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Background and Aim: Maintenance of stability using external fixation devices is an important principle to ensure successful treatment of osteomyelitis (OM). In this study, we report our experience with femoral OM treated with acute compression and bone transport using the Orthofix limb reconstruction system (LRS). Patients and Methods: This prospective study included 30 consecutive patients with femoral OM. LRS insertion and corticotomy were done according to the standard technique. Radiographic evaluation was performed every 2 weeks during the distraction phase and every 2-4 weeks during the consolidation phase. The clinical outcome measurements included union time, limb length discrepancy, additional operative procedures, refractare and infection. Results: The present study included 30 patients with femoral OM. They comprised 27 males (90.0%) and 3 females (10.0%) with an age of 28.1 [+ or -] 15.6 years. All, except one, achieved union with a mean union time of 8.6 months (range 4-20 months). The mean union time for acute compression was 7.6 months (range 4-20 months) while for patients with bone transport it was 14.5 months (range 1218 months). The mean limb length discrepancy was 1.8 cm (range 0-4 cm). At the end of the follow=up, two patients were not able to ambulate without support; one due to non-union and one due to paraplegia. Conclusion: The present study identified treatment of femoral OM using LRS as a feasible and effective technique with good outcomes. Reported complications could be adequately managed in most cases. Keywords: osteomyelitis, external fixation, limb reconstruction system

BackgroundMinimally invasive reduction and fixation of intra-articular calcaneal fractures poses great challenges for orthopaedic surgeons. The aim of the present study was to report the technical points, evaluate the efficacy of minimally invasive reduction and internal fixation assisted by the temporary limb reconstruction system (LRS) external fixator for intra-articular calcaneal fractures, and propose the indications of our protocol.MethodsIn this retrospective study, a series of 34 consecutive closed and displaced intra-articular calcaneal fractures involving the articular surface were treated by this technology between June 2016 and April 2018. X-ray and computed tomography (CT) scans were performed before and after surgery to measure Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot. Postoperative complications were recorded. Imaging and clinical outcomes were comprehensively evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scoring system. After testing the normality of the data, Bohler's angle and the length of calcaneus were compared using the Wilcoxon signed-rank test. The height, width of the calcaneus, and the mechanical axis of the hindfoot were compared using the Paired-Samples t-test.ResultsThirty-two fractures were followed up for an average of 20.66 months (from 12 to 32 months). All fractures achieved stable reduction and bony union. The articular surface was reduced and fixed with direct vision through the sinus tarsi incision. No failure of internal fixation or loss of reduction was detected during follow-up. There were no soft tissue complications. Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot improved significantly. The AOFAS scores averaged 84.12 points; seven cases were rated excellent, 20 good, four fair, and one poor.ConclusionsFor intra-articular calcaneal fractures, minimally invasive surgery assisted with temporary LRS external fixation can reconstruct the calcaneal shape and the sub-talar articular surface. This simple surgical modality with limited complications may be helpful in the surgical treatment of most type II and III calcaneal fractures except comminuted fractures of the calcaneal tuberosity.

(1) Objective: External fixation systems are commonly used by surgeons to ensure stabilization and consolidation of bone fractures, especially in patients who are at high risk for systematic complications. Both rigid and elastic external fixations are important in the fracture healing process. This study aims to evaluate the behavior of the Orthofix Limb Reconstruction System (LRS)® in the dynamic compression mode. (2) Methods: Experimental and numerical setups were developed using a simplified model of a human tibia which consisted of a nylon bar with a diameter of 30 mm. The bone callus was included in both setups by means of a load cell-based system, which consisted of two carbon epoxy laminated composite plates with a final stiffness of 220 N/mm. The system was evaluated experimentally and numerically, considering different numbers of pins and comparing distances between the external fixator frame and the bone, achieving a good correlation between experimental and numerical results. (3) Results: The results identified and quantified the percental load transferred to the fracture and its sensibility to the distance between the external fixator and bone. Additionally, LRS locking stiffness was evaluated which resulted from the clamp-rail clearances. The results show that the blocking effects of the free clamp movement are directly related to the fixator configuration and are responsible for changes in the amount of load that crosses the bone callus. (4) Conclusions: From the biomechanical point of view, the results suggest that the average bending span of Schanz pins and the weights of the patients should be included into clinical studies of external fixators comparisons purpose.

Background: Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously. Materials and Methods: Thirty open fractures of tibial diaphysis with bone loss of at least 4 cm or more with a mean age 32.5 years were treated by using the LRS after debridement. Distraction osteogenesis at rate of 1 mm/day was done away from the fracture site to maintain the limb length. On the approximation of fracture ends, the dynamized LRS was left for further 15-20 weeks and patient was mobilized with weight bearing to achieve union. Functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. Results: Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4–9 cm). The mean duration of bone transport was 13 weeks (range 8–30 weeks) with a mean time for LRS in place was 44 weeks (range 24–51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31–60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal. Conclusion: Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.

