Leg lengthening over an intramedullary nail

Tibial Lengthening along Submuscular Plate with Simultaneous Acute Tibial Deformity Correction by High-Energy Osteotomy: A Comparative Study

Submuscular plating and osteotomy using power saw have shown the benefits in certain situations of limb lengthening. However, no previous studies combining both procedures have been conducted for acute tibial deformity correction and limb lengthening. Nineteen cases were enrolled in this study. Ten patients received tibial lengthening with acute knee angular deformity correction using high-energy osteotomy (Group 1), and nine patients received tibial lengthening only with osteotomy using multiple drills and osteotome (Group 2). Radiographic parameters retrieved before and after the operation included leg-length discrepancy, tibial length, length gained, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), and mechanical axis deviation (MAD). There were significant differences between groups in terms of external fixator index (EFI) (p = 0.013) and healing index (HI) (p = 0.014), but no significance in the length gained (p = 0.356). The latest postoperative mLDFA (p = 0.315), MPTA (p = 0.497), and MAD (p = 0.211) of Group 1 were not distinguishable from Group 2. The functional outcomes were excellent, and there were no permanent complications. Despite showing a longer healing time, this alternative lengthening procedure which combines fixator-assisted plate lengthening in the tibia with simultaneous surgical intervention of acute tibial deformity correction using an oscillating saw is appropriate for patients with leg-length discrepancy and angular deformity of the tibia.

Comparison of Intramedullary Magnetic Nail, Monolateral External Distractor, and Spatial External Fixator in Femur Lengthening in Adolescents with Congenital Diseases

The aim of this study is to evaluate the course of the treatment and clinical and functional outcomes of femur lengthening in adolescents with congenital disorders by the application of different surgical methods. This retrospective study comprised 35 patients (39 procedures). A total of 11 patients underwent femur lengthening with the use of the intramedullary magnetic nail (IMN) Precise 2 (NuVasive, San Diego, CA, USA), 7 patients (11 procedures) with the use of the monolateral external distractor Modular Rail System (MRS) (Smith and Nephew, Memphis, TN, USA), and 17 with the use of the computer-assisted external fixator Taylor Spatial Frame (TSF) (Smith and Nephew, Memphis, TN, USA). The inclusion criteria were as follows: (1) congenital femoral length deficiency without any axial deformities and (2), independently of the finally applied treatment, the technical possibility of use of each of the analyzed methods. The distraction index did not differ significantly between the groups (p = 0.89). The median lengthening index was the lowest in the IMN group (24.3 d/cm; IQR 21.8–33.1) and statistically different in comparison to the MRS (44.2 d/cm; IQR 42–50.9; p < 0.001) and the TSF groups (48.4 d/cm; IQR 38.6–63.5; p < 0.001). Similarly, the consolidation index in the IMN group (12.9 d/cm; IQR 10.7–21.3) was statistically lower than that in the MRS (32.9 d/cm; IQR 30.2–37.6; p < 0.001) and the TSF (36.9 d/cm; IQR 26.6–51.5; p < 0.001) groups. This study indicates that IMN is a more valuable method of treatment for femoral length discrepancy without axial deformity than MRS and TSF in complication rate and indexes of lengthening and consolidation.

Management of post-traumatic femoral defects with a monorail external fixator over an intramedullary nail

PURPOSE

The management of limb-length discrepancy secondary to traumatic femoral bone loss poses a unique challenge for surgeons. The Ilizarov technique is popular, but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail.

METHODS

Eight patients were included from October 2015 to May 2019 with post-traumatic femoral defects that underwent treatment with monorail fixator-assisted intramedullary nailing. Primary outcome was time to bone union and bone results according to ASAMI classification. Secondary outcomes were lengthening index, consolidation time and index, external fixator index (EFI), time to partial weight bearing(PWB) and full weight bearing (FWB), and complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores (OKS), and Oxford hip scores (OHS) were recorded after recovery.

RESULTS

Mean follow-up time was 227 weeks. Average bone defect size was 9.69 cm. Average consolidation time and index were 11.35 months and 1.24 months/cm, respectively. Mean lengthening and external fixator index were 20.2 days/cm and 23.88 days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, five patients had pin site infections, and two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p = 0.104, p = 0.238, respectively). Average OKS was 32.17 and OHS was 34.00.

CONCLUSION

Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time and returning patients' quality of life to a level comparable with the normal population.

Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications

Purpose

Circular frames have been the gold standard of treatment for complex deformity corrections and bone loss. However, despite the success of frames, patient satisfaction has been low, and complications are frequent. Most recently, lengthening nails have been used to correct leg length discrepancies. In this article, we review the current trends in deformity correction with emphasis on bone lengthening and present our case examples on the use of lengthening nails for management of complex malunions, non-unions, and a novel use in bone transport.

Materials and methods

A nonsystematic literature review on the topic was performed. Four case examples from our institute, Brighton and Sussex University Hospitals, East Sussex, England, UK, were included.

Results

New techniques based on intramedullary bone lengthening and deformity correction are replacing the conventional external frames. Introduction of lengthening and then nailing and lengthening over a nail techniques paved the way for popularization of the more recent lengthening nails. Lengthening nails have gone through evolution from the first mechanical nails to motorized nails and more recently the magnetic lengthening nails. Two case examples demonstrate successful use of lengthening nails for management of malunion, and two case examples describe novel use in management of non-unions, including the first report in the literature of plate-assisted bone segment transport for the longest defect successfully treated using this novel technique.

Conclusion

With the significant advancement of intramedullary lengthening devices with lower complications rates and higher patient satisfaction, the era of the circular frame may be over.

How to cite this article

Barakat AH, Sayani J, O'Dowd-Booth C, et al. Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications. Strategies Trauma Limb Reconstr 2020;15(1):54–61.

[Plate-assisted segmental bone transport with a lengthening nail and a plate : A new technique for treatment of tibial and femoral bone defects]

BACKGROUND

Distraction osteogenesis represents an effective procedure for treatment of bone defects from various causes (e.g. trauma, malignancy, congenital and infection). In the past the available procedures were practically exclusively external.

PRINCIPLES

In the plate-assisted segmental bone transport (PABST) procedure a commercially available motorized intramedullary lengthening nail is used for segment transport. The transport segment is transported along a bone plate, which is responsible for maintaining the position of the proximal and distal main fragments.

SURGICAL TECHNIQUE

In staged sequences, a plate spanning the defect is placed. A lengthening nail is inserted in an antegrade or retrograde direction and a vascularized transport segment is created with an osteotomy. Bone transport is initiated at 1.0 mm a day. The transport segment is pulled or pushed into place, depending on the location of the bone void. In due time, a docking procedure is performed and full weight bearing is allowed. Supplementary lengthening can be initiated at docking or in a separate procedure. In smaller defects the gap is closed immediately over the plate and the bone is lengthened by the nail in the opposite end of the defect.

CONCLUSION

The presented method is a valuable addition to the armamentarium for treatment of bone defects. The main advantages are the avoidance of external fixation (fixation wires, Schanz screws) and the creation of physiological bone substitute. Vital soft tissues are essential for a good outcome. With appropriate management (systematic debridement, local and systemic administration of antibiotics and free soft tissue flaps), this method can be a solution to even complex reconstructive problems.

Lower limb lengthening over an intramedullary nail: a long-term follow-up study of 28 cases

Background

Limb lengthening using an external fixator requires a long period of external fixation and may be associated with several complications such as axial deformity, fracture of the regenerated bone, and joint stiffness. With the goal of reducing the time of external fixation as well as some of these complications, we performed femoral or tibial lengthening over an intramedullary nail, according to Paley’s technique, in 28 patients, followed up after a mean period of 8 years.

