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Abstract
BACKGROUND Limb lengthening using intramedullary externally controlled motorized devices is becoming increasingly popular. There is limited literature regarding their use in the pediatric and adolescent population. This study reviews outcomes on 50 consecutive cases of intramedullary lower limb lengthening surgery in this population. METHODS A retrospective review of all pediatric and adolescent patients treated in our institution by intramedullary lengthening for lower limb length discrepancy using the PRECICE and STRYDE intramedullary lengthening nails between 2013 and 2019. All patients were operated by a single surgeon. Data were prospectively recorded. We report on nail accuracy and reliability, consolidation index, time to full weight-bearing from completion of lengthening, joint range of movement, ASAMI bone and functional scores, presence of problems, obstacles and complications, and patient reported outcome measures (PROMS). RESULTS Fifty cases (43 femoral and 7 tibial nails) were performed in 42 patients (20 males, 48% and 22 females, 52%). Six patients had bilateral lengthening and 2 patients had sequential lengthening. There were 28 antegrade femoral, 13 retrograde femoral and 5 tibia PRECICE nails, 2 tibial and 2 femoral PRECICE STRYDE nails. Mean age at surgery was 15 years old (12 to 17). Mean preoperative length discrepancy was 49 mm (20 to 90). Mean achieved lengthening was 46.5 mm (20 to 80). Mean percentage lengthening was 12.6% (5% to 25%). Nail accuracy was 96% and reliability 90%. Average distraction rate was 0.92 mm/d for femur and 0.64 mm/d for tibias. Consolidation index was 28 d/cm (18 to 43) and 39 d/cm (20 to 47), respectively. Time from completion of lengthening to independent full weight-bearing as observed in clinic was 45 days (21 to 70) and 34.2 days (23 to 50), respectively. ASAMI bone and functional scores were favorable and PROMS demonstrated high patient satisfaction levels. No significant complications were observed. CONCLUSIONS We have demonstrated excellent clinical results and high patient satisfaction with intramedullary lengthening in a pediatric/adolescent population. We highly recommend thorough preoperative preparation, patient education, and a multidisciplinary approach. LEVEL OF EVIDENCE Level IV.
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Dvorzhinskiy A, Zhang DT, Fragomen AT, Rozbruch SR. Cost Comparison of Tibial Distraction Osteogenesis Using External Lengthening and Then Nailing vs Internal Magnetic Lengthening Nails. Strategies Trauma Limb Reconstr 2021; 16:14-19. [PMID: 34326897 PMCID: PMC8311750 DOI: 10.5005/jp-journals-10080-1513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective Tibial lengthening can be performed by distraction osteogenesis via lengthening and then nailing (LATN) or by using a magnetic lengthening nail (MLN). MLN avoids the complications of external fixation while providing accurate and easily controlled lengthening. Concerns exist still regarding the high upfront cost of the magnetic nail, which serves to limit its use in resource-poor areas and decrease adoption among cost-conscious surgeons. The purpose of this study was to compare the hospital, surgeon, and total cost between LATN and MLN when used for tibial lengthening. Materials and methods A retrospective review was performed comparing consecutive tibial lengthening using either LATN (n = 17) or MLN (n = 15). The number of surgical procedures and time to union were compared. Surgeon and hospital payments were used to perform cost analysis after adjusting for inflation using the consumer price index (CPI). Results Patients treated with MLN underwent fewer surgeries (3.6 vs 2.8; p < 0.001) but had a longer time to union as compared with patients treated with LATN (19.79 vs 27.84 weeks; p = 0.006). Total costs were similar ($50,345 vs $46,162; p = 0.249) although surgeon fees were lower for MLN as compared with LATN ($6,426 vs $4,428; p < 0.001). Conclusion LATN and MLN had similar overall costs in patients undergoing tibial lengthening. MLN was associated with fewer procedures but a longer time to union as compared with LATN. Clinical significance Despite an increased upfront cost in MLN, there was no difference in total cost between LATN and MLN when used for tibial lengthening. Thus, in cases where either method is feasible, cost may not be a deciding factor when selecting the appropriate treatment. How to cite this article Dvorzhinskiy A, Zhang DT, Fragomen AT, et al. Cost Comparison of Tibial Distraction Osteogenesis Using External Lengthening and Then Nailing vs Internal Magnetic Lengthening Nails. Strategies Trauma Limb Reconstr 2021;16(1):14-19.
