Ilizarov Tibial Lengthening

Ilizarov patella lengthening is used to extend the limbs of children. Limb lengthening is only a common method for correcting unequal length of limbs, while contralateral shortening and osteophyte blockade are also effective ways to achieve limb balance, but the latter is not easily accepted. Therefore, this chapter focuses on limb lengthening. For various reasons, such as congenital sacral pseudoarthrosis, congenital limb shortening, and limb shortening due to infection and trauma, limb extension can be used to resolve limb shortening. Codivilla (1905) proposed a method of oblique osteotomy of the femur. Putti (1992) extended the extension of a Kirschner wire at the upper and lower ends of the osteotomy. Abbott (1928) improved the method of traction of Putti's bone, ie, at the upper and lower ends of the fracture. Each of the two Kirschner wires was inserted for fixed traction, which enhanced the pulling force of the traction, prevented the steel needle from slipping, and improved the effect of bone lengthening. The author also proposed the humerus extension in 1927. Bost (1956) was treated with a slanted osteotomy and an intramedullary nail. In the osteotomy defect area, Westin (1967) used the periosteum wrapping method to achieve the purpose of prolongation. At present, Abbott has developed a number of improved methods based on the extension of the humerus, such as percutaneous transection of the upper and lower ends of the humerus, percutaneous bone drilling, closure of the humerus, humeral osteotomy and ankle joint fusion to prevent sputum. Articular valgus deformity and so on. Anderson (1952) believes that this method has the advantages of light soft tissue damage, retention of periosteum, and promotion of local bone tissue growth. Limb lengthening involves the elongation and regeneration of tissues such as bones, muscles, nerves, and blood vessels. There are many problems involved in the limb extension process, and the problem of bone lengthening of the lower limbs is emphasized here. 1. According to the reasons that affect limb shortening and bone growth and development, choose the best time for bone extension. Normal children in the growth and development stage, the lower limb bone growth and development stop time, the boy is 16 years old, the girl is 14 years old. Colemen (1967) believes that children aged 8 to 12 are the best time to extend bone. After the age of 20, due to the slow healing of the bone, careful consideration should be given to the bone extension. 2. According to the growth rate of the long bones of the lower limbs, the site of bone extension is selected. Normal children from 4 years old to growth and development, the lower extremity femur increased by 2cm per year, the tibia increased by an average of 1.6cm per year. Dighy observation showed that 70% of the femur growth comes from the lower end of the femur, 30% from the proximal femur; 65% of the tibia growth From the proximal end of the humerus, 35% came from the distal radius. Therefore, the femoral lengthening is mainly performed in the lower middle part of the femur, while the tibia is mainly selected in the upper middle part of the tibia. Although the extension of the femur or the extension of the tibia can correct the unequal length of the limb, in principle, the femoral extension should be performed in the case of thigh shortening. Conversely, if the calf is shortened, the humerus extension is selected. 3. Calculation method of length of bone extension In order to achieve the expected effect of bone lengthening, it is necessary to comprehensively consider the growth and development of children. Age is a major factor in the extension of bone. X-ray films of the wrist must be taken to determine the bone age of the child. . Bone extension = [tibia shortening length + (male 15.5/female 14.5 - age at surgery) x 0.1] cm. 15.5 and 14.5 are the average ages at which the lower limbs of boys and girls stop growing. 4. At present, the commonly used limb extension method can be divided into a single extension of the femur and a daily extension according to the extension speed. The former is limited in length and has many complications, such as vascular nerve injury, long bone healing time, and even non-healing. At present, there are many methods of daily extension and daily extension. The main difference is that the osteotomy site is different from the external fixation device (extension device) used. For example, Wagner adopts a bone osteotomy extension and a cantilever extender. When the required length is reached, autologous bone implantation and internal fixation are required. DeBastiani selects the metaphyseal osteotomy and is fixed with a single arm external fixator. It is extended