Papers by Austin T Fragomen
Techniques in Knee Surgery, Sep 1, 2005
... Patients with laxity of the posterolateral ligaments will benefit from use of the TSF. Wherea... more ... Patients with laxity of the posterolateral ligaments will benefit from use of the TSF. Whereas closing wedge osteotomy increases the relative length of the lateral ligaments, an opening wedge osteotomy affords us the ability to retension these lateral ligaments. ...
Journal of Bone and Joint Surgery, American Volume, Aug 17, 2016
HSS Journal, Feb 1, 2009
Segmental bone defects of the tibia present a challenging problem, particularly when they are ass... more Segmental bone defects of the tibia present a challenging problem, particularly when they are associated with soft tissue injuries or instability. Various techniques have been reported to treat bone loss in the tibia. This case report describes a patient with massive segmental bone loss associated with a soft tissue injury, which required a flap for coverage. The injury was treated with an ipsilateral fibular transport utilizing an Ilizarov/Taylor spatial frame. At one and a half year follow-up, the patient was able to walk without any support at home and wore a protective shell for outdoor activities. The outcome of this case study indicates that ipsilateral fibular transport using the Ilizarov method is a valuable technique for limb salvage reconstruction.
Clinical Orthopaedics and Related Research, Feb 1, 2008
Congenital limb deficiencies with severe shortening and/or deformity can be difficult to fit with... more Congenital limb deficiencies with severe shortening and/or deformity can be difficult to fit with a prosthesis. We report two patients in whom gradual lengthening and deformity correction with the Ilizarov/Taylor spatial frame TM was used to improve prosthesis fit, comfort, and gait.
Jbjs Essential Surgical Techniques, May 11, 2016
Clinical Orthopaedics and Related Research, Nov 1, 2009
Extension contracture of the knee is a common complication of femoral lengthening. Knee flexion e... more Extension contracture of the knee is a common complication of femoral lengthening. Knee flexion exercises to stretch the contracture with physical therapy can be effective but take a prolonged amount of time to work and place increased stress across the patellofemoral joint. We developed a minimal-incision limited quadricepsplasty surgical technique to treat knee extension contracture secondary to femoral lengthening and retrospectively reviewed 16 patients treated with this procedure. The mean age of the patients was 23 years. Range of motion of the knee and quadriceps strength were recorded preoperatively, after femur lengthening but before additional surgery, after quadricepsplasty, and at each followup. The mean femoral lengthening performed was 4.4 cm. We compared range of motion and time to regain knee flexion with those of historical controls. The minimum followup after quadricepsplasty was 6 months (mean, 38 months; range, 6-84 months). The mean range of motion was 129°preoperatively, 29°after the distraction phase of femoral lengthening, and 108°after limited quadricepsplasty, and at final followup, the mean knee flexion was 125°. There were no major complications. Limited quadricepsplasty improved knee flexion after a knee extension contracture developed secondary to femoral lengthening. In comparison to historical controls who did not have quadricepsplasty, the patients with limited quadricepsplasty had quicker return of knee flexion, although there was no difference in knee flexion achieved ultimately. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Journal of Arthroplasty, Nov 1, 2014
Patients with multiple failures of total knee arthroplasty (TKA) are challenging limb salvage cas... more Patients with multiple failures of total knee arthroplasty (TKA) are challenging limb salvage cases. Twenty one patients over the last 10 years were referred to our service for knee fusion by arthroplasty surgeons who felt they were not candidates for revision TKA. Active infection was present in 76.2% and total bone loss averaged 6.6 cm. Lengthening was performed in 7/22 patients. Total time in Ilizarov frames was 9 months, with 93.3% union. Patients treated with IM fusion nails had 100% union. Average LLD increased from 3.6 to 4.5 cm following intervention, while those with concurrent lengthening improved to 1.6 cm. Findings suggest that bone loss and the soft-tissue envelope dictate knee fusion method, and multiple techniques may be needed. A treatment algorithm is presented.