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Affiliation(s)
- Aleksey Dvorzhinskiy
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States
| | - David T Zhang
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States
| | - Austin T Fragomen
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States
| | - S Robert Rozbruch
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States
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Vogt B, Roedl R, Gosheger G, Toporowski G, Laufer A, Theil C, Broeking JN, Frommer A. Tibial lengthening using a retrograde magnetically driven intramedullary lengthening device in 10 patients with preexisting ankle and hindfoot fusion. Acta Orthop 2020; 91:761-769. [PMID: 32835564 PMCID: PMC8023964 DOI: 10.1080/17453674.2020.1807222] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and purpose - Motorized intramedullary lengthening nails (ILNs) have been developed as an alternative to external fixators for long bone lengthening. The antegrade approach represents the standard method for tibial ILN insertion. In patients with preexisting ankle and hindfoot fusion a retrograde approach provides an alternative technique that has not been evaluated so far. We report the outcome of this method in 10 patients. Patients and methods - This retrospective study included 10 patients (mean age 18 years [13-25]) with preexisting ankle and hindfoot fusion who underwent tibial lengthening with a retrograde ILN (PRECICE). The mean leg length discrepancy (LLD) was 58 mm (36-80). The underlying conditions were congenital (n = 9) and post tumor resection (n = 1). The main outcome measures were: ILN reliability, distraction achieved, distraction index (DIX), time to bone healing, consolidation index (CIX), complications, and functional results. Results - All patients achieved the goal of lengthening (mean 48 mm [26-80]). Average DIX was 0.6 mm/day (0.5-0.7) and mean CIX was 44 days/cm (26-60). Delayed consolidation occurred in 2 patients and healed after ILN dynamization or nail exchange with grafting. Toe contractures in 2 other patients were resolved with physiotherapy or tenotomy. Until last follow-up (mean 18 months [12-30]) no true complications were encountered, knee motion remained unaffected, and full osseous consolidation occurred in all patients. Interpretation - In patients with LLD and preexisting ankle and hindfoot fusion distal tibial lengthening using a retrograde ILN is a reliable alternative to the standard approach with equivalent bone healing potential and low complication rates leaving the knee unaffected.
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Affiliation(s)
- Bjoern Vogt
- Children’s Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster,Correspondence:
| | - Robert Roedl
- Children’s Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster
| | - Georg Gosheger
- General Orthopedics and Tumor Orthopedics, University Hospital of Muenster, Germany
| | - Gregor Toporowski
- Children’s Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster
| | - Andrea Laufer
- Children’s Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster
| | - Christoph Theil
- General Orthopedics and Tumor Orthopedics, University Hospital of Muenster, Germany
| | - Jan Niklas Broeking
- Children’s Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster
| | - Adrien Frommer
- Children’s Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster
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How should we lengthen post-traumatic limb defects? a systematic review and comparison of motorized lengthening systems, combined internal and external fixation and external fixation alone. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:1015-1022. [PMID: 33222112 DOI: 10.1007/s00590-020-02831-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/10/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Various external fixation systems for lower extremity long bone deformities have been used to various degrees of success, while newer mechanical lengthening nail (MLN) systems offer the potential for improved patient outcomes. Proponents of MLNs argue that they reduce the number of operations, infectious complications, and improve quality of life; however, the evidence to support these claims is scant. This systematic review aims to evaluate the optimal lengthening system for treating post-traumatic long bone deformity. METHODS The systematic review was conducted in accordance with PRISMA guidelines. PUBMED, EMBASE, CINAHL, and the Cochrane Library were searched for comparative studies of lengthening techniques among adult patients with axial deformities. Studies were screened and data extracted in duplicate. Treatment groups were pooled into external fixation (EF) alone, combined internal and external fixation (CIF), and mechanical lengthening nail (MLN). Outcomes were mean lengthening achieved, lengthening index, and reported complications. RESULTS Thirteen studies with 725 patients (mean age: 29.6 years, 74% male) were included. Nearly all of the studies were either prospective or retrospective cohort studies (n = 12), with one randomized controlled trial of moderate study quality. The mean limb lengthening achieved, lengthening index, and rate of reoperation were similar among the MLN, EF, and CIF groups. CONCLUSION The purported decreased the duration of lengthening and the risk of reoperation associated with MLNs was not demonstrated in this review. Patients with post-traumatic leg length deformities remain a challenging patient population to treat, with intervention being associated with high rates of infectious complications and need for revision operations.
