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1</A>
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3</A> </LI></UL></DIV>
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<DIV id=fulltext-headers-bottom><A name=5></A>
<DIV class=fulltext-TITLE>Correction of Large Bilateral Tibia Vara With the
Ilizarov Method</DIV><A name=6></A>
<DIV class=fulltext-DOCUTYPE>[CASE REPORT]</DIV><A name=7></A>
<P class=fulltext-AUTHOR>Rozbruch, S. Robert MD; Blyakher, Arkady MD; Haas,
Steven B. MD, MPH; Hotchkiss, Robert MD</P><A name=8></A>
<DIV class="fulltext-INSTITUTION fulltext-INDENT">Drs Rozbruch, Blyakher, Haas,
and Hotchkiss are from the Limb Lengthening Service, Knee Service, Department of
Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College, Cornell
University, New York, NY.</DIV><A name=9></A>
<DIV class="fulltext-INSTITUTION fulltext-INDENT">Reprint requests: S. Robert
Rozbruch, MD, 535 E 70th St, New York, NY 10021.</DIV></DIV></DIV><A
name=10></A>
<DIV class=fulltext-LEVEL1>INTRODUCTION<A
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#toc"><IMG
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src="Ovid Rozbruch Journal of Knee Surgery, Volume 16(1)_January 2003_34–37_files/ftup.gif"></A></DIV><A
name=11></A>
<P class="fulltext-TEXT fulltext-INDENT">Blount's disease in the adult is a
sequel of the infantile, juvenile, or adolescent type depending on the age of
onset.<A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#40">1</A>
Disordered growth of the proximal medial physis and metaphysis produces a
localized varus deformity. In addition, a medial tibial torsion deformity
usually is present.</P><A name=12></A>
<P class="fulltext-TEXT fulltext-INDENT">A variety of methods have been used to
correct the tibia vara, including acute correction of the deformity with various
oblique or dome-shaped osteotomies with different fixation techniques.
Literature review <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#41">2,8,14,18</A>
revealed a high percentage of fair and poor results.</P><A name=13></A>
<P class="fulltext-TEXT fulltext-INDENT">This article presents a case of
neglected bilateral infantile Blount's disease and describes gradual opening
wedge correction of the deformity using distraction osteogenesis as described by
Ilizarov.<A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#45">6</A></P><A
name=14></A>
<DIV class=fulltext-LEVEL1>CASE REPORT<A
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#toc"><IMG
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src="Ovid Rozbruch Journal of Knee Surgery, Volume 16(1)_January 2003_34–37_files/ftup.gif"></A></DIV><A
name=15></A>
<P class="fulltext-TEXT fulltext-INDENT">A 22-year-old woman presented with
severe varus deformities of both legs (<A class=fulltext-GX
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#FF1">Figure
1</A>). She ambulated, but did so with a limp and pain in the knees.</P><A
name=FF1></A><BR>
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<TD class=fulltext-graphic-text><SPAN class=fulltext-GRAPHICTEXT>Figure 1.
Preoperative radiographs showing large varus deformities of both legs (A).
Preoperative supine radio-graphs of the right (B) and left (C)
knees.</SPAN> </TD></TR></TBODY></TABLE>
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<A name=16></A>
<P class="fulltext-TEXT fulltext-INDENT">On physical examination, using a
goniometer, the right leg varus measured 70° and the left leg varus measured
75°. Range of motion of both knees was 0°-130°. Full mobility of the hips was
present. Preoperative supine radiographs showed a right femorotibial angle of
40° varus and a left femorotibial angle of 48° varus (<A class=fulltext-GX
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#FF1">Figure
1</A>). Both sides were consistent with type VI infantile tibia vara according
to the classification of Langenskold and Riska.<A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#46">7</A>
Standing radiographs showed a femorotibial angle of 55° on the right varus and
62° on the left varus.</P><A name=17></A>
<P class="fulltext-TEXT fulltext-INDENT">Bilateral proximal tibia osteotomies,
5-cm proximal fibula resections, and peroneal nerve decompressions were
performed. Bilateral Ilizarov frames were applied to match the varus
deformities. A postoperative right-sided extensor hallucis longus palsy was
noted, which gradually resolved.</P><A name=18></A>
<P class="fulltext-TEXT fulltext-INDENT">Gradual adjustment of the frames began
on postoperative day seven. The speed of correction was determined so that the
bone at the concavity of the deformity was being distracted at 1 mm per day.
Weight bearing as tolerated was encouraged throughout the treatment. At the end
of the correction, the patient was ambulating full weight bearing in the
bilateral frames (<A class=fulltext-GX
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#FF2">Figure
2</A>). At 3.5 months postoperatively, excision of prominent bone from the left
tibia and frame modification was performed.</P><A name=FF2></A><BR>
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<TD class=fulltext-graphic-text><SPAN class=fulltext-GRAPHICTEXT>Figure 2.