Clinical Orthopaedics and Related Research, Aug 29, 2013
Background Although its FDA-approved applications are limited, the pro-osteogenic benefits of rec... more Background Although its FDA-approved applications are limited, the pro-osteogenic benefits of recombinant human BMP-2 (rhBMP-2) administration have been shown in offlabel surgical applications. However, the effects of rhBMP-2 on ankle fusions are insufficiently addressed in the literature, which fails to include a case-control study of adequate sample size to evaluate the efficacy of rhBMP-2 treatment. Questions/purposes In this study we asked whether rhBMP-2 treatment (1) would increase the rate of successful ankle fusion in complex patients (patients with comorbidities associated with poor surgical healing) compared with a control group of patients undergoing ankle fusion who did not receive rhBMP-2; (2) would reduce total time wearing a frame when compared with the control group; (3) would result in a difference in the percentage of bone bridging between the group treated with rhBMP-2 and the control group, as determined by CT scans 3 months after surgery; and (4) would encounter an equal rate of complications different from untreated patients. Methods A retrospective chart study was performed on 82 patients who, because of a host of comorbidities associated with poor healing, required a complex ankle arthrodesis with the Ilizarov technique. The first 40 patients did not receive rhBMP-2, whereas the subsequent 42 patients received intraoperative rhBMP-2. Time wearing the frame was determined by chart review; decision to remove the frame was made by the surgeon based on quantitative bone bridging measured using a CT scan taken 3 months after fusion. Results Patients treated with rhBMP-2 were more likely to obtain fusion after the initial surgery (93% versus 53%, p\0.001; OR, 11.76; 95% CI, 3.12-44.41), spent less total time wearing the frame (124 versus 161 days, p \ 0.01), and showed more bone bridging on CT scans (48% versus 32%, p \ 0.05). All patients with greater than 30% bone bridging observed on CT scans 3 months postoperatively achieved successful union without further intervention. Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDAapproval status, of any drug or device prior to clinical use. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
Clinical Orthopaedics and Related Research, May 1, 2010
Background Optimal leg alignment is the goal of tibial osteotomy. The Taylor Spatial Frame (TSF) ... more Background Optimal leg alignment is the goal of tibial osteotomy. The Taylor Spatial Frame (TSF) and the Ilizarov method enable gradual realignment of angulation and translation in the coronal, sagittal, and axial planes, therefore, the term six-axis correction. Questions/purposes We asked whether this approach would allow precise correction of tibial deformities. Methods We retrospectively reviewed 102 patients (122 tibiae) with tibial deformities treated with percutaneous osteotomy and gradual correction with the TSF. The proximal osteotomy group was subdivided into two subgroups to distinguish those with an intentional overcorrection of the mechanical axis deviation (MAD). The minimum followup after frame removal was 10 months (average, 48 months; range, 10-98 months). Results In the proximal osteotomy group, patients with varus and valgus deformities for whom the goal of alignment was neutral or overcorrection experienced accurate correction of MAD. In the proximal tibia, the medial proximal tibial angle improved from 80°to 89°in patients with a varus deformity and from 96°to 85°in patients with a valgus deformity. In the middle osteotomy group, all patients had less than 5°coronal plane deformity and 15 of 17 patients had less that 5°sagittal plane deformity. In the distal osteotomy group, the lateral distal tibial angle improved from 77°to 86°in patients with a valgus deformity and from 101°to 90°for patients with a varus deformity. Conclusions Gradual correction of all tibial deformities with the TSF was accurate and with few complications. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. The institution of one or more of the authors (SRR, SI, ATF) has received fellowship educational funding from Smith and Nephew Inc (Memphis, TN). Each author certifies that his or her institution has approved the reporting of these cases, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participating in the study was obtained.
HSS Journal, Dec 21, 2006
External fixation has evolved from being used primarily as a last resort fixation method to becom... more External fixation has evolved from being used primarily as a last resort fixation method to becoming a main stream technique used to treat a myriad of bone and soft tissue pathologies. Techniques in limb reconstruction continue to advance largely as a result of the use of these external devices. A thorough understanding of the biomechanical principles of external fixation is useful for all orthopedic surgeons as most will have to occasionally mount a fixator throughout their career. In this review, various types of external fixators and their common clinical applications are described with a focus on unilateral and circular frames. The biomechanical principles that govern bony and fixator stability are reviewed as well as the recommended techniques for applying external fixators to maximize stability. Additionally, we have illustrated methods for managing patients while they are in the external frames to facilitate function and shorten treatment duration.