Materials and methods

Twenty-eight patients treated for lower limb discrepancy by limb lengthening over an intramedullary nail were reviewed from 5 to 11 years after healing of regenerated bone. There were 20 femurs and 8 tibiae, with average age at surgery of 14.2 years and average length inequality of 6.1 cm for femurs and 5.3 cm for tibiae.

Results

The mean lengthening was 5.8 cm for femurs and 4.8 cm for tibiae. The mean period of radiographic consolidation of the regenerated bone was 6 months for femoral lengthening and 4.5 months for tibial lengthening. At follow-up, we observed 8 excellent results, 15 good results, 4 fair results, and 1 poor result, based on Paley’s evaluation criteria. The main complications were one deep infection, one nonunion of the distracted segment, one breakage of the distal fiche of the external fixator, and one breakage of both distal locking screws of the intramedullary nail.

Discussion

We believe that limb lengthening over an intramedullary nail still represents a good method to treat limb length discrepancy because it reduces the time of external fixation, prevents axial deformities and fractures of regenerated bone, and allows early rehabilitation. The new intramedullary lengthening nails, which theoretically are the ideal device for treating limb length inequality, are still very expensive and need longer follow-up for definitive evaluation.

Level of evidence

4.

Plate-assisted Bone Segment Transport With Motorized Lengthening Nails and Locking Plates: A Technique to Treat Femoral and Tibial Bone Defects

This article describes a new bone transport technique for femoral and tibial bone defects using lengthening nails combined with locking plates. We term it plate-assisted bone segment transport (PABST).

All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss

Background

Variety of techniques for management of segmental femoral bone loss have been described, each with different advantages and challenges during treatment. The development of motorized lengthening nails has provided a potential for all internal bone transport, avoiding some of the difficulties with external fixation in the femur. At present, there is limited published literature on experiences in this technique.

Aim

The development of this technique aimed to overcome the difficulties previously reported for internal bone transport in the femur, particularly varus deformity and joint stiffness.

Technique

We describe the technique of double plating with bone transport utilizing a magnetic lengthening nail to manage segmental femoral bone loss. The benefits of the technique are discussed, along with specific challenges and lessons that have been learned through experience of internal bone transport.

Conclusion

Use of a magnetic lengthening nail and double plating as a method of all internal bone transport provides an option for the management of massive femoral bone loss, while avoiding some of the challenges that have been reported with the existing techniques.

Clinical significance

This technique provides an additional method in the armamentarium of the trauma or limb reconstruction surgeon treating massive femoral bone loss.

How to cite this article

Wright J, Bates P, Heidari N, et al. All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss. Strategies Trauma Limb Reconstr 2019;14(2):94–101.

Regenerative medicine in lower limb reconstruction

Bone is a highly specialized connective tissue and has a rare quality as one of the few tissues that can repair without a scar to regain pre-injury structure and function. Despite the excellent healing capacity of bone, tumor, infection, trauma and surgery can lead to significant bone loss requiring skeletal augmentation. Bone loss in the lower limb poses a complex clinical problem, requiring reconstructive techniques to restore form and function. In the past, amputation may have been the only option; however, there is now an array of reconstructive possibilities and cellular therapies available to salvage a limb. In this review, we will evaluate current applications of bone tissue engineering techniques in limb reconstruction and identify potential strategies for future work.

Circular hexapod external fixation for periprosthetic tibial fracture

A poor soft tissue envelope often accompanies periprosthetic tibia fracture around a well-fixed total knee arthroplasty and the tibial stem leaves little room for screw fixation. This article describes the practicability and effectiveness of a novel surgical technique using circular hexapod external fixation, in patients with this clinical scenario. It was applied for fixation of periprosthetic tibia fracture in 2 patients. Contact between the external fixation pins and the prosthesis was avoided. Using a web-based software program, a gradual reduction in all planes was achieved. Adequate fixation, stability, reduction, and quick healing were obtained in the 2 cases, with minimal complications. The patients returned to their activity level a few months after external fixation removal.

Current treatment of infected non-union after intramedullary nailing

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

Regenerate bone fracture rate following femoral lengthening in paediatric patients

PURPOSE

Femoral lengthening using a circular or mono-lateral frame is a commonly used technique. Fracture at the site of the regenerate bone is a major concern especially following removal of the external fixator. This aim of this study was to assess the rate of fracture of the regenerate bone in this single surgeon series of paediatric patients and determine potential risk factors.

METHODS

Retrospective review of all the femoral lengthening performed by the senior author was performed. The medical and physiotherapy notes were reviewed. The gender, age at time of surgery, disease aetiology, total days in the external fixator and length of the new regenerate bone were recorded. Patients who sustained a regenerate fracture were identified.

RESULTS

A total of 176 femoral lengthening procedures were performed on 108 patients. Eight regenerate fractures occurred in seven patients (4.5%). The mechanism of injury was a fall in five cases and during physiotherapy in three cases. The regenerate fracture occurred a median number of nine days following removal of frame. There was no significant difference between gender, age at time of surgery, total time in external fixator between those who sustained a regenerate fracture and those patients who did not. A significant difference was noted between the amount of lengthening between the 'regenerate fracture group' and the 'no fracture group' (50 mm vs 38 mm, respectively; p = 0.029). There was no association between disease aetiology and risk of regenerate fracture.

CONCLUSIONS

Femoral lengthening of more than 50 mm increases the risk of a fracture at the regenerate site regardless of the disease aetiology. We recommend avoidance of aggressive physiotherapy for the initial four weeks following external fixator removal.

The role of the intramedullary implant in limb lengthening

Limb lengthening is now an accepted practice in orthopaedic surgery. The principles of distraction osteogenesis have become well established with the use of external fixators, utilizing both monolateral and ring fixators. Corticotomy technique, frame stability, lengthening rate and rhythm all contribute to the formation of bone regenerate and tissues. Complications are however common including pin-site infection, soft tissue tethering from the pins and wires resulting in pain, regenerate deformity from soft tissue forces or fracture following frame removal and patient intolerance of the frames during treatment. Surgical techniques have changed to try and minimise these complications. The use of intramedullary nails have been used in conjunction with an external fixator or inserted after lengthening has been achieved, to reduce fixator time and prevent regenerate deformity. Implant innovation has led to the production of intramedullary lengthening nails. The initial devices used ratchet mechanisms with rotation of the bone fragments to achieve lengthening (Bliskunov, Albizzia and ISKD). More accurate control of lengthening and a reduction in pain, resulting from the manual rotation of the leg required to achieve the ratchet progression, was achieved by the use of a transcutaneous electrical conduit powered by external high frequency electrical energy (Fitbone). The most recent implant uses an external remote controller which contains two neodymium magnets. These are placed over the nail on the skin and rotate which in turn rotates a third magnet within the intramedullary nail (Precice). This magnet rotation is converted by a motor to extend or retract the extendible rod. There are multiple nail sizes and lengths available, and early results have shown accurate control with few complications. With such promising outcomes the use of this lengthening intramedullary nail is now recommended as the implant of choice in femoral lengthening. This article is an historical account of the intramedullary device and the impact on limb lengthening.

Tibial Lengthening Using a Fixator-Assisted Lengthening Plate: A New Technique

Background

There are many techniques that are used for limb lengthening. Lengthening a limb over a plate is an alternative choice used in children or when using an intramedullary nail is difficult.

Objectives

In this study, we presented a new technique for tibial lengthening using a monolateral external fixator over a lengthening plate.