day by day; Ilizarov uses a ring-extension-pressure system for tarsal extension and metaphyseal osteotomy, as well as bone grafting and internal fixation. The main components of the I-frame for the extension of the tibia are semi-annular rings of 4cm diameter, 11cm, 13cm and 16cm. When used, the two semi-annular rings are combined into a complete ring by bolts and nuts, usually by 4 The rings form the Isilian frame, and each of the two ends constitutes a group, which is connected by a six-sided column; the two sets of rings are connected by four lead screws or extenders, whether extended or compressed. The screw or extender is done. Two sizes of K-wires, 1.5 mm and 1.8 mm in diameter, are usually used for the lower extremities. Some Kirschner wires have "olive" on them to counteract the expected stress on the outside of the bone during bone elongation. In order to avoid Krebs' abnormal pressure on bones and skin, the Kirschner wire must be fixed to the ring in various ways in order to keep the K-wire in a straight line or in a sagittal plane that cannot be bent. If the Kirschner wire passes through the hole in the ring, it is fixed with the bolt with the center hole; if the K-wire is passed from the side of the hole, it is fixed with the slotted bolt; if the Kirschner needle passes through the circle Above or below the ring, use a washer to secure the K-wire without bending; or use an extension plate to secure it. Extension plates are often used in younger children to replace the second ring, only one K-wire is required, but not in the same direction as the K-wire on the adjacent ring. Such a Kirschner wire fixed by an extension plate is also referred to as a "down needle." When fixing, fix the K-wire on one end of the ring first. You must use a wrench to keep the bolts in place. Tighten the nut with another wrench. Otherwise, the bolt will twist the K-wire to one side. Then use a tension pliers to apply a tension of 100 to 130 kg from the other end of the ring to the K-wire. While maintaining this tension, tighten the nut. After each K-wire is tightened, keep the needle tail 4 cm cut to repeat the above operation if necessary. Bend the needle tail toward the ring. The Iris frame must be assembled before surgery. The upper and lower rings must be located slightly below the proximal humerus and slightly above the distal callus. The rings should be symmetrical when connected to keep the two rings in a plane. Also ensure that the distance between the ring and the skin is two horizontal fingers. The top 5/8 ring can be used to ensure the knee flexion activity. Two rings are used at each end of the humerus. Two rings are connected together by two six-sided cylinders to avoid affecting the fixation of the Kirschner wire. After all the K-wires are fixed, add a six-sided cylinder to enhance the stability of the ring. The set of rings near the osteotomy end is closer to ensure that the osteotomy line is at the metaphyseal end; at the other end, the two rings are spaced a little further to increase the stability of the entire I-frame. Place the joints on each ring on the front and rear sides of the limbs, and place the six-sided cylinders on each set of rings against the inside of the joint to make more holes on the outside of the ring for fixing Krebs. Use when using the needle. Now connect the far and near sets of rings with 2 screws or extenders. The lead screws should be placed outside the two inner ring joints. After the osteotomy is completed, the two lead screws will be removed, and the four screws will be used to connect the inner and outer rings of the two groups. For the distribution of calf muscles, it is expected that the forward angulation and eversion will occur during the extension of the tibia. In order to avoid the above situation, the two sets of rings cannot be installed in parallel, but the proximal group should be turned backwards and outwards. Tilt 5°. This degree is controlled by adding 2 sets of tapered washers to the lead screw of the proximal set ring. This washer can provide adjustment in the range of 7° in any direction. The tapered protrusion of each set of washers faces the ring during installation; At the proximal Kirschner wire, the medial end of the tibia is slightly biased toward the tarsal plate. After the osteotomy is completed, the two sets of rings in the distance are adjusted to be parallel to each other. At this time, there is an overcorrection of 5°, and this angle will gradually be corrected and become a straight line during the extension process. There are also some scholars who believe that this step is unnecessary in most of the humerus extensions. It is not too late to correct the angular deformity during the extension. Treatment of diseases: tibial