Limb lengthening and deformity correction with externally controlled motorized intramedullary nails: evaluation of 50 consecutive lengthenings

Background and purpose — Limb lengthening with an intramedullary motorized nail is a relatively new method. We investigated if lengthening nails are reliable constructs for limb lengthening and deformity correction in the femur and the tibia.

Patients and methods — 50 lengthenings (34 Precice and 16 Fitbone devices) in 47 patients (mean age 23 years [11–61]) with ≥12 months follow-up are included in this study. 30 lengthenings were done due to congenital and 20 because of posttraumatic deformity (21 antegrade femora, 23 retrograde femora, 6 tibiae). Initial deformities included a mean shortening of 42?mm (25–90). In 15 patients, simultaneous axial correction was done using the retrograde nailing technique.

Results — The planned amount of lengthening was achieved in all but 2 patients. 5 patients who underwent simultaneous axial correction showed minor residual deformity; unintentionally induced minor deformities were found in the frontal and sagittal plane. The consolidation index was 1.2 months/cm (0.6–2.5) in the femur and 2.5 months/cm (1.6–4.0) in the tibia. 2 femoral fractures occurred in retrograde femoral lengthenings after consolidation due to substantial trauma. There were 8 complications, all of which were correctable by surgery, with no permanent sequelae.

Interpretation — Controlled acute axial correction of angular deformities and limb lengthening can be achieved by a motorized intramedullary nail. A thorough preoperative planning and intraoperative control of alignment are required to avoid residual and unintentionally induced deformity. In the femur relatively fast consolidation could be observed, whereas healing was slower in the tibia.     

Tibial lengthening over an intramedullary nail

Background Long-term application of an external fixator to treat leg-length discrepancy and short stature often causes complications, such as pin-tract infection or loss of range of motion at the knee or ankle (or both). Prolonged fixator use also interferes with the activities of daily living. To minimize such problems, we have combined intramedullary nailing with external fixation. Using this technique, the external fixator can be removed more quickly after completing the lengthening. Methods We combined intramedullary nailing with lengthening in 13 tibias (8 patients) and then compared these cases with 17 standard tibial lengthenings (16 patients) using an external fixator alone. In both groups we excluded patients who had a history of previous bone infection, open fracture, immature bone, soft tissue compromise, antineoplastic chemotherapy, or bone deformity of a severity that required gradual deformity correction. We also excluded cases with lengthening of less than 3 cm. Results The mean external fixation index differed significantly between the two groups, but the consolidation index did not. Mean operating time for lengthening combined with intramedullary nail placement was approximately 60 min longer than for standard lengthening without nail placement; intraoperative blood loss was not greater in the nailing group. Complications related to the external fixator were far fewer in the combined intramedullary nailing and lengthening group compared with the control group, and callus formation was satisfactory for both groups. Conclusions A combination of intramedullary nailing and external fixation produces callus formation as good as that obtained by the standard Ilizarov method of lengthening. Furthermore, this combined procedure decreases the external fixation time and is associated with fewer complications.     

Results of femoral lengthening over an intramedullary nail and external fixator

INTRODUCTION: Current techniques of operative limb lengthening usually are based on distraction osteogenesis. One of the techniques is limb lengthening over an intramedullary nail. AIM OF PAPER: The goal of this study is to evaluate the results of femoral lengthening over an intramedullary nail. MATERIAL: Between 1999 and 200619 femoral "over nail" lengthenings were performed. There were 7 males and 12 females. Mean patients' age at surgery was 15.8 years, and mean initial femoral shortening was 5.1 cm. Operative technique consisted of one-stage implantation of intramedullary nail and external fixator. Ilizarov apparatus was used in 9 patients, monolateral fixator in 10 cases--ORTHOFIX in 9 patients, Wagner fixator--in 1 patient. Intramedullary nail was locked proximally with screws or Schanz pins from external fixator. After distraction phase, external fixator was removed and distal locking screws were applied. METHODS: Evaluation criteria: obtained lengthening, time of external fixator, treatment time, healing index, external fixation index, range of motion in hip and knee joints and complications according to Paley. RESULTS: The mean lengthening was 4.6 cm, and mean distraction time was 66.6 days. Mean time of external fixation was 115.5 days, and external fixation index was 26.2 days for centimeter. Healing index was 36.9 days for centimeter. In cases with monolateral fixator, healing index did not differ with the whole group. During treatment 18 complications occurred, for a rate of 0.9 complication per segment. CONCLUSIONS: Lengthening over an intramedullary nail reduces the time of external fixator. Over nail femoral lengthening can prevent axis deviation following regenerate bending. Complication rate is similar to lengthenings with the classic Ilizarov technique. There are no differences in the treatment time in relation to the type of external fixator.     