Materials and Methods

For tibial lengthening, a monolateral external fixator was attached to the composite bone model medially. After a corticotomy was performed, the lengthening plate was placed laterally. Three locking screws were inserted proximally, and two cortical screws were inserted into a lengthening hole that was 1 cm below the osteotomy site. We avoided contact between the screws of the lengthening plate and the pins of the external fixator. During bone lengthening with the monolateral external fixator, the screws at the lengthening hole were able to slide distally with the distal segment of the tibia to allow for tibial elongation. Two locking screws were fixed at the distal locking holes of the plate when the bone elongation was complete. The external fixator was then removed.

Results

The fixator-assisted lengthening plate allowed bone lengthening without malalignment. There were no mechanical problems associated with the external fixator during the lengthening process. Plate osteosynthesis was stable after the fixator was removed. There was no contact between the screws of plate and the Schanz pins of the external fixator under C-arm fluoroscopy.

Conclusions

The fixator-assisted lengthening plate technique helps to maintain the stability and alignment at both sides of an osteotomy during tibial elongation. It allows the early removal of the external fixator immediately after lengthening is completed. This technique can be applied in children with open physes and in patients with a narrow medullary canal who are unsuitable for limb lengthening over an intramedullary nail.

Distraction osteogenesis using combined locking plate and Ilizarov fixator in the treatment of bone defect: A report of 2 cases

Distraction osteogenesis and bone transport has been used to reconstruct bone loss defect by allowing new bone to form in the gap. Plate-guided bone transport has been successfully described in literature to treat bone loss defect in the femur, tibia, and mandible. This study reports two cases of fracture of femur with segmental bone loss treated with locking plate fixation and bone transport with Ilizarov ring fixator. At the time of docking, when the transport segment is compressed with bone fragment, the bone fragment is fixed with additional locking or nonlocking screws through the plate. The bone defect size was 7 cm in case 1 and 8 cm in case 2 and the external fixation indexes were 12.7 days/cm and 14 days/cm. No shortening was present in either of our cases. The average radiographic consolidation index was 37 days/cm. Both cases achieved infection-free bone segment regeneration and satisfactorily functional outcome. This technique reduces the duration of external fixation during the consolidation phase, allows correction of length and alignment and provides earlier rehabilitation.

Femur lengthening with monoplanar external fixator associated with locked intramedullary nail

OBJECTIVE

This study aimed to demonstrate that the lengthening technique of an external fixator associated with locked intramedullary nail is an efficient method that decreases the duration of the external fixation and improves the rehabilitation period.

METHODS

From January of 2005 to May of 2014, 31 patients with mean lower limb discrepancy of 5.31 cm were treated. The etiologies of the deformity were femur fracture sequelae, infection, hip development dysplasia, polio, and congenital short femur.

RESULTS

The mean duration of external fixation was 2.47 months (external fixation index of 16.15 days per cm). The mean time for bone healing was 6.66 months (consolidation index 43 days per cm). Initial mean knee range of motion was -1° to 100°, progressing to 0°-115° at the end of treatment. The complications observed were incomplete osteotomies, hip subluxation, broken fixator, decreased knee range of motion, and need for locking screw removal.

CONCLUSION

Femur lengthening with a monoplanar external fixator associated with locked intramedullary nail allowed for a shorter period of external fixation use, better protection for the regenerated bone tissue, and early rehabilitation with possible complications.

Fixator-assisted tibial lengthening over a plate in a patient with sequelae of poliomyelitis

There are many techniques for limb lengthening. Lengthening over a plate is an alternative choice of fixation in children or when nailing is difficult. We present a new technique for tibial lengthening with using a monolateral external fixator over a lengthening plate.Lengthening over an intramedullary nail is a commonly used method in patients with short stature or limb-length discrepancy. However, in patients with a narrow and excessively sclerotic intramedullary cavity in the pediatric age group where the skeletal system has not yet fully developed, difficulties have been observed in lengthening methods with nailing.Therefore, in these cases, the use of lengthening techniques over a plate is an alternative treatment option. Nevertheless, in lengthening techniques over a plate, if one side of the osteotomy area cannot be fixed, associated mechanical axis problems have been reported.We applied tibia lengthening with external fixator assistance over a custom-made lengthening plate in a patient with sequelae of poliomyelitis. This new lengthening technique applied over a plate could be the solution to the problems observed in other lengthening techniques over a plate.

Is there an Increase in Valgus Deviation in Tibial Distraction Using the Lengthening Over Nail Technique?

BACKGROUND

During tibial lengthening, the soft tissues of the posterolateral compartment produce distraction-resisting forces causing valgus angulation. Although this occurs with the classic Ilizarov method, whether a valgus deformity develops with the lengthening over nail (LON) technique is questioned, because the intramedullary nail is thought to resist deforming forces and adequately maintain alignment of the distracted bone.

QUESTIONS/PURPOSES

The purposes of this study were to (1) determine the amount of valgus deviation during tibial lengthening with the LON technique; and (2) analyze the factors that may be associated with valgus deviation with the LON technique.

METHODS

Between June 2009 and September 2013, we performed 346 tibial lengthenings using the LON technique, lengthening and then nail technique, or lengthening with an intramedullary lengthening device. Sixty patients (120 tibias) who underwent bilateral lower leg lengthening with the LON technique were enrolled in this retrospective study. To limit the number of variables, we analyzed only the right tibia in all patients (60 tibias). The mean followup was 42 months (range, 26-71 months). The mean age of the patients was 25 years (range, 18-40 years). There were 36 male and 24 female patients. The mean final length gain was 67 ± 9 mm. The mean time for distraction was 100 ± 25 days. The overall valgus deviation was assessed by measuring the change in the medial proximal tibial angle and mechanical femorotibial angle on radiographs obtained before and after surgery and after completion of lengthening. Several demographic, surgical, and distraction-related variables were considered possible factors to prevent valgus deviation: proximal fixation method; presence of a blocking screw; diameter and length of the intramedullary nail; degree of nail insertion; length of the nail in the distal segment after completion of distraction; final length gain; and patient's BMI. During the period studied, the blocking screw was to maintain the mechanical axis in patients who had neutral or valgus alignment preoperatively, or to prevent more valgus change in patients who underwent acute correction of varus deformity intraoperatively. Uni- and multivariate analyses were conducted.

RESULTS

Valgus deviation occurred during the tibial LON. The medial proximal tibial angle increased from 86° (95% CI, 85°-86°) to 90° (95% CI, 89°-91°) (p < 0.001). The mechanical femorotibial angle changed from 2.2° varus (95% CI, 3°-1.4° varus) to 2.6° valgus (95% CI, 1.8°-3.4° valgus) (p < 0.001). Valgus deviation was evident in proximal and distal segments. In the multivariate regression model, use of a blocking screw was the only factor that was associated with decreased valgus deviation, and its effect size, although detectable, was small (-2.62; 95% CI, -4.65 to -0.59; p = 0.013).

CONCLUSIONS

We found that valgus deviation does occur during tibial lengthening using the LON technique, but that blocking screw placement may help to minimize the likelihood that severe valgus deviation will occur. Future prospective studies should be conducted to confirm this preliminary finding.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Lengthening Over an Existing Intramedullary Nail In Cases of Post-traumatic Femoral Shortening. Technical Note. Case Series Study

Background:

Intramedullary (IM) nailing is the method of choice for the treatment of most femoral shaft fractures. However, despite successful solid union, great initial fracture comminution can lead to significant leg length discrepancy affecting normal gait mechanics. Femoral osteotomy and distraction osteogenesis over the pre-existing IM nail could restore this limb inequality.

Methods:

Five patients with an average post-traumatic femoral shortening of 3.83 cm were presented in our department with the nail in situ. Limb lengthening was achieved with the application of a distal hybrid external rail frame over the pre-existing nail. We assumed that the choice of a distal external fixator ring with wires could facilitate the procedure and minimize the possibility of friction–contact problems with the large diameter nail.