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Clinical results and complication rates of lower limb lengthening in paediatric patients using the PRECICE 2 intramedullary magnetic nail: a multicentre study. J Pediatr Orthop B 2020; 29:611-617. [PMID: 31904740 DOI: 10.1097/bpb.0000000000000651] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Implantable intramedullary nail lengthening devices (e.g., PRECICE 2 system) have been proposed as alternative method to external fixation for lower limb lengthening surgery. The aim of this study was to analyse our outcomes and complications using the PRECICE 2 (P2) nail system and review them in light of the existing literature. A retrospective multicentre study was conducted on patients <18 years, who were treated for limb lengthening using the P2 system. The inclusion criteria were a limb length discrepancy ≥ 30 mm and a follow-up ≥6 months after the end of treatment. A total of 26 (15 males) patients were included, average age was 14.7 ± 2.3 years; 26 nails (21 femur, 5 tibia) were implanted. The average goal lengthening was 49.4 ± 12.4 mm, while average achieved lengthening was 44.4 ± 11.6 mm. Average distraction and consolidation indexes were 11.9 ± 2.1 days/cm and 25.1 ± 8.1 days/cm, respectively. Nail accuracy and reliability were 91.1% and 88.5%, respectively. A total of five problems (joint contractures), one obstacle (femur fracture) and three complications (hip joint subluxation, deep infection and nail running back) were encountered. The P2 nail system is a valid alternative to external fixator for limb lengthening in young patients with no significant angular or rotation deformities. Our study confirms a favourable complication rate and available evidence from literature suggests a lower complication rate than external fixator systems. Nevertheless, surgeons should keep a watchful eye on risk of joint subluxation and mechanical complications with intramedullary lengthening.
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Abstract
Intramedullary limb lengthening (LL) is now achievable through motorized intramedullary devices. While this technology mitigates some complications of external-fixation-based lengthening, many complications common to all lengthening procedures persist. New challenges and complications exclusive to this newer technology are also presented. The LL surgeon should be aware of and ready to respond to complications involving device malfunctions, poor local bony and soft-tissue biology, patient compliance, neurovascular compromise, joint instability, regenerate problems, and others. While technology will continue to evolve, study of and adherence to foundational principles of LL will minimize risks and optimize patient outcomes.