Lengthening of the ulna by callotasis in children with multiple hereditary exostoses: comparison of methods with and without internal fixation

PurposeThe goal of this retrospective study was to compare the gradual lengthening of the ulna in children with multiple hereditary exostoses with and without an elastic intramedullary nail.MethodsBetween 1998 to 2018, the ulna was lengthened in 28 forearms in 21 patients (aged 7.1 to 16.6 years) using a monolateral external fixator when relative ulnar shortening exceeded 15 mm. In total, 16 forearms were lengthened with the external fixator (group I) and 12 forearms with the addition of an intramedullary elastic nail (group II). Subjective assessment of function, range of movement (ROM) of the wrist and elbow and complications were compared. Ulnar shortening, radial head dislocation, radial articular angle (RAA) and percentage of carpal slip and radial bowing were followed radiographically. The difference between the groups has been evaluated statistically.ResultsThe function of the extremity improved partially in 81% of patients in group I and in 83% of patients in group II. ROM was not improved except for radial deviation. Radial head position did not change. The values in group II in comparison with group I are higher for gain of length and lower for bone lengthening index and for bone healing index. Carpal slip decreased insignificantly. The RAA and radial bowing decreased, the comparison of values between groups and age under and over ten years were not statistically significant. Complications were more common in group I. No permanent complications were noted.ConclusionThe addition of an intramedullary nail during the gradual ulnar lengthening improves the gain, bone healing index and rate of complications.Level of EvidenceIII.     

Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis

Background In neuromuscular diseases, limb lengthening and foot deformity correction are associated with a high risk of complications associated with distraction callus and joint contracture. We have found no published articles of tibial lengthening and concomitant foot deformity correction using the Ilizarov method or traditional methods. To compare result of gradual distraction with triple arthrodesis for foot deformity combined with tibial lengthening, we investigated healing index and complications of two methods.

Patients and methods We reviewed 14 patients with permanent deformity after poliomyelitis who underwent tibial lengthening and concomitant foot deformity correction using the Ilizarov external fixator. Tibial lengthening over an intramedullary nail was performed in 3 patients and lengthening without a nail was performed in 11 patients.

Results The mean external fixation time was 6 (3.6- 10) months without nail and 1.6 (1.5-1.7) months with nail, whereas the mean healing index was 1.8 (0.8-3.1) months/cm without nail and 2 (1.8-2.3) months/cm with nail. Concomitant foot treatments included triple arthrodesis in 7 patients, pantalar arthrodesis in 2 patients with fiail ankle, and gradual foot frame distraction without bony foot procedures in 5 patients. Delayed consolidation and recurrent equinus contracture of the ankle requiring additional lengthening of the Achilles tendon were the most common bone and joint complications during tibial lengthening.

Interpretation The gradual foot frame distraction method was associated with major complications, such as recurrent foot deformity, joint luxation, and arthritis. We therefore recommend triple arthrodesis as a concomitant procedure during tibial lengthening     

Complications and outcome of tibial lengthening using the Ilizarov method with or without a supplementary intramedullary nail: a case-matched comparative study

We compared the complications and outcome of tibial lengthening using the Ilizarov method with and without the use of a supplementary intramedullary nail. In a retrospective case-matched series assembled from 176 patients with tibial lengthening, we matched 52 patients (26 pairs, group A with nail and group B without) according to the following criteria in order of importance: 1) difference in amount of lengthening (± 2 cm); 2) percentage difference in lengthening (± 5%); 3) difference in patient's age (± seven years); 4) aetiology of the shortening, and 5) level of difficulty in obtaining the correction. The outcome was evaluated using the external fixator index, the healing index and an outcome score according to the criteria of Paley. It was found that some complications were specific to group A or B respectively, but others were common to both groups. The outcome was generally better in lengthenings with a nail, although there was a higher incidence of rectifiable equinus deformity in these patients.     