Results:

The amount of length discrepancy, calculated preoperatively, was restored in all patients. The mean time in frame was 57.6 days and the external fixator index 16.978 d/cm. The mean time of total healing was 152.6 days and the average bone-healing index 44.9d/cm. No deep infection or hardware loosening was observed. One superficial pin track infection was treated successfully with oral antibiotics.

Conclusion:

This technique utilizes the principles and advantages of lengthening over an IM nail, avoids the necessity of nail removal and minimizes the complication rates and the overall time for complete recovery.

Pathological fractures in children: Diagnosis and treatment options

A fracture is defined as pathological when it arises in a bone tissue that has been modified and reshaped by a local or systemic pathological process. In children, pathological fractures can be secondary to several conditions, ranging from metabolic diseases to tumors, infections or neuromuscular pathologies. History, clinical examination and radiologic assessment are essential to making a diagnosis, to identifying the underlying cause and to planning the right treatment of a pathological fracture. Treatment must be tailored to both the fracture and the underlying cause. The objective of this work is to present the diagnostic approach and the course to follow when a child presents with a pathological fracture. The most common causes of pathological fractures, as well as their characteristics, will be described. Pathological fractures occurring in osteogenesis imperfecta and in abused children as well as stress fractures will not be discussed.

Contralateral bone widening and transfer for limb sparing in a cat

OBJECTIVE

To report on a novel surgical procedure to treat a long segmental tibial defect in a five-year-old 5 kg spayed female Main Coon cat using transverse distraction osteogenesis in the contralateral tibia to create a free autograft.

METHODS

A long free bone segment was created from the cranial half of the normal tibia. A circular external fixator was constructed to give the segment 7 mm of cranial distraction. After 42 days the widened section of tibial bone was removed and transferred to the defect in the contralateral tibia. Locking plates were used to stabilize the graft and to protect the donor tibial sites.

RESULTS

By 27 months, both tibias were healed, all implants had been removed, function was excellent, and the overall limb length was 90% of the normal side.

CLINICAL RELEVANCE

Compared with longitudinal distraction osteogenesis in long bone defects, transverse distraction of a normal bone requires a significantly shorter distraction distance to produce a similar amount of bone. Thus, distraction time is reduced, with less likelihood of significant soft tissue damage. New bone may be more reliably regenerated in a normal limb due to better tissue health, and native bone may be more readily incorporated than allografts in compromised sites. Disadvantages include the increased morbidity, as well as the risk and expense associated with involvement of a normal limb.

Importance of dual delivery systems for bone tissue engineering

Bone formation is a complex process that requires concerted function of multiple growth factors. For this, it is essential to design a delivery system with the ability to load multiple growth factors in order to mimic the natural microenvironment for bone tissue formation. However, the short half-lives of growth factors, their relatively large size, slow tissue penetration, and high toxicity suggest that conventional routes of administration are unlikely to be effective. Therefore, it seems that using multiple bioactive factors in different delivery systems can develop new strategies for improving bone tissue regeneration. Combination of these factors along with biomaterials that permit tunable release profiles would help to achieve truly spatiotemporal regulation during delivery. This review summarizes the various dual-control release systems that are used for bone tissue engineering.

Tibial lengthening over intramedullary nails: A matched case comparison with Ilizarov tibial lengthening

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

Methods

In this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who underwent 19 Ilizarov tibial lengthenings were retrospectively matched to the LON group.

Results

The mean external fixation time for the LON group was 2.6 months and for the matched case group was 7.6 months. The mean lengthening amounts for the LON and the matched case groups were 5.2 cm and 4.9 cm, respectively. The radiographic consolidation time in the LON group was 6.6 months and in the matched case group 7.6 months. Using a clinical and radiographic outcome score that was designed for this study, the outcome was determined to be excellent in 17 and good in two patients for the LON group. The outcome was excellent in 14 and good in five patients in the matched case group. The LON group had increased blood loss and increased cost. The LON group had four deep infections; the matched case group did not have any deep infections.

Conclusions

The outcomes in the LON group were comparable with the outcomes in the matched case group. The LON group had a shorter external fixation time but experienced increased blood loss, increased cost, and four cases of deep infection. The advantage of reducing external fixation treatment time may outweigh these disadvantages in patients who have a healthy soft-tissue envelope.

Cite this article: J. E. Herzenberg. Tibial lengthening over intramedullary nails: A matched case comparison with Ilizarov tibial lengthening. Bone Joint Res 2016;5:1–10. doi: 10.1302/2046-3758.51.2000577

Management of complex femoral nonunion with monorail external fixator: A prospective study

AIM

To evaluate 30 patients who underwent distraction osteogenesis with monorail external fixator for complex femoral nonunion.

METHOD

Complex femoral nonunion includes infective non-union, gap nonunion, and limb-length discrepancy secondary to traumatic bone loss, which needs specialized treatment to ensure the functional integrity of femoral bone. 30 patients, including 28 male and 2 female (aged 22-62 years) patients, underwent surgical debridement followed by bone transport with monorail fixator. The lengthening index, radiographic consolidation index, functional status, bone healing, and various problems, obstacles, and complications encountered during the treatment were assessed.

RESULTS

Patients underwent a mean of 2.2 (range 1-4) surgeries before presentation. The mean bone defect after surgical debridement was 5.83 cm (range 2-16 cm). The mean treatment duration was 204.7 days (range 113-543 days). The mean lengthening index was 13.06 days/cm with range from 12 to 16 days/cm. Mean maturation index was 23.51 days/cm with range from 17 to 45.5 days/cm. In our study, bone result was excellent in 17, good in 9, fair in 3, and poor in 1 patient. In our study functional outcome is excellent in 9 [30%], good in 14 [46.67%], fair in 5, and poor in 2 patients. In our study, we encountered 34 problems, 17 obstacles, and 8 complications.

CONCLUSION

We concluded that monorail external fixator is an effective treatment option for complex nonunion femoral shaft fracture and its functional outcome is comparable with any other treatment options. Lack of complications and its effectiveness makes monorail external fixator the treatment of choice for complex nonunion femoral shaft.

Nail-medullary canal ratio affects mechanical axis deviation during femoral lengthening with an intramedullary distractor

INTRODUCTION

Callus distraction of the femur using an intramedullary distractor has several advantages over the use of external fixators. However, difficulty in controlling the mechanical axis during lengthening may cause deformities and knee osteoarthritis. Purpose of the study is to answer the following questions: (1) is lengthening with an intramedullary device associated with a medial or lateral shift of the mechanical axis? (2) Which factors are associated with varisation/valgisation of the mechanical axis during lengthening?

MATERIALS AND METHODS

We analysed pre-treatment and post-treatment radiographs from 20 patients who underwent unilateral femoral-lengthening procedures using intramedullary distractors. Patients with acute correction of pre-existing deformities or combined ipsilateral femoral and tibial lengthening were excluded. Mechanical axis deviations, osteotomy level, and nail-medullary canal ratio were recorded.

RESULTS

Compared to the preoperative axis, the mechanical axis shifted medially in 7 patients (varisation group) and laterally in 13 patients (valgisation group). The groups did not significantly differ regarding preoperative leg length discrepancy (LLD), mechanical axis alignment, LLD-cause and implants used. The nail-medullary canal ratio significantly differed between groups (p<0.001), being <85% in the varisation group and >85% in the valgisation group. The distance between the lesser trochanter and the osteotomy site was significantly longer in the valgisation group (58.9±16.3mm, middle third of the femur) compared to the varisation group (40.6±11.4mm, proximal third of the femur; p=0.02).