Photograph of both legs in Ilizarov frames following deformity
correction.</SPAN> </TD></TR></TBODY></TABLE>
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<A name=19></A>
<P class="fulltext-TEXT fulltext-INDENT">At 5.5 months postoperatively, the
right Ilizarov frame was removed and at 6.5 months, the left Ilizarov frame was
removed. The left proximal tibia was subsequently noted to have a stiff
nonunion, and further surgical treatment was believed necessary.</P><A
name=20></A>
<P class="fulltext-TEXT fulltext-INDENT">Seven months postoperatively, the
Ilizarov frame was reapplied to the left leg to stabilize and compress the
nonunion site. The nonunion was not surgically exposed and was not bone grafted.
Three months later, the left-sided frame was removed.</P><A name=21></A>
<P class="fulltext-TEXT fulltext-INDENT">At 1 year 5 month follow-up
postoperatively, the patient was ambulating well. She reported a mild occasional
ache in the right knee. Range of motion of the right knee was 0°-135° and the
left knee was –3° to 135°. At 2-year follow-up, the patient reported no pain.
Range of motion in the right knee was 0°-130° and the left knee was -5° to 125°.
A mild lateral thrust was noted bilaterally, but the left side was more
pronounced. An erect leg radiograph demonstrated complete bony healing of the
osteotomies. The left leg was 8 mm longer than the right leg. Mechanical axis
deviation was 31 mm medial to the midline on the right side and 44 mm medial to
the midline on the left side. Lateral distal femoral angle was 83° on the right
and 77° on the left. Medial proximal tibial angle was 74° on the right and 65°
on the left <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#51">12</A>
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3</A>).</P><A name=FF3></A><BR>
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href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?S=KNJAFPJPOCDDCPCCNCILFEPJOEPPAA00&Save+As+Jumpstart=Image%7c%26PAGE%3dimage%26IMAGE%3d01257075-200301000-00006%7cFF3%26D%3dovft&WebLinkReturn=Full+Text%3dL%7cS.sh.20.21%7c0%7c01257075-200301000-00006"><SPAN
class=fulltext-imagehelp>[Email Jumpstart To Image]</SPAN></A> </TD>
<TD class=fulltext-graphic-text><SPAN class=fulltext-GRAPHICTEXT>Figure 3.
Erect leg radiograph 2 years postoperatively (A). Front view (B), standing
radiograph of both knees 10 years postoperatively (C), and lateral
radiographs of the right (D) and left (E) knees 10 years
postoperatively.</SPAN> </TD></TR></TBODY></TABLE>
<HR class=fulltext-LINESOLID>
<A name=22></A>
<P class="fulltext-TEXT fulltext-INDENT">At 10-year follow-up, the patient
ambulates without assistance. She reports mild and intermittent pain in both
knees, which responds to the occasional short-term use of nonsteroidal
anti-inflammatory medications. Knee alignment is visibly normal (<A
class=fulltext-GX
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#FF3">Figure
3</A>). No significant coronal sagittal plane instability is noted. Standing
radiographs demonstrate a femorotibial angle of 2° varus of the right and left
sides (<A class=fulltext-GX
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#FF3">Figure
3</A>). Knee joint spaces are maintained, and bony remodeling has occurred.
Lateral radiographs demonstrate the absence of deformity and advanced bone
remodeling (<A class=fulltext-GX
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#FF3">Figure
3</A>).</P><A name=23></A>
<DIV class=fulltext-LEVEL1>DISCUSSION<A
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#toc"><IMG
class=fulltext-top
src="Ovid Rozbruch Journal of Knee Surgery, Volume 16(1)_January 2003_34–37_files/ftup.gif"></A></DIV><A
name=24></A>
<P class="fulltext-TEXT fulltext-INDENT">In cases of severely neglected Blount's
disease, ligamentous laxity, a large varus deformity, extreme sloping and
depression of the posteromedial plateau of the tibia, and hypermobility of the
medial meniscus may exist.<A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#54">15</A>
Extreme medial deviation of the mechanical axis line leads to abnormal stress
transmission across the knee, which causes knee pain and progressive
degenerative arthritis in adulthood.</P><A name=25></A>
<P class="fulltext-TEXT fulltext-INDENT">Oyemade <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#49">10</A>
reported 25 Nigerian adolescent patients with advanced tibia vara, 15 of whom
had bilateral deformities. They were treated with closing wedge osteotomies,
acute correction through an open technique, and casting. Four residual
deformities, 1 osteomyelitis, 1 wound necrosis, and several large keloid scars
were the reported complications. The closing wedge osteotomies led to further
shortening and decreased metaphyseal bone stock.</P><A name=26></A>
<P class="fulltext-TEXT fulltext-INDENT">Medial mechanical axis deviation and
increased stress on the medial joint compartment is believed to be the etiology
of Blount's disease and a contributing factor to progressive medial compartment
degeneration. In a report of 133 knees in 86 patients with Blount's disease,
Zayer <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#59">20</A>
found that patients aged < 30 years did not have degenerative joint disease,
whereas in patients aged > 30 years, 41% had radiographic evidence of