Objective Guidelines for Removing an External Fixator after Tibial Lengthening Using Pixel Value Ratio: A Pilot Study

During limb lengthening over an intramedullary nail, decisions regarding external fixator removal and weightbearing depend on the amount of callus seen at the lengthening area on radiographs. However, this method is subjective and objective evaluation of the amount of callus likely would minimize nail or interlocking screw breakage and refracture after fixator removal. We asked how many cortices with full corticalization of the newly formed bone at the lengthening area are needed to allow fixator removal and full weightbearing and how to radiographically determine the stage of corticalization. We retrospectively reviewed 17 patients (34 lengthenings) who underwent bilateral tibial lengthenings over an intramedullary nail. The average gain in length was 7.2 ± 3.4 cm. We determined the pixel value ratio (ratio of pixel value of regenerate versus the mean pixel value of adjacent bone) of the lengthened area on radiographs. There were no nail or screw breakage and refracture. Partial weightbearing with crutches was permitted when the pixel value ratio was 1 in two cortices and full weightbearing without crutches was permitted when the pixel value ratio was 1 in three cortices. The pixel value ratio on radiographs can be an objective parameter for callus measurement and may provide guidelines for the timing of external fixator removal. We cannot determine from our limited data the minimum pixel value in how many cortices would suggest safe removal, but we can say our criteria were not associated with subsequent refracture.     

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.     

Femoral lengthening over an intramedullary nail using the external fixator

Background The time for femoral lengthening is shortened if external fixation is combined with intramedullary nailing. However, several complications have been reported with this procedure.

Patients and methods We retrospectively reviewed the outcome of femoral lengthening performed over an intramedullary nail using external fixation in 22 patients. These patients were followed for a mean of 3.2 (2-5.2) years. The mean age was 22 (13-35) years at the time of the index procedure. The mean lengthening was 5 (2.7-8.1) cm and the external fixator was removed after median 20 (8-30) weeks. The mean external fixation index was 24 (11-35) days/cm and the mean consolidation index was 43 (26-55) days/cm of lengthening.

Results 3 patients who had a past history of infection or open trauma developed osteomyelitis which required removal of the nail. There were 4 knee joint complications when the lengthening was over 20%, including posterior knee subluxation and patella subluxation. In 1 patient, the lengthened segment collapsed with breakage of locking screws.

Interpretation Although lengthening over a nail can reduce the duration of external fixation, caution is required to prevent major complications.     

肱骨干骨折髓内外固定的生物力学研究

目的 通过对单一加压钢板螺钉加髓内针、交锁髓内钉和微创技术简单有限内固定加单臂外支架3种不同固定方法治疗肱骨干复杂骨折的生物力学性能进行对比研究,为临床应用提供可靠的生物力学依据.方法 取自愿捐赠的18个新鲜湿润肱骨标本,制备肱骨干复杂骨折模型,根据不同固定方式随机分为3组,每组6个.钢板组:采用单一加压钢板螺钉加髓内针固定;髓内钉组:采用交锁髓内钉固定;外支架组:采用微创技术简单有限内固定加单臂外支架固定.分别进行轴向压缩实验和水平扭转实验.结果 轴向压缩实验:各组载荷-位移曲线呈线性到非线性变化.钢板组及髓内钉组最大载荷值分别为(6162.09±521.06)N和(6738.32±525.89)N,两组比较差异无统计学意义(P>0.05);外支架组最大载荷值为(2753.57±185.59)N,与其余两组比较,差异均有统计学意义(P<0.05).钢板组及外支架组刚度值分别为(171.69±6.49)N/mm和(132.59±2.93)N/mm,两组比较差异无统计学意义(P>0.05);髓内钉组的刚度值为(333.04±36.85)N/mm,与其余两组比较差异有统计学意义(P<0.05).水平扭转实验:各组扭矩-扭角曲线呈线性到非线性变化.髓内钉组和外支架组的最大扭矩分别为(17.12±5.73)Nm和(20.26±6.42)Nm,两组比较差异无统计学意义(P>0.05);钢板组的最大扭矩为(38.24±7.08)Nm,与其余两组比较差异有统计学意义(P<0.05).钢板组及外支架组刚度值分别为(16.36±2.07)Ncm/°和(18.79±2.62)Ncm/°,差异无统计学意义(P>0.05);髓内钉组的刚度值为(11.45±0.22)Ncm/°,与其余两组比较差异有统计学意义(P<0.05).结论 钢板组压缩和扭转强度均较强,旋转刚度较强而压缩刚度较弱;髓内钉组压缩强度和压缩刚度较强,而扭转强度和扭转刚度较弱;外支架组仅在扭转刚度上与钢板组相当,而在其他3项指标上均较弱.     