tuberosity osteochondrosis Indication Ilizarov humerus extension is suitable for: 1. Congenital or acquired constipation of short limb deformity, limb shortening >3cm. 2. The appropriate age for surgery is 10 to 12 years old. If the extension of the tarsal plate is used, it should be carried out when the development is mature, that is, the bone age is about 14 years old. 3. The hip joints and knee joints of the lower limbs function well, and the muscle strength is above grade IV or the lower limbs are prolonged, and the muscle balance is conditionally adjusted. Contraindications 1. Age <8 years old. 2. The limb is shortened below 3cm or greater than 15cm. 3. Lower extremity muscle strength, postoperative bone extension, no adjacent normal muscle replacement. 4. The hips, knees, and ankles are unstable or have obvious deformities. Preoperative preparation 1. Measurement of body height and lower limb length. 2. True length measurement of femur and tibia X-ray films. 3. Determine the total length of the unequal length of the lower limbs. 4. Take a X-ray of the wrist and determine the bone age. 5. Raise the affected limb to adjust the pelvic tilt, balance the trunk and other comprehensive factors to determine the length required for bone extension, and increase the total length of the bone extension by 0.5 ~ 0.6cm, as a compensation for bone shortening deformity. Surgical procedure 1. The affected side is disinfected and laid, usually without a tourniquet. The pre-assembled Iset is placed in the lower leg by lifting the affected calf through an extra-purpose sterile wooden tray. 2. Needle: First, thread the needle, fix it on the nearest and farthest ring, and put the needle as close as possible to the seesaw. These two are to be worn with olive needles from the outside to the inside, parallel to the tarsal plate, slightly below the proximal tarsal plate and slightly above the distal tarsal plate (a and b). Adjust the Istler frame and keep the gap between the ring and the skin at least 2 cm, and fix the above two needles to the ring. A lead screw connecting the two sets of rings should be located directly in front of the surface of the tibia and parallel to the leading edge of the tibia. The next two needles, called the humeral needle, were needled from the outside to the inside using a Kirschner wire without olives. The proximal end is to pass the small head of the humerus. Because the common peroneal nerve is located behind it, the needle should be inserted perpendicularly to the medial side of the tibia (c). The distal end should be inserted through the humerus and humerus in the same direction, but Fix it on the proximal ring of the proximal group (d) to avoid damage to the lower iliac ligament. Two K-wires are then threaded from the lateral to the medial side of the tibia from the outside to the inner end, and are fixed on the distal ring of the proximal and distal ends (e, f). The last two needles were traversed from the inside to the outside with olive needles and fixed in the middle two rings (g, h). After all 8 needles (4 proximal and 4 distal) were fixed, the lead screw connecting the two sets of rings was removed to prepare for osteotomy. 3. Osteotomy: The Istler technique emphasizes cortical osteotomy and preserves the structure of the medullary cavity and the integrity of the endosteal membrane. Unlike femoral extension, the proximal humerus osteotomy should be selected for the extension of the tibia. The skin was cut 2 cm longitudinally at the outer edge of the iliac crest, and the periosteum was cut longitudinally. The subperiosteal dissection revealed the inner and outer sides of the humerus, and the periosteum was pulled open with a plate-shaped hook. Osteotomy was performed 1 cm below the most distal Kirschner wire in the proximal group. The anterior cortical bone was first cut with a 1 cm wide bone knife; then the lateral and medial cortical bones were sequentially cut with a 0.5 cm wide bone knife. Since the osteotomy of the posterior cortical bone cannot be completed without damaging the intramedullary structure, the posterior osteotomy can only be performed by osteotomy, that is, the osteotomy is inserted at the posterior medial and posterolateral cortical osteotomy. The sputum caused a fracture of the posterior cortical bone. In order to confirm the completeness of the osteotomy, the two groups of rings in the distal and proximal sides should be pulled, and the outer ring of the distal group should be confirmed. Suture the periosteum and close the incision. Whether cortical osteotomy can protect the blood supply in the medullary cavity has been controversial in academic circles. In addition, the fracture line of the posterior cortical bone produced by osteotomy may lead to one side of the needle channel, thus affecting the stability of fixation. . Therefore, the osteotomy method described in the one-arm external fixator extension technique seems to be simpler and easier, avoids the above complications, and does not seem to affect bone healing. 