Clinical Orthopaedics and Related Research, Mar 28, 2014
Background Previous designs of internal bone lengthening devices have been fraught with imprecise... more Background Previous designs of internal bone lengthening devices have been fraught with imprecise distraction, resulting in nerve injuries, joint contractures, nonunions, and other complications. Recently, a magnet-operated PRECICE 1 nail (Ellipse Technologies, Inc, Irvine, CA, USA) was approved by the FDA; however, its clinical efficacy is unknown. Questions/purposes We evaluated this nail in terms of (1) accuracy and precision of distraction, (2) effects on bone alignment, (3) effects on adjacent-joint ROM, and (4) frequency of implant-related and non-implant-related complications. Methods We reviewed medical and radiographic records of 24 patients who underwent femoral and/or tibial lengthening procedures using the PRECICE 1 nail from August 2012 to July 2013 for conditions of varied etiology, the most common being congenital limb length discrepancy, posttraumatic growth arrest, and fracture malunion. This group represented 29% of patients (24 of 82) who underwent a limb lengthening procedure for a similar diagnosis during the review period. At each postoperative visit, the accuracy and precision of distraction, bone alignment, joint ROM, and any complications were recorded by the senior surgeon (SRR). Accuracy reflected how close the measured lengthening was to the prescribed distraction at each postoperative visit, while precision reflected how close the repeated measurements were to each other over the course of total lengthening period. No patients were lost to followup. Minimum followup from surgery was 3 weeks (mean, 14 weeks; range, 3-29 weeks). Results Mean total lengthening was 35 mm (range, 14-65 mm), with an accuracy of 96% and precision of 86%. All patients achieved target lengthening with minimal unintentional effects on bone alignment. The knee and ankle ROM were minimally affected. Of the complications requiring return to the operating room for an additional surgical procedure, there was one (4%) implant failure caused by a nonfunctional distraction mechanism and six (24%) non-implant-related complications, including premature consolidation in one patient (4%), delayed bone healing in two (8%), delayed equinus contracture in two (8%), and toe clawing in one (4%). Conclusions We conclude that this internal lengthening nail is a valid option to achieve accurate and precise limb lengthening to treat a variety of conditions with limb shortening or length discrepancy. Randomized, largersample, long-term studies are required to further confirm Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research 1 neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
Clinical Orthopaedics and Related Research, Dec 1, 2008
Distraction osteogenesis is an effective method for lengthening, deformity correction, and treatm... more Distraction osteogenesis is an effective method for lengthening, deformity correction, and treatment of nonunions and bone defects. The classic method uses an external fixator for both distraction and consolidation leading to lengthy times in frames and there is a risk of refracture after frame removal. We suggest a new technique: lengthening and then nailing (LATN) technique in which the frame is used for gradual distraction and then a reamed intramedullary nail inserted to support the bone during the consolidation phase, allowing early removal of the external fixator. We performed a retrospective casematched comparison of patients lengthened with LATN (39 limbs in 27 patients) technique versus the classic (34 limbs in 27 patients). The LATN group wore the external fixator for less time than the classic group (12 versus 29 weeks). The LATN group had a lower external fixation index (0.5 versus 1.9) and a lower bone healing index (0.8 versus 1.9) than the classic group. LATN confers advantages over the classic method including shorter times needed in external fixation, quicker bone healing, and protection against refracture. There are also advantages over the lengthening over a nail and internal lengthening nail techniques. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Background Distal femoral osteotomies (DFO) can be used to correct deformities around the knee. A... more Background Distal femoral osteotomies (DFO) can be used to correct deformities around the knee. Although osteotomies can be fixed with either internal or external fixation techniques, the advantages of one over the other are unclear. Questions/purposes We asked whether (1) for both techniques, we could accurately correct the deformities based on our preoperative goals for mechanical axis deviation (MAD) and lateral distal femoral angle (LDFA), and (2) intraoperative times, (3) preoperative and postoperative knee ROM, and (4) complications differed. Patients and Methods We identified 26 patients (34 limbs) who underwent femoral osteotomies. We compared accuracy of correction (based on correction of the MAD and the LDFA), duration of surgery, preoperative and postoperative knee ROM, and complications. The minimum followup was 20 months (mean, 29 months; range, 20‐40 months). Results We achieved the desired MAD within 10 mm of the goal in 18 of 21 limbs with the unilateral frame and in 12 of 13 limbs using fixator-assisted plating. Operative time for fixator-assisted plating was longer (122 ± 34 minutes) than when using a unilateral frame (94 ± 65 minutes). Preoperative and postoperative knee ROMs were similar for both techniques and there were no major complications. Conclusions We obtained accurate correction of deformities with both fixation techniques. Our experience suggests the method to be used should be left to the discretion of the surgeon and the needs and wishes of the patient after adequate explanation of the advantages and
Synonyms and related keywords: varus derotational osteotomy, VDO, coxa vara, shepherd's crook deformity, femur deformity, nonunion, malunion, osteotomy, Ilizarov, internal fixation, femoral anteversion, fibrous dysplasia, developmental dysplasia of the hip, DDH, osteonecrosis, hip, arthritis, fem...
