Page 3 - Patients and Methods Continued

Patient follow-up was performed every 3 months for the first year and then every 2 years, evaluating patient satisfaction, possible axial deviation, range of movement of the knee and ankle, pronation of the foot, leg length discrepancy and scars. According to the patient and physician scores based on these parameters, the outcome of surgery was classified as poor (0–4), fair (5–9), good (10–14) or excellent (15–18).

Finally, psychological outcome after treatment was evaluated by determining improvement in self-esteem, distress, shyness and quality of life. All patients were asked if they would undergo surgery again and whether they would recommend it to others of similar stature.

Operative technique
The hybrid advanced fixator is a modification of the classic Ilizarov fixator [9] combining Kirschner wires with halfpins and full rings with arches [1, 11]. The standard apparatus (3 rings and one half-ring for the leg) was assembled preoperatively with the rings being sized directly onto the patient’s legs and the wires and half-pins applied with routine transfixation. The whole construct was connected with threaded rods [11, 12].

Two osteotomies, using the Gigli saw or multiple drill holes were carried out—one below the tibial tuberosity and the other at the supramalleolar level. A fibular osteotomy was performed at the junction of the middle and distal third of the leg. A hand-controlled drill with a speed of 0–1000 revolutions/min was used for the insertion of the wires, and pilot holes were drilled before insertion of the half-pins.

Lengthening was started 10 days after surgery at a rate of 0.75 mm per day (one-quarter turn every 8 h) for each tibia osteotomy.

Weight-bearing was encouraged on the second day after surgery, according to tolerance, followed by a rehabilitation program of gradual increased load-bearing and physiotherapy.

Pin care began the day after surgery using hydrogen peroxide and betadine.

Patients were discharged with instructions for bi-weekly care of the pin site. Clinical and radiological examinations were carried out every 30–40 days to assess new bone formation, pin sites, patient satisfaction, tibia length and joint movements.

Bilateral leg lengthening of 5–8 cm was considered satisfactory. Radiological criteria for successful lengthening included complete bone bridging in at least two radiographic projections. Bone regeneration was assessed clinically by loosening the connecting rods and applying stress. When consolidation of new bone was confirmed clinically and radiologically, the frames were removed under sedation. A fiberglass cast or braces including the foot were applied for a mean of 6 weeks.

Results
The mean lengthening achieved in all patients who underwent surgery was 7.2 cm (range 5–11 cm), with a mean duration of treatment of 9 months and 15 days (range 7–18 months).

After removal of the frame, the fiberglass cast was applied in 31 patients (49.2%) and braces including the foot in 21 patients (33.3%). All patients performed physiotherapy for a mean of 6 weeks (range 4–8 weeks). The mean follow-up time was 6.14 years (range 1–10). Varus knee deformity was corrected simultaneously in 8 patients. In 21 patients (33.3%), bilateral lengthening of the Achilles tendon was also necessary to correct the equinus deformity that developed during distraction (Fig. 1).