4. Tibial osteotomy: osteotomy in the middle of the humerus, in order to avoid early healing of the humerus, it is best to cut off a small section of the tibia. 5. Connect the two rings in the near and far with 4 screws or extenders. complication Isilaz is Ilizarov's major contribution to orthopedic surgery worldwide. It is also a magical, Rubik's-like combination of orthopedic techniques that can solve many of the problems encountered in orthopedics. The limb extension technique is the essence. However, during the limb extension process, many problems and even complications occur. If not handled properly, it will affect the effect of the extension. Dror Paley (1990) summarized the problems that occurred during the extension process into problems, obstacles, and complications, and proposed specific solutions. It is defined as follows. Problems in the prolongation process: a difficulty that may occur during prolongation and fixation, and is completely resolved by non-surgical methods before the end of prolongation. Obstacles in the prolongation process: a difficulty that may occur during prolongation and fixation, and is completely resolved by surgical methods before the end of prolongation. Complications: including local and systemic, intraoperative and postoperative complications, ie difficulties that cannot be resolved before the end of the extension. Divided into minor complications and major complications. 1. Muscle contracture: usually caused by an increase in muscle tension due to prolongation. Due to the imbalance of muscle strength between the flexor and extensors, muscle contracture is likely to occur on one side of a strong muscle group and across two joints. For example, the hamstrings in the calf extension and the hamstrings in the femur. In addition, if the Kirschner wire penetrates the tendon or fascia, it will hinder the joint's mobility. Therefore, prevention of muscle contracture is part of the treatment of limb lengthening. The main preventive measures include physical therapy, use of braces and cross-articular fixation. The focus of physical therapy is on the main muscle groups involved in passive stretching. Since these affected muscle groups usually span 2 joints, it is not enough to draw only one end of the muscle. For example, in the case of the triceps of the calf, the knee joint is flexed first to maximize the dorsiflexion of the ankle joint, and then the ankle joint is dorsiflexed and passive. Straighten the knee joint. Sick children should be encouraged to repeat this exercise every day. It is now clear that active practice and electrical stimulation contribute to the regeneration of muscle fibers; the role of continuous passive practice is not yet certain. The key to preventing muscle contracture is to put the muscles under tension for as long as possible. Clinical practice has shown that stretching exercises of less than 6 hours per day are not enough to prevent muscle contracture, not to mention that most patients cannot tolerate such a long time. Exercise. Therefore, only with the help of the brace, such as the knee extension and the ankle joint extension brace used by Professor Paley, the knee joint is fully extended and the ankle joint is extended by 90°. The knee extension brace is only used at night, 8~12h; the ankle joint extension brace should be applied throughout the day. The brace should be used continuously for 3 to 4 weeks until the muscle tension is reduced. The other is to use a dynamic brace that allows the knee to actively flex, and when relaxed, the brace will gradually straighten the knee. Dynamic brace is more in line with human biomechanics. When the tibia is more prolonged (greater than 6cm, especially when the biplane is extended), it is recommended to fix the ankle joint with a Kirschner wire. Ilizarov uses a needle to fix the calcaneus. Professor Paley uses two needles to fix the calcaneus and maintain the ankle joint. The back extension is 90°, and the knee joint is used to keep the knee joint straight. When the muscle has undergone significant contracture, dynamic braces can be used for corrective treatment; another treatment method is to excessively extend 10mm, then compress 15mm, and finally reach the purpose of shortening 10mm to reduce the tension of soft tissue. If the muscle contracture still exists, it is necessary to install the Iris frame across the joints, and the contraction section is contracted; if the Iset is removed after contraction, and the rehabilitation is not effective, the tendon extension is performed. According to the previous definition, if the muscle contracture is solved by non-surgical treatment, it is a problem of prolongation; if it is solved by surgery before the end of the extension, it is classified as an extensional disorder; if the contracture persists after the extension, the non-surgical Therapy eventually overcomes contracture and is classified as a minor complication; the main complication is the muscle contracture that is ultimately resolved by tendon elongation or joint capsule release. 