HSS Journal, Mar 19, 2019
Background: Mechanical axis malalignment contributes to abnormal forces across the knee joint. Ge... more Background: Mechanical axis malalignment contributes to abnormal forces across the knee joint. Genu varum, or increased medial mechanical axis deviation (MAD), increases force transmission and contact pressures to the medial compartment. With increasing MAD and femoral-tibial mechanical axis angle (MAA), contact forces within the medial or lateral compartment of the knee significantly increase with increasing deformity. This may lead to knee pain, further deformity, and medial compartment degenerative joint disease, which can interfere with participation in sports and diminish quality of life. Purposes/ Questions: We sought to evaluate patients with knee pain with bilateral genu varum and determine the effect of bilateral proximal tibial osteotomies on knee biomechanics, deformity correction, and functional outcomes. Methods: This was a single-center, prospective study of eight limbs in four patients. Consecutive patients presenting with knee pain and bilateral genu varum originating from the proximal tibia were included. All patients underwent staged bilateral proximal tibial osteotomies with gradual deformity correction with an external fixator. Subjects underwent a threedimensional (3D) instrumented motion analysis during level walking. A 3D lower extremity model was built and bilateral knee frontal plane kinematics and kinetics during the stance phase of gait were determined. Radiographic analysis was performed including assessment of MAD, MAA, and medial proximal tibial angle (MPTA). Functional outcomes were assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS), the 36-item Short-Form Survey (SF-36), the Lower Limb Questionnaire (LLQ), and a visual analog scale (VAS) for pain. Results: The average time in the external fixator for a single limb was 97 days. The average follow-up period was 310 days. All biomechanical outcomes significantly improved, including knee adduction angle (7.8°to 1.8°), knee adduction moments (first peak, − 0.450 to − 0.281 nm/ kg, and second peak, − 0.381 to − 0.244 nm/kg), and knee adduction moment impulse (− 0.233 to − 0.150 nm s/kg). There was a significant improvement in MAA, MAD, and MPTA. All patients showed qualitative improvement in mean scores on VAS (11.8 to 0.0), LLQ (77 to 93), KOOS (64 to 84), and SF-36 (71 to 88). Conclusion: These findings suggest that bilateral proximal tibial osteotomy may be effective in improving knee biomechanics during gait and correcting mechanical alignment in patients with bilateral genu varum. Patients also demonstrated improvement in functional outcome scores. This technique should thus be considered in patients with varus knee osteoarthritis in the setting of genu varum to alleviate symptoms and potentially decrease further clinical deterioration.
