the distraction callus healed on maintaining its length or correcting into the original alignment. The mean external fixation index was 26.93 days/cm and healing index was 52.01 days/cm. One complication of superficial pin-track infection occurred, which resolved completely with conservative treatment. None of the patients developed deep infection or implant failures. The mean follow-up after plating was 28 months (range, 18-62 months). Submuscular plating over the distraction callus may be a successful method that permits early removal of fixator with fewer complications. This method can be a useful alternative in children or when nailing is difficult.

Clinical Outcomes of Conversion Surgery from an External Fixator to an Iodine-Supported Titanium Alloy Plate

“…There are several cases which progressed to osteomyelitis [17][18][19]. Moreover, there are some reports on conversion operations following limb lengthening, in the same way as in the present case [9,[12][13][14]; however, it is difficult to evaluate them due to their small number of cases. A report by Harbacheuski, with the largest number of cases, had seven limbs with alignment changes, two limbs with infections, and two limbs with plate breakage, with extremely high complilcation rates [12].…”

“…Since locking plates started being used at the beginning of the 21st century, there have been several reports on surgery for conversion to plates with a concept of external fixation in the body. However, an external fixator removal site is connected to outside the body, and inserting internal fixation materials into the site raises concerns over infection risks; therefore, this method still has not been generally accepted as a therapy [12][13][14].…”

Does Integrated Fixation Provide Benefit in the Reconstruction of Posttraumatic Tibial Bone Defects?

“…The consolidation phase of distraction osteogenesis serves as a natural point of intervention to remove the external fixator, thus shortening the time patients are in the frame. However, the conversion to internal fixation must avoid any iatrogenic contamination and be strong enough to stabilize the immature bone (regenerate) [1,9,25,28,39,41]. The onerous patient experience with traditional Ilizarov reconstruction is a powerful way to completely restore nearnormal anatomy and restoration of function in a cost-effective manner [23].…”

“…The consolidation phase is typically twice as long as the distraction phase, making it an effective source of intervention to decrease the time the patient spends in the external fixator. This can be achieved by supplanting the external fixator with internal fixation during, or subsequent to, lengthening and deformity correction, respectively [1,9,25,28,39,41]. The use of internal fixation with intramedullary nails or plates and screws has been described to stabilize the regenerate allowing for earlier external fixator removal [10,16,33].…”

Clinical application of locked plating system in children. An orthopaedic view

“…External fixation is a good option for the treatment of open fractures [5,23], fractures with compartment syndrome, long-bone fractures with significant comminution [23,24] or bone loss [5] as well as for limb lengthening and bone transport [25,26]. However, concerns about delayed healing, pin track infections, joint stiffness and re-fracture have blunted the broad acceptance of these devices.…”