2. Axis displacement: The tendency of the osteotomy end to gradually shift during the extension process is due to the imbalance of the muscles on both sides of the bone. The direction of displacement depends on the different bones and the different osteotomy planes. Proximal femur osteotomy, femur tends to varus and forward angulation; femur distal osteotomy, femur tends to valgus and forward angulation; proximal humerus osteotomy, humerus tends to valgus and forward angulation The distal radius of the humerus, the tibial star tends to varus and forward angulation. Another factor that causes displacement is instability, including instability of the Istler, loss of tension by the Kirschner wire, and loosening of the Kirschner wire. The best treatment is prevention. The K-wire can be tilted by 5° to 10° in the opposite direction of the expected tilt. Taking the proximal end of the humerus as an example, the proximal ring should be in the position of high internal low, high front and low rear. If the displacement is found early (less than 5°), it can be completely corrected. That is, the side on which the displacement occurs is excessively extended (for example, the outer side is extended 5 times per day, 0.25 mm each time; the inner side is only extended 3 times, each time 0.25 mm). When the displacement is greater than 5°, the joint is added to the extension screw; when the extension distance is large, an extra olive needle is required to pull the displaced end of the bone back; in order to correct the forward angle, at the proximal end of the osteotomy A drop needle can be placed. If the displacement is solved by non-surgical treatment, it is classified as an extension problem; if it is corrected by surgery, it is an extension of the obstacle; if the displacement has healed, less than 5° is classified as a minor complication, and greater than 5° is classified as Main complications. 3. Nerve damage: can occur after surgery, or can occur after the start of extension. The surgeon should be familiar with the anatomy of the needle plane and choose a safe area to insert the needle to avoid nerve damage caused directly by the needle. When traversing the needle, the needle should be inserted into the bone before drilling, only the sides of the bone are drilled, and then the Kirschner wire is penetrated to the contralateral soft tissue by tapping. The purpose of this is to reduce the time of rotation in the soft tissue and reduce the chance of injury caused by the involvement of the nerve. There is also the need to master the speed, high speed is easy to cause local obvious mechanical and thermal damage, the diameter of the needle is also proportional to the damage, 1.5 ~ 1.8mm smooth needle rarely cause nerve damage. In addition, the anesthesiologist should not use the muscle relaxant, so that if the nerve is injured during the needle insertion, the contraction of the muscles it controls can be observed. If the postoperative child is often awakened by severe pain and points out that the pain is from the vicinity of the affected K-wire, striking the Kirschner wire with a metal object causes a local paresthesia, such as a burning sensation or acupuncture-like pain. It can be determined that the Kirschner wire has injured the nerve. Once it is confirmed that the Kirschner wire has injured the nerve (whether intraoperative or postoperative), it should be removed. Neurological damage during surgical procedures may also result from direct injury of the osteosynthesis of the humeral cortical osteotomy, direct injury of the wire saw in the tibial osteotomy, and more traction injuries from the trabecular surgery of the posterior cortical fracture. Therefore, in the proximal humerus of the humerus, the distal end should be externally rotated to avoid damage to the common peroneal nerve near the humeral head. The nerve damage caused by the prolongation process is very rare, and the focus is on understanding the early signs and symptoms of nerve damage. Sick children often complain of local obvious discomfort. The first signs are skin allergies and pain. The pain may be reflexive, such as a deep nerve injury that reflects the pain in front of the