Strategies in Trauma and Limb Reconstruction
Introduction: Historically, blocking screws have been used to assist in acute reduction of fractu... more Introduction: Historically, blocking screws have been used to assist in acute reduction of fractures during intramedullary (IM) nailing. The reverse-rule-of-thumbs (RROT) for blocking screws was introduced to facilitate internal lengthening nail use in deformity correction and limb lengthening. Our study investigated the ability of blocking screws, using same principle, to accurately correct long-bone deformity with and without lengthening and to prevent lengthening-induced deformity. Materials and methods: This is an institutional review board (IRB)-approved retrospective study on 86 patients who had IM nail-assisted limb reconstruction of femur or tibia with blocking screws. Surgeries were performed for deformity correction, limb lengthening, or deformity correction and limb lengthening. Data on the following variables were collected: number of blocking screws, distance of each blocking screw to osteotomy, distance of osteotomy from joint line, and amount of lengthening. Mechanical axis deviation (MAD) and joint alignment parameters were measured preoperatively and at the final postoperative follow-up. The primary outcome was the ability to obtain desired MAD and joint orientation angles. Accuracies were reported as postoperative measurements relative to goal. Association for the Study and Applications of the Methods of Ilizarov (ASAMI) scores were collected. Results: The accuracy of deformity correction was within 6 mm from goal, while joint orientation was corrected to within 1.5° of goal. Number of blocking screws did not significantly impact accuracy. Distance of blocking screw to osteotomy and amount of lengthening did not affect accuracy. In femurs, osteotomies greater than 10 cm from the joint line were more accurate in MAD goal (p = 0.017). This result was not replicated in tibias. ASAMI scores were excellent or good. Conclusion: Using RROT configuration, blocking screws were effective in correcting deformities of lower extremity long bones and in preventing deformity during limb lengthening. If positioned correctly, number of screws and their distance to osteotomy did not affect accuracy. Amount of lengthening did not impact accuracy. Distal femoral osteotomy less than 10 cm from knee joint may be challenging even with using blocking screws.
The Journal of Knee Surgery, 2020
Preoperative planning is important for accurate intraoperative execution in many surgical fields.... more Preoperative planning is important for accurate intraoperative execution in many surgical fields. Planning for distal femoral osteotomies (DFOs) and proximal tibial osteotomies (PTOs) consists of choosing the level of the osteotomy, measuring the angle of the osteotomy based on hip-knee-ankle alignment, and choosing a proper osteotomy wedge size. Medical imaging IT solutions company Sectra has implemented a new osteotomy tool in their radiographic system that is simpler than the accepted standard of modified center of rotation of angulation (mCORA) technique, yet unvalidated. In this study, we aim to compare the Sectra osteotomy tool versus the mCORA technique to measure the osteotomy angles as well as wedge sizes in both DFOs and PTOs to validate this new tool.We enrolled n = 30 consecutive patients with DFOs and n = 30 PTOs from the last year. The Pearson correlation coefficient (PCC) along with descriptive statistics was used to evaluate for similarity between the two techniques....
HSS Journal ®, 2020
Background: Leg-length discrepancy (LLD) after primary THA is not uncommon. Little is known, howe... more Background: Leg-length discrepancy (LLD) after primary THA is not uncommon. Little is known, however, about the role of hip-sparing procedures for equalization of LLD after THA. Questions/Purposes: The aim of this study is to report our experiences with these techniques in patients presenting at one institution over a 10-year period. Methods: We retrospectively reviewed records at one institution to find patients who had sought surgical treatment for LLD after THA between January 2007 and August 2017. Patients who had LLD related to conditions other than the THA, such as bone loss or traumatic defects, were excluded. We recorded the time after THA, laterality, and LLD. Assessment of LLD was performed using clinical and radiographic examinations. Patient demographics and true LLD were recorded, as were prior conservative treatment, equalization procedure performed, final leg length after equalization surgery, time to healing, and complications. Results: After exclusion of patients with LLD related to other causes, eight patients in whom conservative treatment had failed and who had undergone hipsparing leg-length equalization surgery were included in the study. The average age was 44.6 years (range, 18 to 66 years). Seven of the patients were female. The preoperative mean LLD was 3.1 cm (range 1.5 to 7 cm). In those who were long after THA, ipsilateral (THA-side) shortening of femur with a retrograde intramedullary nail (IMN; n = 1) or with a plate (n = 1) was performed. In those who were short after THA, ipsilateral femur lengthening with retrograde Precice nails (n = 2), ipsilateral tibial lengthening with Precice nails (n = 2), or contralateral femur shortening with a retrograde IMN (n = 2) was performed. The average time to full consolidation or union was 6.6 months (range, 2 to 19 months). Two patients had delayed union. All patients but one were satisfied with final results. Conclusion: We believe that hip-sparing equalization procedures can be part of the treatment algorithm of LLD after THA. These advancements in the field are promising and might expand the indications of lengthening and equalization procedures to include LLD after THA.
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Papers by Austin T Fragomen