Background Management of complex nonunions is difficult due to the presence of infection, deformities, shortening and multiple surgeries in the past. Complex nonunions are traditionally managed by Ilizarov fixation. The disadvantages of Ilizarov are poor patient compliance, inconvenience of the frame and difficult frame construction. We conducted a study on 30 long bone complex nonunions treated by the limb reconstruction system (LRS). Materials and Methods Between April 2009 and September 2012, we treated 30 cases of complex nonunion of long bone with the LRS. 28 were male and 2 females. Average shortening was 5.06 cm and 14 cases presented with infected implants. Initially we managed with implant removal, radical debridement followed by fixation with the LRS. In 16 cases, corticotomy and lengthening was done. The average duration of treatment was 9.68 months. We compressed the fracture site at the rate of 0.25 mm per day for 1-2 weeks and distracted the corticotomy at the rate of 1 mm/day till lengthening was achieved. Result : The union occurred in 89.28% cases and eradication of infection in 91.66% cases. Average lengthening done was 4.57 cm. We had 79% excellent, 11% good and 10% poor bony result and fnctional result was excellent in 40% cases, good in 50% and failure in 10% cases using ASAMI scoring system. Conclusion LRS is an alternative to the Ilizarov fixation in their management of complex nonunion of long bones. It is less cumbersome to the patient and more surgeon and patient friendly.

Background: To assess combination of an intramedullary interlocking (IMIL) nail with limb reconstruction system (LRS) in cases of infected nonunion tibia and to show influence of nail in predicting good outcome. Materials and Methods: From 2009 to 2011, records of 20 patients (17 men and three women) aged 18 to 65 years (mean, 38.4 years) with infected nonunion of the tibia treated with the LRS over IMIL Nail technique were prospectively reviewed. According to Jain et al., patients were classified into five cases of A1, five cases of type A2, seven cases of type B1, and three cases of type B2. All cases underwent LRS and IMIL. Mean amount of target lengthening was 54.65 mm. The mean follow-up was 14 months. Results: Mean amount of tibia lengthening was 51.70 mm. Leg length equalization was achieved in 19 cases (±5). According to modified scoring by Paley et al., 12 patients had excellent results, three patients had good, four patients had fair outcome, and one patient had poor outcome. Mean distraction index was 0.97. Mean maturation index was 2.43. Mean consolidation index was 3.47. Mean healing index was 1.40. One case had proximal locking screw failure. One case developed pre mature consolidation as distraction was started at delayed period due to non-compliance. Two cases developed decreased dorsi flexion of ankle. Two cases required flap surgeries for cover of bone. One case had pin breakage, which had to be exchanged. One case developed re-infection. Conclusion: The advantages of this technique include complete eradication of infective foci, reduced risk of deformity during lengthening, decrease risk of fractures post external fixator removal and reduction of time required for external fixator use thus decreasing healing index: Number of days of external fixation required per centimetre of lengthening.

The purpose of the present study was to review and report clinical outcomes of the Kyocera Modular Limb Salvage System (KMLS) using a thin-mantle titanium stem fixated with cement, for reconstruction after resection of malignant femoral-bone tumors. Twenty consecutive patients who had undergone reconstruction using the KMLS with cemented thin-mantle titanium stem fixation between July 2010 and December 2019 at Ryukyu University Hospital were included. We retrospectively collected the following data: age, sex, follow-up period, tumor location, histological diagnosis, stem size, overall implant survival, radiolucency, postoperative complications, overall survival, and oncological survival. The median follow-up period was 63 months (range=10.7-261 months). The bone tumors were in the proximal part of the femur in 9 patients and in the distal part of the femur in 11 patients. The 5-year overall implant survival rate was 90.9% among surviving patients. A revision surgery was required for only one patient (5%), due to infection. Radiolucency, due to an instability of the implant, was observed in 7 out of 20 patients: 6 patients with distal femoral reconstruction, and 1 patient with proximal femoral reconstruction. However, none of the patients complained of any symptoms or required revision surgeries at the last follow-up. The 5-year overall patient-survival rate was 67.6%. The KMLS with cemented thin-mantle titanium stem fixation for femoral bone reconstruction after resection for bone malignancy resulted in long-term patient benefit.