ankle joint. Next is the decline in muscle strength, and finally muscle paralysis. Paralysis can be avoided if it is handled in a timely manner. The focus of treatment is to increase rehabilitation training, especially joint function training and limb weight bearing; at the same time, it must slow down the extension, or even stop extending for a few days to a week. When starting to extend again, it is 0.25 to 0.5 mm/d slower than the previous extension. Once muscle strength declines or muscle paralysis occurs, it is necessary to compress the Istler and expect nerve damage to be restored. After the nerve injury occurs, especially when it is related to the fixed needle, the corresponding plane nerve decompression should be performed, such as the common peroneal nerve decompression of the humeral head plane. Nerve damage caused by surgery, whether recovered or not, is classified as a complication. The nerve damage that occurs during the prolongation process is a prolonged problem after treatment recovery; the nerve decompression recovery is to extend the process obstacle; the nerve injury remaining after the extension is a complication. 4. Vascular injury: Divided into direct injury and prolonged injury during surgery. The former is mainly caused by the insertion of Kirschner wire for arteriovenous injury. Because of the smaller diameter needle, vascular injury caused by needle insertion rarely occurs. If a vascular injury occurs during surgery, the Kirschner wire should be removed immediately and then stopped to stop bleeding. Osteotomy may also cause vascular damage. For example, a bone knife may damage the artery during the osteotomy of the humerus, and the vein may be damaged during the osteotomy of the tibia. Once a vascular injury occurs, compression or tamponade usually stops. Occasionally, hematoma may form, which may cause osteofascial compartment syndrome. Fasciotomy and decompression should be performed prophylactically. If the compartment syndrome is suspected after surgery, clinical examination and osteofascial compartment pressure measurement should be performed. Once the diagnosis is made, the fascial incision decompression is performed. Manometry is a very important diagnostic method because the false positives of traction pain are high (due to the fixation of the needle through the muscle). Vascular damage during prolongation is mainly due to the fact that the elongation is too fast and the extended distance is too long, especially the latter. The treatment is to slow down the extension, and even stop extending for a few days to a week. Swelling: Swelling often occurs during prolongation, especially if the sick child is active or walking too much. It is often taken after a few months of taking off the shelf to resolve. Vascular injury is classified as a complication, both during remodeling and during prolongation. 5. Early healing of the epiphysis: This condition is usually caused by incomplete osteotomy and no extension of the osteotomy end when the osteotomy is started. There is also a late start of the postoperative extension (the waiting time is too long after surgery), so that a large number of callus formation, hindering the opening of the osteotomy end. The sign is that the fixed needle is drawn into an arch, and the convex surface of the bow faces the osteotomy end. This can also occur during the extension to correct the angle or displacement. Especially the osteotomy end of the femur and tibia. Treatment can continue to be extended until the healing osteophytes are broken. The sick child must be told that when the bone is opened, it is very sudden, it will feel pain, hear or feel the sound of opening. To relieve the pain, you must compress back a few millimeters. Failure to do so may result in excessive separation of the osteotomy ends, induction of delayed healing, and non-healing. Another treatment is to close the rotary osteotomy under anesthesia. If the osteotomy fails, re-cortical osteotomy is performed. It should be noted that there will be a large amount of bleeding when the new bone is cut off. It is recommended to use a tourniquet during surgery. Early healing is resolved by non-surgical methods and is classified as a prolonged problem; surgery is a prolonged disorder; complications are only considered when early healing forces the physician to abandon prolonged treatment. 