Limb lengthening and deformity correction of congenital and acquired deformities in children using the Taylor Spatial Frame

Background and purpose — Hexapod ring fixators such as the Taylor Spatial Frame (TSF) have shown good outcomes. However, there have only been a few studies comparing the use of TSF with various etiologies of the deformity. We compared the use of TSF in congenital and acquired deformities in children.

Patients and methods — We reviewed 213 lower extremity reconstructive procedures with the TSF in 192 patients who were operated between October 2000 and October 2015. 128 procedures (67 proximal tibiae, 51 distal femora, and 10 distal tibiae) in 117 children (median age 14 (4–18) years; 59 girls) fulfilled the inclusion criteria. 89 procedures were done in children with congenital deformities (group C) and 39 were done in children with acquired deformities (group A). Outcome parameters were lengthening and alignment achieved, lengthening index, complications, and analysis of residual deformity in a subgroup of patients.

Results — Mean lengthening achieved was 3.9 (1.0–7.0) cm in group C and 3.7 (1.0–8.0) cm in group A (p = 0.5). Deformity parameters were corrected to satisfaction in all but 3 patients, who needed further surgery for complete deformity correction. However, minor residual deformity was common in one-third of the patients. The mean lengthening index was 2.2 (0.8–10) months/cm in group C and 2.0 (0.8–6) months/cm in group A (p = 0.7). Isolated analysis of all tibial and femoral lengthenings showed similar lengthening indices between groups. Complication rates and the need for secondary surgery were much greater in the group with congenital deformities.

Interpretation — The TSF is an excellent tool for the correction of complex deformities in children. There were similar lengthening indices in the 2 groups. However, congenital deformities showed a high rate of complications, and should therefore be addressed with care.     

Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis

BACKGROUND: In neuromuscular diseases, limb lengthening and foot deformity correction are associated with a high risk of complications associated with distraction callus and joint contracture. We have found no published articles of tibial lengthening and concomitant foot deformity correction using the Ilizarov method or traditional methods. To compare result of gradual distraction with triple arthrodesis for foot deformity combined with tibial lengthening, we investigated healing index and complications of two methods. PATIENTS AND METHODS: We reviewed 14 patients with permanent deformity after poliomyelitis who underwent tibial lengthening and concomitant foot deformity correction using the Ilizarov external fixator. Tibial lengthening over an intramedullary nail was performed in 3 patients and lengthening without a nail was performed in 11 patients. RESULTS: The mean external fixation time was 6 (3.6-10) months without nail and 1.6 (1.5-1.7) months with nail, whereas the mean healing index was 1.8 (0.8-3.1) months/cm without nail and 2 (1.8-2.3) months/cm with nail. Concomitant foot treatments included triple arthrodesis in 7 patients, pantalar arthrodesis in 2 patients with flail ankle, and gradual foot frame distraction without bony foot procedures in 5 patients. Delayed consolidation and recurrent equinus contracture of the ankle requiring additional lengthening of the Achilles tendon were the most common bone and joint complications during tibial lengthening. INTERPRETATION: The gradual foot frame distraction method was associated with major complications, such as recurrent foot deformity, joint luxation, and arthritis. We therefore recommend triple arthrodesis as a concomitant procedure during tibial lengthening     

Postoperative Cox inhibitors and late prosthetic loosening—suspicion increases!

Background and purpose In clinical practice, achieved lengthening of a callotasis zone should be maintained after the external fixator has been removed. The common understanding has been that the regenerated bone may subside. To investigate this, we used high-resolution radiostereometric analysis (RSA) with accurate measurement of the lengthening zone.

Patients and methods We assessed the longitudinal subsidence of a callotasis zone after removal of the external fixator in distraction osteogenesis in 16 patients who underwent 17 segmental lengthening operations on the tibia (n = 9) or femur (n = 8). Median lengthening was 32 (6–80) mm. RSA was performed at the end of the consolidation period before the external fixation device was removed, and this was later repeated at a median time of 11 (4–32) weeks after frame removal.

Results A minimal median longitudinal change of 0.01 (–0.28 to 0.60) mm across the lengthening zone occurred in uncomplicated cases.

Interpretation Our results indicate that no subsidence of clinical interest occurs after external frame removal.     