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The Economics of New Technology. Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lee RC, Aulisio M, Liu RW. Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria. Strategies Trauma Limb Reconstr 2020; 15:163-168. [PMID: 34025797 PMCID: PMC8121106 DOI: 10.5005/jp-journals-10080-1502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM To promote a discussion on the ethics and justifications of stature lengthening in patients without skeletal deformity. BACKGROUND Stature lengthening for height gain in patients without skeletal deformity has stirred controversy within the orthopedic community. However, current literature does not delineate the ethical issues surrounding this procedure. Improvements in the techniques, technology, and safety profile of stature lengthening warrant an ethical discussion to challenge, justify, and guide the use of this surgical procedure. REVIEW RESULTS Examination of ethical issues leads to the distinction between the dual roles of stature lengthening as a treatment vs an enhancement. The primary focus on stature lengthening as treatment allows for exploration of "height dysphoria"-a psychological burden caused by a dissatisfaction with one's height-as the primary pathology that may justify surgical intervention. CONCLUSION In our opinion, additional work is required to establish "height dysphoria" as a true pathology in order to ethically justify stature lengthening as a legitimate form of treatment. Further discussion is needed to address the ethics of stature lengthening as an enhancement. CLINICAL SIGNIFICANCE This paper addresses salient ethical issues of stature lengthening in patients without skeletal deformity by exploring historical, contemporary, and comparative contexts. HOW TO CITE THIS ARTICLE Lee RC, Aulisio M, Liu RW. Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria. Strategies Trauma Limb Reconstr 2020;15(3):163-168.
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Affiliation(s)
- Richard C Lee
- Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Mark Aulisio
- Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
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Theyse LFH. CORR Insights®: Percutaneous CO2 Treatment Accelerates Bone Generation During Distraction Osteogenesis in Rabbits. Clin Orthop Relat Res 2020; 478:1936-1938. [PMID: 32732578 PMCID: PMC7371037 DOI: 10.1097/corr.0000000000001368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/27/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Lars F H Theyse
- L. F. H. Theyse, College of Veterinary Medicine, University of Leipzig, Department for Small Animals, Soft Tissue and Orthopaedic Surgery Service, Leipzig, Germany
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Abstract
BACKGROUND Lengthening of the humerus has traditionally been accomplished by the use of external fixation. Intramedullary motorized lengthening nails are now frequently used for lower limb lengthening, and this technology is slowly being adopted for use in the humerus. METHODS A retrospective, single-surgeon experience of pediatric humeral lengthenings was performed. The time period surveyed included use of external fixation (EF) for lengthening, and the use of a motorized nail (MN) for lengthening. The primary outcome measures were lengthening magnitude achieved, duration of lengthening, frequency and type of complications encountered, or further procedures required, during each lengthening. RESULTS From 1999 to 2018, 13 humeral lengthenings were performed in 9 patients. Six lengthenings were performed using the MN technique and 7 using the EF technique. The average absolute lengthening achieved was 8.5±1.3 cm in the EF group and 6.6±2.3 cm in the MN group. The duration of lengthening averaged 114 days in the MN group and 103 days in the EF group. The average duration of EF time was 215 days. Two patients underwent an initial EF lengthening of a humerus and then underwent a second lengthening using the MN technique. Two of 6 (33%) MN lengthenings and 3 of 7 (43%) EF lengthenings experienced complications during treatment. Two patients in the MN group underwent planned reversal and redeployment of their motorized nails to attain the planned lengthening magnitude. CONCLUSIONS Humeral lengthening using motorized intramedullary nails is a safe technique that mitigates some of the complications of EF including pin site infection. It is well tolerated by patients. For lengthenings of a large magnitude, reversal and reuse of MN can be considered.