CONCLUSION

The nail-medullary canal ratio should be considered during preoperative planning. To avoid a varisation effect-for example, in cases with pre-existing varus alignment-it would be advisable to perform an osteotomy at the middle third of the femur with implantation of a nail that fully covers the medullary canal at the osteotomy site.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Complications in leg lengthening using an Ilizarov external fixator and intramedullary alignment in children: comparative study during a fourteen-year period

BACKGROUND

The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA).

PATIENTS AND METHODS

The study was performed at the University Children's Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed.

RESULTS

There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation.

CONCLUSION

IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs.

Tibial lengthening with a submuscular plate in adolescents

BACKGROUND

Lengthening over an intramedullary nail has become a common technique for reducing the period of external fixation. However, the technique presents difficulties in patients with an open physis or a small marrow canal. Lengthening using a submuscular plate offers a new substitute in such situations, but few studies have been undertaken to determine its efficacy in teenagers.

PATIENTS AND METHODS

A retrospective review was performed on 20 consecutive tibiae of 16 patients who underwent tibial lengthening with the aid of external fixator and submuscular plate. Charts and radiographs were reviewed for demographics, surgical details, and complications related to the technique.

RESULTS

The average age of the 16 patients was 14.3 years (range 10-17), and the amount of lengthening averaged 4.1 cm (range 3.0-5.0 cm), which represented 12.7 % of preoperative bone length (range 9.1-15.8 %). Mean time in the fixator was 60.3 days, mean external fixation index was 14.8 days/cm (range 13.2-22.5 days/cm), and mean healing index was 49.1 days/cm (range 37-59.3 days/cm). Twenty-seven complications occurred giving an overall complication rate of 1.35. Twenty of the 27 were minor complications, but 7 were major. These major complications were resolved surgically or by a resolution period exceeding 3 months. There were 3 cases of transient angular deformity of distraction callus, 2 cases of transient peroneal nerve palsy, 1 case of clamp loosening, and 1 case of plate failure. Functional results were good or excellent with an average score of 95.6 according to modified Paley's criteria.

CONCLUSIONS

Although complications were not uncommon, tibial lengthening with a submuscular plate proved to be a reliable technique for treating limb length discrepancy in adolescents with reduced external fixation duration.

LEVEL OF EVIDENCE

Level IV, case series.

Experimental study of progressive tibial lengthening in dogs using the Ilizarov technique. Comparison with and without associated intramedullary K-wires

A delay in the union of bone regenerate in surgical lengthening procedures and the healing index (HI) are major factors in the quality of the results in progressive bone lengthening. Early removal of the external fixator (EF) is associated with a low rate of postoperative complications, including pin track infection, and with better muscle and joint function recovery. Addition of intramedullary wires (IMWs) to the EF led to a 9-49% decrease in the HI depending on the clinical series. We hypothesized that IMWs may accelerate the ossification process of bone regenerate and tested it in this experimental study.

METHODS

Progressive tibial lengthening of 28 mm was obtained in 12 dogs operated with the classical Ilizarov technique (group I) and in 12 dogs operated with the same technique and addition of two IMWs 1.5 mm in diameter (group II). The following criteria were assessed: HI, X-ray measurements, and histological aspect of the bone regenerate and postoperative complications.

RESULTS

The mean HI was 32.3% lower in group II than in group I. The radiological bone union criteria were observed on day 15 of the fixation period in group II versus day 30 in group I. Histology showed that maturation occurred earlier and bone cortices were thicker in group II than group I. Intramedullary ossification was present along the IMW in group II, whereas it was absent in group I. No clinical complications were observed in either group.

DISCUSSION

The presence of the IMWs clearly contributes to stimulation of the ossification processes of the bone regenerate and to acceleration of bone union. IMWs allowed an earlier removal of the external fixator for a 32% time reduction compared to cases without IMWs. In addition, new intramedullary bone formation and presence of IMWs are expected to increase the mechanical resistance of the bone regenerate.

CONCLUSION

Improvement of quantitative and qualitative criteria of bone regenerate in progressive bone lengthening with an EF combined with IMWs was demonstrated in this experimental study.

SIGNIFICANCE

Favorable results encourage the authors to continue using IMWs in addition to the EF in patients treated with long-bone progressive lengthening.

LEVEL OF EVIDENCE

II.

Bilateral tibial lengthening over the nail: our experience of 143 cases

INTRODUCTION

Using lengthening over an intramedullary nail as a technique for cosmetic purposes improves the individuals' quality of life and provides more satisfactory results due to less external fixator period.

METHODS

This study reports a case series of 143 individuals who underwent bilateral tibial lengthening over an intramedullary nail for cosmetic purposes together with the review of parameters related to the surgery and complications. Level of satisfaction was measured with the standard visual analog scale at least 1 year after removal of external fixator.

RESULTS

In this study, mean (SD) age of patients was 26.6 (7.26) years. 85 (59.4%) participants were male and 58 (40.6%) were female. Mean end lengthening of all individuals was 6.65 cm. The mean external fixator period was 93.7 days. Complication rate was 0.74 per segment but it decreased to 0.45 when pin-tract infection was excluded. Complications were categorized based on Paley et al.'s classification as 129 problems, 85 obstacles and no sequelae. Interestingly, 44 (30.8%) individuals had no problem and obstacle.

CONCLUSIONS

Lengthening over an intramedullary nail provides bone formation in equal quality to that obtained by the conventional Ilizarov method, along with lower rate of complications. The large number of individuals involved in our study is a remarkable benefit which could be used as an appropriate sample to compare results for outcomes and complications.

Limb Lengthening with a Submuscular Locking Plate

Introduction

Limb-lengthening with a submuscular locking plate provides a good alternative for patients, especially children, in whom lengthening over an intramedullary nail would be difficult.

Step 1 External Fixation for Lengthening with Submuscular Plating

The first operation is divided into two steps, submuscular plating and external fixation with corticotomy; due to the anatomical characteristics, the procedures differ in the tibia and femur.

Step 2 Lengthening

Start distraction at seven to ten days after surgery and continue until the target length is achieved.

Step 3 Locking of the Distal Segment and Removal of the External Fixator

When the target length has been achieved, place screws into the distal segment through plate holes and remove the fixator.

Step 4 Postoperative Care

Start with partial weight-bearing, obtain a radiograph every four to eight weeks, and allow full weight-bearing with crutches when osseous consolidation is observed.

Results

We prospectively performed limb lengthening using an external fixator and a submuscular locking plate in ten patients¹⁶.IndicationsContraindicationsPitfalls & Challenges.

Comparison between lengthening over nail and conventional Ilizarov lengthening: a prospective randomized clinical study

The aim of this study is to compare lengthening over an intramedullary nail to the conventional Ilizarov method with regard to percentage length increase, external fixation index, consolidation index and incidence of complications. This is a prospective randomized controlled study. Thirty-one limbs in 28 patients were included in the study; 15 were lengthened over an intramedullary nail, and 16 limbs were lengthened conventionally. The mean duration of external fixation in the lengthening over nail group was 52.2 days compared to 180.4 days in the conventional group. There was higher incidence of complications in the conventional method group. In comparison with conventional Ilizarov lengthening, lengthening over an intramedullary nail offers a shorter period of external fixation and fewer complications overall, but there is a high incidence of deep intramedullary infection which is serious.