Lengthening of the femur over an existing intramedullary nail

Leg length discrepancies can occur despite successful union of femur fractures after intramedullary nailing (IMN). Often, the leg length discrepancy can result in significant disability to the patient, altered gait biomechanics, pelvic obliquity, and pain. Therefore, a successful clinical result for such deformities after IMN involves addressing the leg length inequality. Femoral reconstruction with an osteotomy around an existing intramedullary nail was introduced to address axial deformity correction and limb lengthening without changing or removing a previously inserted IMN. This technique uses the principles of lengthening over an IMN. The presence of the nail has minimized the time needed for the external fixator because the nail supports the regenerate bone or osteotomy during the consolidation phase. With this technique, surgery is minimized by avoiding the need for exchange nailing.     

弹性髓内钉固定与外固定支架治疗儿童股骨干骨折疗效比较

目的：比较弹性髓内针与外固定支架治疗儿童股骨干骨折的疗效。方法：2002年9月至2008年8月治疗儿童股骨干骨折共67例,使用弹性髓内针治疗儿童股骨干骨折36例,男23例,女13例,年龄5～11岁,平均（7.1±1.6）岁;外固定支架治疗31例,男19例,女12例,年龄3～12岁,平均（6.5±2.3）岁。所有病例均为闭合复位,对两种不同内固定术后骨折愈合时间、术后并发症进行比较分析。结果：全部病例均获随访,时间9～24个月,平均（12±3）个月。弹性随内针组治疗小儿股骨骨折在骨折临床愈合时间和骨性愈合时间均短于外固定支架组（P〈0.05）。外固定支架组,继发钉道感染5例,骨折延迟愈合3例,再骨折2例,螺钉断裂1例;弹性髓内针组钉尾激惹3例。结论：弹性髓内针治疗儿童股骨干骨折有很大优势,而对高能量骨折及多发伤的病例外固定支架则不失为一种良好的选择,股骨近端和远端骨折尽量避免使用弹性髓内针固定。     

Tibial lengthening using a reamed type intramedullary nail and an Ilizarov external fixator

The aim of this study was to evaluate the efficacy of tibial lengthening using a reamed type intramedullary nail and an Ilizarov external fixator for the treatment of leg length discrepancy or short stature. This retrospective study was performed on 18 tibiae (13 patients) in which attempts were made to reduce complications. We used an Ilizarov external fixator and a nail (10 mm diameter in 17 tibiae and 11 mm in one tibia) in combination. Average limb lengthening was 4.19 cm (range, 2.5-5.5). The mean duration of external fixation was 12.58 days per centimetre gain in length, and the mean consolidation index was 40.53 (range, 35.45-51.85). All distracted segments healed spontaneously without refracture or malalignment. Gradual limb lengthening using a reamed type intramedullary nail and circular external fixation in combination was found to be reliable and effective and reduced external fixation time with fewer complications.     

Lengthening of the tibia over an intramedullary nail, using the llizarov external fixator: Major complications and slow consolidation in 9 lengthenings

We lengthened 9 tibial segments over a nail to reduce the time in the external fixator in 5 patients with constitutional shortness. The median lengthening was 7 (5.5-7.3) cm and the external llizarov frame was removed after median 99 (63-125) days. In spite of a short time in the external fixator, consolidation was slow, with a median lengthening index of 4.4 (2.4-6.1) months/cm. The procedure resulted in 3 fatigue fractures of the intramedullary nail or interlocking screws that needed revision and bone grafting. In 1 patient, a deep intramedullary infection occurred. After the experience of these major complications we have returned to the traditonal callotasis lengthening method described by llizarov.     

Lengthening of the tibia over an intramedullary nail, using the Ilizarov external fixator. Major complications and slow consolidation in 9 lengthenings.

We lengthened 9 tibial segments over a nail to reduce the time in the external fixator in 5 patients with constitutional shortness. The median lengthening was 7 (5.5-7.3) cm and the external Ilizarov frame was removed after median 99 (63-125) days. In spite of a short time in the external fixator, consolidation was slow, with a median lengthening index of 4.4 (2.4-6.1) months/cm. The procedure resulted in 3 fatigue fractures of the intramedullary nail or interlocking screws that needed revision and bone grafting. In 1 patient, a deep intramedullary infection occurred. After the experience of these major complications we have returned to the traditional callotasis lengthening method described by Ilizarov.     

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.