degenerative changes. Increasing varus deformity predisposed to degenerative
change, but the relationship was not constant. Legs with smaller medial proximal
tibial angles were predisposed to degenerative change, and medial proximal
tibial angles < 73° were only seen in knees with osteoarthritis.</P><A
name=27></A>
<P class="fulltext-TEXT fulltext-INDENT">Our patient had severe sloping and
depression of the medial plateau. Although this was not addressed, some authors
advocate elevation of the plateau. Zayer <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#58">19</A>
reported hemicondylar osteotomy in two 15-year-old patients with neglected
Blount's disease. At 6-year follow-up, he reported good results and recommended
this technique for late neglected cases.</P><A name=28></A>
<P class="fulltext-TEXT fulltext-INDENT">Gregosiewicz et al <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#44">5</A>
advocated a double elevating osteotomy for severe cases of tibia vara. They
performed an acute closing wedge osteotomy in the metaphysis and used this wedge
of bone to fill an opening wedge osteotomy through the medial physis. This was
performed in children (average age: 8 years) and stabilized with crossed wires
and a long leg cast. The improvement of the congruence of the articular surface
in addition to mechanical axis realignment may help protect the knee from future
degeneration.</P><A name=29></A>
<P class="fulltext-TEXT fulltext-INDENT">Disadvantages of internal fixation
after proximal tibial osteotomy include the lack of postoperative adjustability,
difficulty in translating the distal fragment laterally, and the need for
limited weight bearing or casting. The inability to obtain a standing
hip-to-ankle radiograph during surgery limits the precision of an intraoperative
correction. With external fixation stabilization, the position can be changed
acutely or gradually after a standing hip-to-ankle radiograph is obtained and
the appropriate mechanical axis analysis is performed.<A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#51">12</A></P><A
name=30></A>
<P class="fulltext-TEXT fulltext-INDENT">Acute deformity corrections and
stabilization with external fixation have been reported by several authors.
Miller et al <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#48">9</A>
reported the use of an inverted arcuate osteotomy, acute correction, and
stabilization with a hybrid external fixator in 12 patients. The average
deformity correction obtained was 21.7°. No nerve palsies or compartment
syndromes were reported.</P><A name=31></A>
<P class="fulltext-TEXT fulltext-INDENT">Smith et al <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#55">16</A>
reported the use of a gigli saw percutaneous osteotomy, acute correction, and
stabilization with an Orthofix unilateral external fixator (Orthofix Inc,
Richardson, Tex) in 19 patients with an average weight of 258 lbs. The average
correction performed was 27.6° and the time to healing was 141 days. At union,
the average mechanical axis was 1.9° of varus. Four patients underwent
adjustment of the fixator in the postoperative period. One patient had a
peroneal nerve palsy that was resolved.</P><A name=32></A>
<P class="fulltext-TEXT fulltext-INDENT">Disadvantages of acute deformity
correction may include an increased risk of neurovascular insult and compartment
syndrome, particularly with large deformities. Several authors have reported the
use of gradual deformity correction with external fixation for tibia vara. Price
et al <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#52">13</A>
reported the use of dynamic axial external fixation in 23 patients, obtaining an
average 20° of correction.</P><A name=33></A>
<P class="fulltext-TEXT fulltext-INDENT">De Pablos et al <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#43">4</A>
reported the use of gradual correction in 10 patients. An average of 15° angular
correction was obtained at the proximal tibia osteotomy. The average time in the
frame was 12 weeks.</P><A name=34></A>
<P class="fulltext-TEXT fulltext-INDENT">Stanitski et al <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#56">17</A>
reported the use of gradual correction with circular external fixation for 17
obese children. The average preoperative angular deformity was 27° varus, and
all patients achieved alignment within 5° of normal. Three patients had
leg-length discrepancy and underwent an average of 3.5-cm simultaneous
lengthening. The time in the frame was 12 weeks for patients treated without
lengthening and 16.9 weeks for those requiring lengthening. No nerve palsies or
compartment syndromes were reported.</P><A name=35></A>
<P class="fulltext-TEXT fulltext-INDENT">Although correction of the varus
deformity in Blount's disease is desirable, many methods have been advocated.
These include open or percutaneous osteotomy in the metaphysis of the proximal
tibia, opening or closing wedge correction, acute or gradual correction,
stabilization with internal or external fixation, and opening wedge correction
through the proximal tibia physeal area. The use of a percutaneous osteotomy in
the metaphysis and gradual correction of a large deformity with an external
fixator has many advantages. The osteotomy is minimally invasive and does not
require extensive soft-tissue stripping, improving the bony healing potential.