(1) Background: The reconstruction of periacetabular defects after tumor resection remains one of the most challenging procedures in orthopaedic oncology. The modular LUMiC system was designed to improve fixation stability and reduce implant-related complications compared with earlier hemipelvic prostheses. We investigated patient and implant survival after LUMiC reconstruction, complication types and functional outcomes. (2) Methods: Eighteen patients (8 men, 10 women; mean age 58.9 years) underwent LUMiC endoprosthetic reconstruction between 2011 and 2025. Kaplan-Meier analysis was used to estimate patient and implant survival. Complications were categorized according to Henderson. Functional results were evaluated at follow-up using MSTS and TESS. (3) Results: Mean follow-up was 35.52 months (SD 36.89). Overall implant survival was 72.2%. Instability (27.8%) and infection (16.7%) were the leading complications. Two-thirds of patients required at least one revision (mean 3.1 revisions per case). Metastatic disease reduced patient survival ( = 0.012) but did not affect implant longevity ( = 0.31). Functional outcomes were available for only 3 of 18 patients and should therefore be regarded as exploratory. Mean MSTS was 58.9% (SD 21.43) and mean TESS was 73.4% (SD 6.836). (4) Conclusions: Despite high revision rates, the LUMiC prosthesis provides durable fixation. Early revision does not appear to compromise implant survival. However, the small and heterogeneous cohort represents a limiting factor of this study.

Transosseous distraction osteosynthesis is prioritized in orthopedic care for children with achondroplasia. However, difficulties encountered during treatment and rehabilitation directly impact patients' quality of life. Using rod external fixators within a semicircular frame for osteosynthesis is less traumatic compared to spoke circular devices. Their straightforward assembly and mounting on the limb segment can help significantly reduce treatment duration, thereby improving children's quality of life during treatment and rehabilitation. This study aimed to conduct a comparative analysis of the quality of life (measured by postoperative pain syndrome, physical activity, and emotional state) among children with achondroplasia undergoing paired limb lengthening using either an external fixator with modified distraction control or a circular multiaxial system developed by the authors. This was an observational, prospective, nonrandomized, and longitudinal study with historical control. The study group consisted of 14 patients ranging from 5 to 15 (mean 7.6, SD 2.3) years old with a genetically confirmed diagnosis of achondroplasia. All patients underwent paired limb lengthening with a rod external fixator and a modified distraction control developed by the authors. A total of 28 limb segments, among them 4 (14%) humeri, 8 (29%) femurs, and 16 (57%) tibias, were lengthened in 1 round. Unpublished data from the previous study served as the control group, comprising 9 patients (18 limb segments) of the same age group (mean age at surgery 8.6, SD 2.3 years), who underwent limb lengthening surgery using a circular multiaxial system-2 (11%) humeri, 6 (33%) femurs, and 10 (56%) tibias. The Wong-Baker Faces Rating Scale was used to measure pain symptoms, while the Russified Pediatric Quality of Life (PedsQL) v4.0 questionnaire assessed quality of life. During the latent phase (7 to 10 days after surgery), a more pronounced decrease in the indicators of physical activity and emotional state on the PedsQL v4.0 questionnaire was noted in the control group (mean 52.4, SD 4.8 versus mean 52.8, SD 5.5 points according to children's responses and their parents' responses, respectively) compared to the experimental group (mean 59.5, SD 6.8 points and mean 61.33, SD 6.5 points according to the children's responses and their parents' responses, respectively). The differences between the groups were statistically significant (P<.05 for children's responses and P<.01 for parents' responses). Importantly, 6 months after surgery, these quality-of-life indicators, as reported by children in the experimental group, averaged 70.25 (SS 4.8) points. Similarly, their parents reported a mean of 70.54 (SD 4.2) points. In the control group, the corresponding values were 69.64 (SD 5.6) and 69.35 (SD 6.2), respectively. There was no statistically significant difference between the groups. The external fixator with modified distraction control developed by the authors provides a higher standard of living compared with the circular multiaxial system during the latency phase.

Our expanding expertise in peripheral nerve regeneration and soft tissue reconstruction is enabling the development of novel innervated tissue constructs that can be combined with artificial interfacing technologies to facilitate control and sensation of limb prostheses. By utilizing the body’s native afferent and efferent signalling pathways, these mechanoneural interfaces have demonstrated the capacity to enhance volitional prosthetic control, refer somatosensory sensation within proprioceptive and cutaneous modalities, and reduce post-amputation pain. This Review discusses the biophysical principles underpinning recent advancements in targeted reinnervation techniques, regenerative peripheral nerve interfaces and agonist–antagonist neuromuscular architectures that can be combined with artificial technologies, including implanted electrodes, magnetic interfacing and osseointegrated structures, for improved integration with upper-extremity and lower-extremity prostheses. Expanding the capacity for bidirectional information transfer between the peripheral nervous system and external assistive devices will increase the potential of prosthetic embodiment and rehabilitation.Mechanoneural interfaces combine surgically modified soft tissues and artificial components to enhance peripheral neural signalling for the reconstruction of bionic limbs. This Review discusses different mechanoneural interface architectures and presents preclinical and clinical evidence of their afferent and efferent properties.