Page 3 - Introduction Continued
We believe that optimum lengthening of the lower limb can be done only up to 5 to 7 cm, beyond which outcome may be suboptimal in view of cosmesis (trunk-limb proportions) [4, 19], altered biomechanics, and soft tissue function [10]. Therefore, most lengthenings were planned only for the tibial segment, bilaterally simultaneously, either monofocally (\5 cm) or bifocally ([5 cm to reduce the duration of fixator [18]). However, for patients who wanted more lengthening, we planned additional lengthening of the femoral segment. For the tibia, we used the standard three-ring construct for monofocal and bifocal lengthenings, with more wires for bifocal lengthening. The tibial corticotomy was below the tibial tuberosity for monofocal lengthening and also at the supramalleolar level for bifocal lengthening. A fibular osteotomy was done at the junction of the middle and distal thirds. Bifocal tibial corticotomies were accompanied by two level fibular osteotomies during the 1980s and 1990s. Later the proximal fibular osteotomy was avoided as it was found to be unnecessary and posed the possibility of injury to the common peroneal nerve. The femur was lengthened at the supracondylar level using an assembly consisting of two rings and a single arch with wires distally and half pins proximally.

Distraction started on the seventh postoperative day. Monofocal lengthening was commenced at a rate of 0.75 to 1 mm/day over three to four fractions and gradually increased to 1 to 1.5 mm/day over four to six fractions as guided by clinicoradiographic assessment of new bone formation. We observed that the rate could be increased slightly more than 1 mm/day for teenagers and could be maintained only at less than 1 mm/day for patients in the older age categories. The rate for bifocal distraction was 1.25 to 1.5 mm/day per bone over three to four fractions, with distraction at one site being greater than at the other site in the beginning. Distraction gradually become equal, and then gradually reversed toward the end of distraction.

ROM exercises of the joints (as much as the fixator allowed) and weightbearing walking with use of axillary crutches were encouraged as much as tolerated from the second postoperative day. All patients were monitored as inpatients until removal of the fixator. Radiographs were taken every 2 weeks to assess the quality of regenerate, lengthening, and occurrence of any deformity. After gaining sufficient length by distraction, the fixators were left in place for the necessary time to allow consolidation of the regenerate. The decision to remove the fixator was based on a satisfactory stress test after removing the connecting rods and satisfactory consolidation observed on the radiographs as evidenced by complete bone bridging in at least two projections. After fixator removal, the patients wore a cast extending from the thigh to the supramalleolar region for 2 to 4 weeks as determined during stress testing at the time of fixator removal. We did not use a removable orthosis for any patient because of unavailability.

We looked for the incidence of pin tract and soft tissue infections, common peroneal neuropathy, and assessment of knee and ankle ROM during and after external fixation to assess for soft tissue complications. For bone-related complications we watched for the incidence of osteomyelitis during treatment, and did clinicoradiologic monitoring for knee and ankle congruity to rule out any subluxations, speed of regeneration, incidence of any deformity, or fracture of regenerate during and after external fixation. We recorded how each of these challenges was approached or treated and the final outcome. We also recorded all technical challenges and how they were managed.

The patients were followed up every 3 months for 1 year and then yearly thereafter. Assessment was for patient satisfaction, axial deviation, ROM of the joints, foot and ankle deformities, limb length discrepancy, infection, pain, and functional status. A physician-based outcome score developed by one of us (KIN) was used to assess outcome: excellent = planned increase in the length of limb segments achieved with good preservation of body proportions and function in the absence of deformity and joint stiffness; good = planned extension of the limbs achieved against trunk-limb proportions, or partial restriction of limb function, in the form of abnormal gait, 3 degrees to 5 degrees axial deviation, or 5 degrees to 10 degrees limitation of joint movement; satisfactory = lengthening of limbs achieved up to 75% of the planned value or presence of 5 degrees to 10 degrees axial deviation or 10 degrees to 15 degrees limitation of joint movement; and unsatisfactory = lengthening achieved to less than 75% of the planned value or presence of axial deviation greater than 10 degrees or limitation of joint movement greater than 15 degrees.

Patient-based outcomes were measured in terms of patient satisfaction and improvement of self-esteem. Patient-related outcome was measured by asking the patient at the completion of treatment whether they were satisfied (yes/no), whether the procedure led to improvement of their self-esteem (yes/no), whether they would undergo the procedure again (yes/no), and whether they would recommend it to someone with subjective feelings of short stature (yes/no).