Complications of osteomyelitis, wound dehiscence, and large keloid scar
formation are less likely. The benefits of external fixation include increased
weight bearing and lateral translation of the distal fragment along with the
angular correction. Another benefit is the postoperative adjustability after a
standing hip-to-ankle radiograph is obtained and the mechanical axis analysis is
performed. A gradual correction may decrease the likelihood of neurovascular
insult and compartment syndrome particularly in a patient with a massive
deformity as in the current report. Gradual correction should be relatively safe
in a patient with Blount's disease with a massive varus deformity along with
procurvatum and internal tibial torsion. Another advantage of gradual correction
with a frame is the possibility for limb lengthening, if necessary, to correct
length discrepancy. Opening wedge correction prevents further shortening and
loss of bone stock.</P><A name=36></A>
<P class="fulltext-TEXT fulltext-INDENT">In the current patient, correction of
large varus deformities was performed. The corrections were 53° and 60° on the
right and left sides, respectively. Simple knee radiographs were used
preoperatively and during the correction, limiting a comprehensive deformity
analysis.<A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#51">12</A>
Anatomic femorotibial measurements were used as a result. Although the
corrections were large and the cosmetic and functional results very good, some
mechanical axis deviation exists in both lower limbs. Erect leg radiographs that
include the hip, knee, and ankle and a mechanical axis analysis of the deformity
and correction <A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#51">12</A>
are currently used. This may result in a more accurate and critical deformity
correction and analysis of the result.</P><A name=37></A>
<P class="fulltext-TEXT fulltext-INDENT">Complications encountered in the
present case included a right extensor hallicus longus palsy noted immediately
postoperatively. This was probably related to surgical technique during the
proximal fibula resection and peroneal nerve decompression. The current
recommendation would be for a middle fibula resection or oblique osteotomy
without nerve decompression. If during the gradual correction, peroneal nerve
symptoms and signs occur, a secondary nerve decompression should be performed. A
stiff nonunion of the left proximal tibia also was encountered, which required
reapplication of the Ilizarov frame for compression. Uneventful bony union
occurred after 3 months. Compression of a stiff nonunion without surgical
exposure or open bone grafting is another helpful application of the Ilizarov
method.<A class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#42">3,6</A>
Complications encountered with the Ilizarov method were reviewed by Paley.<A
class=fulltext-RA
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#50">11</A>
Eleven of 46 patients required a return to the operating room. Despite this, the
original goals of surgery were achieved in 57 of 60 limb segments and patient
satisfaction was 94%.</P><A name=38></A>
<P class="fulltext-TEXT fulltext-INDENT">This case represents the early American
experience with the Ilizarov method for correction of large bilateral varus
deformities in a young adult with neglected Blount's disease. An evolution in
the method of deformity analysis may explain the imperfect although greatly
improved position.</P><A name=39></A>
<DIV class=fulltext-LEVEL1>REFERENCES<A
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#toc"><IMG
class=fulltext-top
src="Ovid Rozbruch Journal of Knee Surgery, Volume 16(1)_January 2003_34–37_files/ftup.gif"></A></DIV><A
name=40></A><A name=RF></A>
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<P class=fulltext-REFERENCES>3. Catagni MA, Guerreschi F, Holman JA, Cattaneo R.
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href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#37">[Context
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<P class=fulltext-REFERENCES>4. De Pablos J, Azcarate J, Barrios C. Progressive
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Full Text</A> <A class=fulltext-SL
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?Link+Set+Ref=01257075-200301000-00006|00004624_1995_77_387_pablos_progressive_%7c01257075-200301000-00006%23xpointer%28id%28R4-6%29%29%7c60%7chttp%3a%2f%2facs.tx.ovid.com%2facs%2f.14038a58de48ffa86f4ee5c84b99ffb3634b4b40918581081964493cf03a9948ecbddf0655fc0acf8b.gif%7covftdb%7c00004624-199505000-00010&P=43&S=KNJAFPJPOCDDCPCCNCILFEPJOEPPAA00&WebLinkReturn=Full+Text%3dL%7cS.sh.20.21%7c0%7c01257075-200301000-00006">Bibliographic
Links</A> <A class=fulltext-BK
href="http://gateway.tx.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=01257075-200301000-00006&NEWS=N&CSC=Y&CHANNEL=PubMed#33">[Context
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<P class=fulltext-REFERENCES>5. Gregosiewicz A, Wosko I, Kandzierski G, Drabik
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<P class=fulltext-REFERENCES>6. Ilizarov GA. Pseudoarthrosis and defects of long
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<P class=fulltext-REFERENCES>8. Loder RT, Schaffer JJ, Bardenstein MB.
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Links</A> <A class=fulltext-BK
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