Conversion of external fixation to internal fixation in a non-acute, reconstructive setting: a case series

The aim of the study is to determine the outcomes in patients who underwent conversion from an external fixator to an internal fixation device. This is a retrospective review of 18 patients (24 limbs) who underwent conversion from external to internal fixation. The patients had external fixators applied for traumatic bone defects or congenital deformities. Conversion to internal fixation was performed for reasons of patient dissatisfaction with external fixation, pin track sepsis, persistent non-union or refracture. The complexity of cases was graded using Paley's level of difficulty score. Patients were either converted acutely or delayed. Internal fixation devices were either intramedullary nails or plate and screws. Outcome was regarded as excellent if the patients were fully weight-bearing and pain-free on a mechanically well-aligned limb and without need for further surgery: good if the patient required subsequent surgery to achieve union and poor if irreversible complications occurred. Acute conversions (fixator removal and introduction of internal fixation device at same surgery) were done in 19 limbs and delayed conversion (interval between fixator removal and internal fixation) in 5. In the acute group, 17 limbs (89.4 %) had at least a good outcome, 16 of these limbs had an excellent result. Two limbs (10.6 %) had a poor result and required amputation. Both cases were after acute conversion to intramedullary nails; the original presenting diagnosis was of an infected non-union of the tibia and both had Paley scores above 7. In the delayed conversion group, all limbs (100 %) had at least a good outcome, with 4 limbs (80 %) having an excellent result. The mean external fixator time was 185 days (61-370). Both the cases with poor outcomes had longer external fixation times. This series supports the practice of conversion of external fixation to internal fixation with the majority of patients attaining good results. It identifies that plate devices appear to produce fewer deep sepsis complications, as compared to intramedullary nails, particularly when the original presenting diagnosis is a septic non-union.

Reconstruction with tibial lengthening for limb length discrepancy in Crowe Type IV developmental dysplasia of hip in adulthood

BACKGROUND

Persistence of hip dysplasia into adolescence and adulthood can lead to an abnormal gait, which would do harm to patients' physiological and psychological health. The aim of this study was to summarize our results of tibial lengthening for reconstruction of limb length discrepancy in Crowe Type IV developmental dysplasia of hip in adulthood.

METHODS

Between January 2000 and December 2002, 11 patients' limb length discrepancy in Crowe Type IV developmental dysplasia of hip was treated by tibial lengthening. There were 8 women and 3 men, aged from 18 to 25 years, averaged 21.2 years. The limb length discrepancy was 4.0-7.1 cm.

RESULTS

Eleven patients were followed up for a mean of 110 months. The limping was much improved from a moderate or severe degree to a mild degree in all patients. In the group of callus distraction with external fixation, the average external fixation index was 37.0 days/cm. In the group of callus distraction over an intramedullary nail, the average external fixation index was 16.6 days/cm, and the mean radiographic consolidation index was 34.4 days/cm. The extent of lengthening ranged from 4.0 to 7.0 cm.

CONCLUSIONS

Tibial lengthening may be a reliable treatment for untreated unilateral developmental dysplasia of hip in adolescents without pain but eager for improving limping.

Fracture following lower limb lengthening in children: a series of 58 patients

INTRODUCTION

Fracture is one of the main complications following external fixator removal used in cases of progressive lower limb lengthening; rates as high as 50% are found in the literature. The aim of this study was to determine the factors influencing this complication.

MATERIALS AND METHODS

One hundred and eleven cases of lower limb lengthening were performed in 58 patients (40 femurs and 71 tibias). The mean age at surgery was 10.1years old. Lengthening was performed in all cases with an external fixator alone, associated in 39.6% of cases with intramedullary nailing. The patients were divided into three groups according to disease etiology (congenital, achondroplasia and other). The fractures were classified according to the Simpson classification.

RESULTS

Twenty fractures were recorded (18%). Sixteen fractures were found in patients with congenital disease, four with achondroplasia and none in the group of other etiologies. The fracture was more often in the femur (27.5%) than in the tibia (12.7%).

DISCUSSION

The rate of fracture is influenced by different factors depending on the etiology of disease. In congenital diseases, the fracture rate is higher when there is lengthening of more than 15% of the initial length and a delay between surgery and the beginning of lengthening of less than 7days. In patients with achondroplasia, the influence of a relative percentage of lengthening is less important than in those with congenital disease. However, to avoid fractures, lengthening should not be started in children under the age of nine. Moreover, lengthening should begin at least 7days after the fixator has been placed.

TYPE OF STUDY

Retrospective.

LEVEL OF EVIDENCE

Level IV.

Staged protocol for the treatment of chronic tibial shaft osteomyelitis with Ilizarov's technique followed by the application of intramedullary locked nail

Open tibial shaft fractures are the most common open fractures, and many complications can occur. During the treatment period, infection leading to osteomyelitis was the most common complication. However, no consensus exists regarding the ideal management for such cases in the literature.The purposes of this retrospective study were to review the treatment of patients with chronic tibial shaft osteomyelitis over the past 14 years who were referred to the authors' institution and to provide a staged protocol for spontaneous wound healing. The staged protocol included: (1) radical debridement for infected bone and soft tissue; (2) immediate application of Ilizarov's apparatus for all patients except those needing delayed application; (3) osteotomy in healthy bone; (4) simultaneous distraction-compression osteogenesis and histogenesis; (5) additional docking-site bone grafting; and (6) shifting the external fixator to a locked nail when callus formation was visible at the distraction site. Union was achieved in 15 of 16 patients, with an average external fixation time of 4.5 months (range, 3-6 months). No deformity or leg-length discrepancy greater than 1 cm occurred.In the treatment of chronic osteomyelitis, this staged protocol was safe and successful and allowed for union, realignment, reorientation, and leg-length restoration. Regarding the soft tissues, this technique provides a unique type of reconstructive closure for infected wounds. It is suggested that the staged protocol is reliable in providing successful simultaneous reconstruction for bone and soft tissue defects without flap coverage.

Does the use of an intramedullary nail alter the duration of external fixation and rate of consolidation in tibial lengthening procedures? A systematic review

We performed this systematic review to evaluate tibial lengthening procedures with the use of an intramedullary nail. We investigated the hypothesis that lengthening over a nail can reduce the time spent in an external fixator and increase the rate of consolidation thereby reducing the risk of complications and improving patient satisfaction. We conducted a comprehensive literature search using the MEDLINE, EMBASE and PubMed databases using the key words 'tibia' or 'tibial lengthening' and 'nail'. This search was performed in December 2011 and repeated by both authors. Specific outcome measures were the duration of external fixation, rate of consolidation and complication rates. A total of 6 comparative studies published between 2005 and 2011 consisting of 494 procedures met our inclusion and exclusion criteria and were eligible for critical appraisal. The methodological quality of the studies was variable, and they were not homogenous enough for meta-analysis. Patients who have tibial lengthening over an intramedullary nail spend significantly less time in an external fixator. However, there is no reliable evidence to suggest that the rates of consolidation or complication are any different to those lengthened without an intramedullary nail.

Classification of complications after progressive long bone lengthening: proposal for a new classification

INTRODUCTION

Long bone lengthening surgery using progressive surgical methods has been the source of frequent complications. Some authors have classified these complications either descriptively, according to the date of onset after the operation, or based on their severity. The Caton classification (1985) has had the virtue of contributing the notion of the treatment contract stipulating the objective to reach in treatment. Within the context of the preoperative information delivered to patients and their family, this contract can be improved by adding a notion of maximum treatment duration. The objective of this study was therefore to propose a classification that includes honoring a triple contract associating the planned gain in bone length, the duration of treatment, and the occurrence of sequelae.