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Eltayeby HH, Alrabai HM, Jauregui JJ, Shabtai LY, Herzenberg JE. Post-retrieval functionality testing of PRECICE lengthening nails: The "Sleeper" nail concept. J Clin Orthop Trauma 2020; 14:151-155. [PMID: 33717907 PMCID: PMC7920018 DOI: 10.1016/j.jcot.2020.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/14/2020] [Accepted: 06/04/2020] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION PRECICE intramedullary magnetic lengthening nails, introduced in 2011, have changed the landscape of long bone limb lengthening. The implants have a stroke ranging from 5 to 8 cm, but it may be desirable to perform part of the lengthening at one treatment, allow bone healing, leave the implant in place, dormant, and then return one or more years later to re-lengthen with the same implant. We call this the "sleeper" nail concept. This strategy may be gentler for the joints and soft tissues. Would the nail mechanism still be functional one or more years later? METHODS We tested 102 intact, consecutively explanted nails. Using a "fast magnet," the male part was lengthened to 5 mm short of its maximum stroke capacity and retracted back to 35 mm (all nails start with the male part exposed 30 mm). The nails passed the test if the male part succeeded in lengthening to 5 mm short of the maximum stroke capacity and back to 35 mm (or only retract in case fully deployed at testing). During our testing, the nails were prevented from reaching their full capacity of lengthening/retraction to avoid jamming the gears. Failure was defined as the inability or partial ability to complete the process. RESULTS Eighty-six nails (84.3%) performed successfully according to our testing standard. When comparing successful and failed nails in terms of nail type, generation, diameter, length and in vivo interval, there was no statistical significance. Comparing both groups in terms of status at testing (fully deployed or not) showed statistical significance with 9 of the 16 failed nails fully deployed at testing (p < 0.001). CONCLUSION Dormant PRECICE nails can be reactivated for further lengthening. The results imply that full deployment may damage the mechanism, making future re-use by retracting and then re-lengthening unsuccessful. The candidate nails for this purpose should not have any signs of clear damage (bending or breakage) and should not have been fully deployed. However, surgeons and patients should be aware of the need for possible nail exchange if the "sleeper" nail fails to wake up. LEVEL OF EVIDENCE Level IV case series analysis of retrieved surgical implants.
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Affiliation(s)
- Hady H. Eltayeby
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD, USA,Department of Orthopedics, Alexandria University, Alexandria, Egypt
| | - Hamza M. Alrabai
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD, USA,Department of Orthopedics, King Saud University, Riyadh, Saudi Arabia
| | - Julio J. Jauregui
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - John E. Herzenberg
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD, USA,Corresponding author. Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA.
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Abstract
Limb lengthening by distraction osteogenesis is an accepted orthopaedic surgical technique. The Precice intramedullary lengthening system is the most recent innovation in limb lengthening. Early results have been favourable in femoral lengthening but there is little reported on the outcome in tibial lengthening. The aim of this study is to present our early results of Precice tibial lengthening, and the stepwise evolution of our surgical technique. Materials and methods A case series of 17 consecutive tibial lengthenings were prospectively analysed. Healing index, length achieved, range of motion, and complications were recorded. The initial cases followed the recommended surgical technique. Progressive regenerate deformity during lengthening required changes to the surgical method. Results No cases were lost to follow-up. All the nails lengthened at the desired rate. There were no complications of infection or poor regenerate formation. Progressive valgus and procurvatum was prevented in later cases by the positioning of Poller blocking screws at the time of nail insertion. Conclusion The tibial Precice nail is successful in obtaining length and good regenerate formation. The recommended technique was insufficient to control the deforming forces from the lower limb muscle compartments during lengthening. We therefore recommend the addition of multiple blocking screws in an amended technique. How to cite this article Wright SE, Goodier WD, Calder P. Regenerate Deformity with the Precice Tibial Nail. Strategies Trauma Limb Reconstr 2020;15(2):98-105.