6. Late healing: Many factors can lead to delayed healing, which can be divided into technical factors and sick children. Technical factors include excessive trauma at the time of osteotomy, excessive separation of the osteotomy at the beginning, instability of the I-frame and elongation too fast. Infant factors include infection, malnutrition, and metabolic abnormalities. In order to reduce the risk of delayed healing, the damage to the periosteum and endosteum should be minimized during osteotomy. Anchor instability is also a factor in delayed healing. When the epiphysis in the prolonged gap is not longitudinal and parallel growth, but the tendon grows, indicating that the epiphysis is unhealthy, the stability of the fixator and the tension of the fixed needle should be checked to ensure that the fixator is strong and firm, and the fixed needle maintains tension. Malnourished sick children are not suitable for bone lengthening; hypophosphatemic rickets slow down the formation of new bone. When you can't find the cause of delayed healing, consider the possibility of infection. Delayed healing is usually diagnosed on X-ray films and often has large defects when found. Ultrasound examination can detect the formation of new bone at an early stage, and the formation of new bone can be observed about 2 weeks apart, which provides a new diagnostic tool for early detection of delayed healing. Once delayed healing is detected, it should be immediately pressurized (compressed) to stimulate the growth and maturation of the callus. The fractured bone is restored to its continuity and continues to prolong, but the elongation is slowed down. This process can be repeated. Occasionally, this method can not be successful (ultrasound shows a cystic change in the middle of new bone), and bone graft surgery is required. Delayed healing reaches the healing problem by non-surgical methods; if it is cured by additional Kirschner wire, it is a prolonged disorder; if it is cured by bone grafting, it is a complication. 7. Needle problem: It is related to three factors, namely the activity between the needle and the skin, the amount of soft tissue between the skin and the bone, and the diameter of the needle used. The focus is on maintaining sufficient tension on the needle to reduce needle-to-skin and needle-to-bone movement; applying a certain amount of pressure to the skin is also a means of stabilizing the needle, ie a commercial foam sponge dressing at the needle eye and The elastic clip applies pressure to the skin of the needle eye, and the foam sponge can also shield the air from entering the eye of the needle, and can also drop some antibiotics on the sponge. The needle problem always develops from the outside to the inside, starting with soft tissue swelling, followed by soft tissue infection, which eventually leads to osteomyelitis. For needle redness, local antibiotic treatment can be applied while maintaining the proper tension of the fixed needle; when a soft tissue infection occurs, the needle is incision and drainage, and antibiotics such as cephalosporin are injected radially around the needle. In most cases, needle infections can be controlled within 24 hours. Oral antibiotics can also be used for 1 week instead of antibiotics around the needle. Stubborn infections can enter the joints and cause cellulitis around the needle, and the fixation needle must be removed for treatment. If the needle is removed and the stability of the holder is affected, the other fixed needle must be repositioned. Needle infection is still a prolonged problem by using local methods, applying antibiotics or even removing the fixed needle; if the fixed needle is re-inserted, it is a prolonged disorder; once osteomyelitis occurs, it is a complication. 8. Re-fractures: All of them are complications after they have been removed. The manifestation may be an axial displacement caused by incomplete healing, a complete fracture, or a bamboo-like compression fracture. The best way to prevent it is to carefully evaluate the quality of the new bone in the extended area before removing the holder. The new bone must reach a uniform density, signs of new cortical bone, and a fixed frame when there is no light transmission area with the surrounding bone tissue. . At the time of taking the holder, one principle must be observed, that is, it is better to take one month later and never take one day. All of the aforementioned re-fractures are complications, and those that result in a short reduction of 1 cm and an angular deformity of less than 5° are classified as minor complications; exceeding the above criteria are major complications. 9. Joint stiffness: It is also a late complication because anti-muscle contracture or bone lengthening increases the pressure on the articular surface. When joint stiffness is suspected, if the fixture does not cross the joint, the component is added across the joint and 5mm is extended between the joints. All joint stiffness is classified as a complication, in which the knee extension and the ankle extension are lost by 15°, which is more severe than the loss of flexion and plantar flexion.