MATERIALS AND METHODS

The classification of complications proposed includes four grades: grade I: triple contract honored, including a few treatments without general anesthesia; grade II: triple contract fulfilled, but with unplanned interventions under general anesthesia; grade III: the time stipulated was not honored because the time to obtain bone union was too long or because the program was interrupted; grade IV: sequelae are present. This classification was assessed based on a consecutive series of 34 surgical procedures in 32 patients (two patients underwent two lengthening procedures during this period) at 43 bone segments associating progressive lengthening with external fixation or with nail lengthening. The grade of each complication was determined by each of the authors according to the classification proposed and other classifications reported in the literature (Caton, Paley, Popkov, and Donnan).

RESULTS

Approximately one-third (10) of the 34 lengthening procedures did not present any complications. Two-thirds (24) presented 30 complications. Consensus was obtained between all the authors on the grades proposed for our classification and the Caton classification, but consensus was not reached with the other classifications in which part of the interpretation was subjective (Paley, Popkov, and Donnan).

DISCUSSION

The classification proposed required respecting predetermined objectives during limb lengthening surgery based on a triple contract: gain, duration, and function. It is reliable and reproducible by different operators because the criteria are objective. It can also be applied to diverse surgical techniques, whether with external fixation and/or internal osteosynthesis.

LEVEL OF EVIDENCE

Level IV: retrospective study or historical series.

Current concepts of leg lengthening

Any lower limb discrepancy may be equalised by conservative means (insoles, prosthesis and orthosis). However, their long-term acceptance is low in regard to function, costs, expenditure and appearance. Timely epiphysiodesis is the best option in uniplanar deformities with adequate remaining growth and for patients whose predicted final body height is above the 50th percentile. However, many patients present late or with multi-planar deformities, which warrant more sophisticated operative approaches. The history of surgical bone lengthening comprises 100 exciting years of struggling, development and ongoing learning. The initial strategy of acute or rapid incremental distraction had lasted almost half a century until Ilizarov recognised the benefits of biological periosteum-preserving osteotomies and incremental lengthening at slow rates (1 mm/day) at a 4 × 0.25-mm daily rhythm, well appreciated as callotasis. In parallel, ring and wire constructs made complex three-dimensional axial, translational and rotational bone moulding possible. Taylor Spatial Frames-built on hexapod strut-linked platform technology as known from flight simulators-took limb correction to a more reliable, more precise and aesthetical level, all the more that the whole process became web-based. It represents state-of-the-art methodology and technology for complex, multi-plane deformities. Due to the significant risk of secondary malalignment, indications for lengthening by unilateral fixation have shrunken to moderate amounts of length disparity and uni- to bi-planar deformities in patients with still open physes. Mechanical or motorised, minimally invasively placed nails prevent muscle fixation and, therefore, ease rehabilitation, increase patient comfort and potentially shorten the overall time of sick leave and refrain from sports activities. Hence, they offer a valuable alternative for low-grade complexity situations. It remains to be proved if the significantly higher implant costs are compensated by lower treatment costs. Overall, limb lengthening, particularly in combination with multi-planar deformity correction, can still be an arduous endeavour. In any case, wise judgement of the patient's deformity, medical and biological situation, psychosocial environment, selection of the appropriate method and hardware, as well as meticulous operating technique by an experienced surgeon are the cornerstones of successful outcomes.

Elastic intramedullary nailing as a complement to Ilizarov's method for forearm lengthening: a comparative pediatric prospective study

PURPOSE

Most of the techniques for forearm lengthening involve external fixation to achieve stability and provide progressive distraction. We introduce the use of elastic stable intramedullar nailing (ESIN) in combination with external circular assembly for the procedure. The purpose of this prospective study was to compare Ilizarov's classical technique with this combined technique.

METHODS

Fifty-seven patients, with forearm length discrepancies or deformities either congenital or acquired, were prospectively followed-up. Patients were divided in two groups: 35 had only external fixation, and 22 had external fixation-ESIN combined techniques. Patients were assessed for clinical and radiographic outcome with a mean follow-up of 21 months after external device removal.

RESULTS

Overall lengthening was 45.0mm. Healing index (HI) was 22.2d/cm with the combined technique, and 32.0 d/cm with external fixation. HI was 30% better when ESIN was used, for congenital and for overall cases. Combined technique has a lower complication rate.

CONCLUSION

Although forearm lengthening still remains a time-consuming procedure, ESIN can shorten external fixator wearing time. No additional complication occurred and bony complications seem to be limited by the nails. We recommend this technique, which we now use for most of our patients undergoing limb lengthening.

LEVEL OF EVIDENCE

Level IV.

Femoral lengthening with lengthening over a nail has fewer complications than intramedullary skeletal kinetic distraction

BACKGROUND

Lengthening over a nail and internal lengthening nails have been developed to minimize or eliminate patients' time wearing a frame during femur lengthening. However it is unclear whether either of these two approaches results in faster times to union or fewer complications over the other.

QUESTIONS/PURPOSES

We asked which technique better achieved: (1) the lengthening goals, (2) the distraction rate control, (3) quality of the regenerate bone, (4) fewer complications, and (5) if SF-36 scores and American Academy of Orthopaedic Surgeons Lower Limb Module (AAOS LLM) scores differ in each treatment modality?

METHODS

We retrospectively reviewed the records and radiographs of 11 patients who had 12 Intramedullary Skeletal Kinetic Distractor (ISKD) procedures between 2002 and 2005, and 21 patients with 22 femoral lengthenings performed as lengthening over nail procedures between 2005 and 2009. Details such as leg length discrepancies, operative time, time of removal of the external fixator or ISKD, and any complications encountered were recorded. SF-36 and AAOS LLM scores also were compiled. The minimum followups for the ISKD and the lengthening over nail cohorts were 62 months (average, 76 months; range, 62-93 months) and 13 months (average, 27 months; range, 13-38 months), respectively.

RESULTS

We observed no difference in achieving the lengthening goals between the two procedures. Distraction was not well controlled in the ISKD group; the distraction rates were 1.7 mm per day for the fast group (distraction rate greater than 1 mm/day) and 0.84 mm per day for the slow group (less than 1 mm/day). The lengthening over nail group had an average distraction rate of 0.88 mm per day. One of 20 of the patients who had lengthening over a nail had complications requiring additional unanticipated surgeries whereas six of 12 patients who had femoral lengthening in the ISKD group had such complications.

CONCLUSIONS

Based on our observations, we believe the lengthening over nail technique for femoral lengthening is associated with fewer complications than the ISKD.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Pitfalls of lengthening over an intramedullary nail in tibia: a consecutive case series

BACKGROUND

Lengthening over a nail was introduced to reduce the overall complication rate in the classic Ilizarov method. Previous studies reported that an intramedullary nail could decrease the time of external fixation, prevent anatomic malalignment and collapse; Internal friction, damage to endosteal blood supply and infection rates, however, may be higher. Whether the approach achieves it goals with acceptable complication rates is unclear. The aim of this study was to describe the results and complications of tibial lengthening over a nail.

METHODS

We retrospectively reviewed 40 patients with 80 lengthened tibial segments over an intramedullary nail between 2004 and 2009. The average age of the patients at the time of surgery was 22 years (range 18-38 years). Functional and psychological outcomes were evaluated using the questionnaires.

RESULTS

The average lengthening achieved was 7.73 cm, 23.5% of initial length. The external fixation index was 1.1 months/cm, and bone-healing index was 1.7 month/cm. The most common complications were valgus angulations of tibia in 20 segments (25%) and equinus contracture in 58 segments (72%). Functional and psychological outcomes were satisfactory after surgery.

CONCLUSIONS

Lengthening over a nail did not fully prevent axial deviation of regenerate. Equinus contracture was the most common complication but it could be rectified by early intervention such as intramuscular recession or an additional foot frame. Limb lengthening increased functional and psychological outcomes even though there were many complications after surgery.