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Affiliation(s)
- Sally Elizabeth Wright
- Limb Reconstruction Unit, Queen Elizabeth University Hospital Birmingham, Mindelsohn Way, Birmingham, UK
| | - William David Goodier
- Limb Reconstruction Unit, Royal National Orthopaedic Hospital, Brockley Hill, Middlesex, UK
| | - Peter Calder
- Limb Reconstruction Unit, Royal National Orthopaedic Hospital, Brockley Hill, Middlesex, UK
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PRECICE intramedullary nail in the treatment of adult leg length discrepancy. Injury 2020; 51:1091-1096. [PMID: 32164952 DOI: 10.1016/j.injury.2020.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/15/2020] [Accepted: 03/01/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Limb length discrepancy in adults is not an uncommon occurrence following trauma and limited literature exists on limb lengthening in skeletally mature populations using modern techniques. This study aimed to evaluate outcomes of limb lengthening surgery using the PRECICE magnetic limb lengthening intramedullary nail in an adult population. METHOD From 2013 to 2018, 21 adult patients were operated by a single surgeon, using the PRECICE nail, for lower limb length discrepancies. Low energy femoral osteotomies were performed via a limited approach. Tibial osteotomies were performed using a percutaneous technique and Gigli saw. A distraction rate of 0.75 mm/day was used as a standard protocol with change in rate of 0.25 mm/day implemented as required. Patients were followed up until radiological evidence of consolidation. RESULTS Mean patient age was 36.4 years (range 21-65), with 19 patients being male. Seventeen femoral and four tibial lengthenings were performed. Mean follow up was 15.1 months (range 6-30). Eleven patients underwent deformity correction at time of nail insertion (10 femoral, 1 tibial). All patients achieved correct lengthening (mean gain 36.5 mm, range 18-80 mm). All patients consolidated their regenerate bone (mean 268 days, range 99-825). Mean femoral consolidation index was 6.5, mean tibial consolidation index was 16.1 (p = 0.002). Six patients had delayed consolidation of regenerate bone. Increasing age (p = 0.04), number of prior operations (p = 0.03), and smoking (p = 0.01) were associated with delayed consolidation. Four of 21 (19%) patients suffered a complication, with one implant failure. CONCLUSIONS The PRECICE intramedullary nail is a reliable limb lengthening device in skeletally mature patients, providing predictable lengthening and bone regeneration.
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Metikala S, Kurian BT, Madan SS, Fernandes JA. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020; 15:91-97. [PMID: 33505525 PMCID: PMC7801897 DOI: 10.5005/jp-journals-10080-1459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective Ilizarov hip reconstruction (IHR) is a traditional method of salvaging chronic adolescent problem hips but faces practical problems from external fixators leading to reduced compliance. We present the same reconstruction utilising only internal devices with a modification in technique and aim to review early results. Materials and methods We retrospectively evaluated eight patients between 2014 and 2017 with chronic painful hips treated by a two-stage reconstruction; stage 1 included femoral head resection and pelvic support osteotomy using double plating, while stage 2 comprised distal femoral osteotomy avoiding varus followed by insertion of retrograde magnetic nail for postoperative lengthening. Patients continued physiotherapy postoperatively while protecting from early weight-bearing. Results At mean follow-up of 19 months (range 6–36), all osteotomies healed with bone healing index of 47 days/cm (range 30–72). Pain improved from 8.3 (range 7–9) to 2 (range 0–6), while limb length discrepancy got corrected from 4.3 cm (range 3–5) to 1.4 cm (range 0–2.5) at final follow-up. Trendelenburg sign was eliminated in three and delayed in five. No examples of infection or permanent knee stiffness were noted. One patient had plates breakage due to mechanical fall and one had 35 mm of lateral mechanical axis deviation requiring corrective osteotomy. Conclusion Pelvic support hip reconstruction with exclusive internal devices is a technique in evolution with encouraging early results. It avoids common complications of external fixators and facilitates quick rehabilitation of joints. Refraining from distal varus can effectively eliminate Trendelenburg gait, albeit with some degree of lateral mechanical axis deviation. Unlike external fixation where there is a possibility of gradual correction, this staged procedure of internal fixation is technically demanding with a learning curve. Clinical significance Pelvic support hip reconstruction performed by internal implants is a viable alternative to IHR with potential benefits. How to cite this article Metikala S, Kurian BT, Madan SS, et al. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020;15(2):91–97.