Femoral angular correction and lengthening in a large-breed puppy using a dynamic unilateral external fixator

OBJECTIVE

To report treatment of a large-breed puppy with combined distal femoral valgus and length deficit caused by partial distal physeal closure.

STUDY DESIGN

Clinical report.

ANIMALS

Bernese Mountain Dog (4.5-month-old male).

METHODS

The puppy was admitted for evaluation of a progressive severe left pelvic limb lameness (grade 3/4) of 6-week duration. Distal femoral valgus and severe length deficit deformity were treated by acute angular correction using a closing wedge ostectomy and progressive rapid-rate callus distraction using a dynamic, telescoping unilateral External Skeletal Fixator (ESF) designed for people. After acute angular correction and a 3-day latency period, a mean linear distraction rate of 3 mm/day was maintained for 3 weeks. The dynamic ESF (dESF) was removed at 4 weeks, after a 1-week consolidation phase.

RESULTS

The dESF was stable and functional during distraction and bone healing. Distal femoral valgus conformation improved 50° (from 41° to 91°) and femoral length increased 42 mm at dESF removal (from 158 mm to 200 mm; 27%). After cessation of bone growth, no valgus and minimal (6%) length deficit were detected. At 4, 5, 6, 12, and 24 months after surgery, the dog was walking, trotting, and galloping normally.

CONCLUSION

Acute angular correction and progressive rapid-rate callus distraction using a unilateral dESF allowed satisfactory treatment of combined distal femoral valgus and length deficit in a large-breed puppy.

Limb lengthening over plate

BACKGROUND

The limb lengthening over plate eliminates the associated risk of infection with limb lengthening over intramedullary nail. We present our experience of limb lengthening in 15 patients with a plate fixed on the proximal segment, followed by corticotomy and application of external fixator.

MATERIALS AND METHODS

15 patients (7 females, 8 males) were included in this consecutive series. The average age was 18.1 years (range 8-35 years). Fifteen tibiae and one femur were lengthened in 15 patients. Lengthening was achieved at 1 mm/day followed by distal segment fixation with three or four screws on reaching the target length.

RESULTS

The preoperative target length was successfully achieved in all patients at a mean of 4.1 cm (range 1.8-6.5 cm). The mean duration of external fixation was 75.3 days (range 33-116 days) with the mean external fixation index at 19.2 days/cm (range 10.0-38.3 days/cm). One patient suffered deep infection up to the plate, three patients had mild procurvatum deformities, and one patient developed mild tendo achilles contracture.

CONCLUSION

Lengthening over a plate allows early removal of external fixator and eliminates the risk of creating deep intramedullary infection as with lengthening over nail. Lengthening over plate is also applicable to children with open physis.

Comparative study of callus progression in limb lengthening with or without intramedullary nail with reference to the pixel value ratio and the Ru Li's classification

INTRODUCTION

Callus progression is a great concern during limb lengthening. In this study, we investigated the difference in callus progression between tibial lengthenings with and without intramedullary nail.

METHOD

Seventy tibiae in 38 patients with an average age of 24 years were lengthened with Ilizarov external fixator and nail; 56 tibiae in 40 patients with an average age of 28.6 years were lengthened with the same Ilizarov external fixator but without nail. The callus progression was compared with reference to pixel value ratio (PVR) and Ru Li's classification. Statistical analysis was performed to compare the variation trend of PVR and incidence of various callus pathways (particular patterns of callus progression as outlined in Ru Li's classification) and shapes of each aspect of callus between the two groups.

RESULTS

The trend of PVR was not statistically different in posterior, lateral and medial aspects of the callus between the two groups, but averagely lower in the anterior aspect in the group without nail than that with nail. The group without nail presented less incidence of homogeneous pathway, greater incidence of heterogeneous pathway; also greater incidence of fusiform callus, less incidence of cylindrical callus.

CONCLUSION

It was concluded that with nail, the callus underwent a more favorable progression and even longer lengthening could be allowed.

Tibial lengthening over an intramedullary nail in patients with short stature or leg-length discrepancy: a comparative study

PURPOSE

The aim of this study was to review our experiences with tibial lengthening over an intramedullary nail in comparison to the conventional Ilizarov method.

METHODS

We performed a retrospective comparison of tibial lengthening using the conventional Ilizarov method (group A: 23 limbs in 13 patients) versus over a nail (group B: 51 limbs in 26 patients). The percentage increase in tibial length, lengthening index, external fixation index, consolidation index and complications were assessed.

RESULTS

The mean gain in tibial length was 7.4 cm, which represents a mean increase of 26.0%. There was no difference in lengthening index or consolidation index; however, the patients in group A wore the external fixator longer than those in group B (281.5 versus 129.0 days), which represents a larger external fixation index (40.0 versus 17.4 day/cm). Group A had a higher complication rate (1.0 versus 0.47 per tibia) than group B.

CONCLUSIONS

Tibial lengthening over an intramedullary nail confers advantages over the conventional Ilizarov method, including shorter time needed for external fixation and lower complication rates.

Insufficient bone regenerate after intramedullary femoral lengthening: risk factors and classification system

BACKGROUND

Control of distraction rate with an intramedullary skeletal kinetic distractor (ISKD) may be problematic and a high distraction rate may result in insufficient bone regenerate.

QUESTIONS/PURPOSES

Are distraction problems preventable when using the ISKD, and what are the risk factors for and radiologic types of insufficient bone regenerate during ISKD lengthening?

PATIENTS AND METHODS

We analyzed 37 consecutive ISKD femoral lengthening procedures in 35 patients with a mean age 33 ± 11 years and minimum followup of 12 months (average, 27 ± 9 months; range, 12-55 months). The average length gain was 42.8 ± 12.9 mm.

RESULTS

Eight patients had problems during distraction: seven had "runaway nails" and one had a nondistracting nail. Insufficient bone regenerate developed in eight patients. Important risk factors were a distraction rate greater than 1.5 mm/day (9.1 times higher risk), age 30 years or older, smoking, and lengthening greater than 4 cm. Less important risk factors identified were creation of the osteotomy at the site of previous trauma or surgery and acute correction of associated deformities. We proposed a radiologic classification for failure of bone regeneration: partial regenerate failure (Type I) or complete failure resulting in a segmental defect subdivided according to a length of 3 cm or less (Type IIa) or greater than 3 cm (Type IIb).

CONCLUSIONS

Distraction problems with the ISKD were related mostly to internal malfunction of the lengthening mechanism. A distraction rate greater than 1.5 mm/day should be avoided in femoral intramedullary lengthening. Smoking should be a contraindication for femoral lengthening.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Tibial lengthening over humeral and tibial intramedullary nails in patients with sequelae of poliomyelitis: a comparative study

Leg discrepancy is common after poliomyelitis. Tibial lengthening is an effective way to solve this problem. It is believed lengthening over a tibial intramedullary nail can provide a more comfortable lengthening process than by the conventional technique. However, patients with sequelae of poliomyelitis typically have narrow intramedullary canals allowing limited space for inserting a tibial intramedullary nail and Kirschner wires. To overcome this problem, we tried using humeral nails instead of tibial nails in the lengthening procedure. In this study, we used humeral nails in 20 tibial lengthening procedures and compared the results with another group of patients who were treated with tibial lengthening over tibial intramedullary nails. The mean consolidation index, percentage of increase and external fixation index did not show significant differences between the two groups. However, less blood loss and shorter operating time were noted in the humeral nail group. More patients encountered difficulty with the inserted intramedullary nail in the tibial nail group procedure. The complications did not show a statistically significant difference between the two techniques on follow-up. In conclusion, we found the humeral nail lengthening technique was more suitable in leg discrepancy patients with sequelae of poliomyelitis.