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Affiliation(s)
- Sreenivasulu Metikala
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital, Sheffield, UK
| | - Binu T Kurian
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital, Sheffield, UK
| | - Sanjeev S Madan
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital, Sheffield, UK; Department of Trauma and Orthopaedics, Sheffield Children's Hospital NHS Trust, Sheffield, UK
| | - James A Fernandes
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital, Sheffield, UK
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Sheridan GA, Falk DP, Fragomen AT, Rozbruch SR. Motorized Internal Limb-Lengthening (MILL) Techniques Are Superior to Alternative Limb-Lengthening Techniques. JB JS Open Access 2020. [DOI: 10.2106/jbjs.oa.20.00115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Metikala S, Kurian BT, Madan SS, Fernandes JA. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020; 15:34-40. [PMID: 33363639 PMCID: PMC7744672 DOI: 10.5005/jp-journals-10080-1450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim and objective Ilizarov hip reconstruction (IHR) is a traditional method of salvaging chronic adolescent problem hips but faces practical issues from external fixators leading to reduced compliance. We present the same reconstruction procedure using only internal devices with a modification in the technique and review early results. Materials and methods We retrospectively evaluated eight patients between 2014 and 2017 with chronic painful hips treated by two-stage reconstruction; stage I included femoral head resection and pelvic support osteotomy using double plating, whereas stage II comprised distal femoral osteotomy avoiding varus followed by the insertion of a retrograde magnetic nail for postoperative lengthening. Patients continued physiotherapy postoperatively while protecting from early weight-bearing. Results At a mean follow-up of 19 months (range, 6–36), all osteotomies healed with a bone healing index of 47 days/cm (range, 30–72). Pain improved from 8.3 (range, 7–9) to 2 (range, 0–6) while the limb length discrepancy got corrected from 4.3 cm (range, 3–5) to 1.4 cm (range, 0–2.5) at the final follow-up. Trendelenburg sign was eliminated in three patients and delayed in five patients. No examples of infection or permanent knee stiffness were noted. One patient had plate breakage due to mechanical fall, and another patient had 35 mm of lateral mechanical axis deviation (MAD) requiring corrective osteotomy. Conclusion Pelvic support hip reconstruction with exclusive internal devices is a technique in evolution with encouraging early results. It avoids common complications of external fixators and facilitates quick rehabilitation of joints. Refraining from distal varus can effectively eliminate Trendelenburg gait, although with some degree of lateral MAD. Unlike external fixation where there is a possibility of gradual correction, this staged procedure of internal fixation is technically demanding with a learning curve. Clinical significance Pelvic support hip reconstruction performed by internal implants is a viable alternative to Ilizarov hip reconstruction with potential benefits. How to cite this article Metikala S, Kurian BT, Madan SS, et al. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020;15(1):34–40.
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Thaller PH, Frankenberg F, Degen N, Soo C, Wolf F, Euler E, Fürmetz J. Complications and Effectiveness of Intramedullary Limb Lengthening: A Matched Pair Analysis of Two Different Lengthening Nails. Strategies Trauma Limb Reconstr 2020; 15:7-12. [PMID: 33363635 PMCID: PMC7744673 DOI: 10.5005/jp-journals-10080-1448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Intramedullary limb lengthening has become an accepted concept in reconstructive surgery, but as yet comparative clinical studies are missing. We compared the complications and effectiveness of two types of intramedullary limb lengthening devices (ISKD®; Fitbone®). Materials and methods In a retrospective series of 278 consecutive patients with internal limb lengthening, we found 17 matching pairs in terms of predefined matching parameters (group I with ISKD® and group II with Fitbone®). The surgeries were all performed with the same technique and managed with equivalent pre- and postoperative treatment protocols. The performance of the implants was evaluated using the distraction index and the weight-bearing index. Complications were rated according to Paley's classification for external lengthening. Results The distraction index in group I (ISKD®) was 0.99 mm/day (range 0.55-1.67) and in the group II (Fitbone®) 0.55 mm/day (range 0.14-0.92) (p value = 0.001). The mean weight-bearing index differed between group I and group II from 32.0 day/cm (range 16.4-64.0) to 51.6 day/cm (25.8-95.0) (p value = 0.001). There were 17 recorded incidents in group I and 19 in group II during lengthening. Conclusion Specific technical handicaps of the two systems, such as the so-called runaway of the ISKD® and backtracking of the Fitbone® nails seem to result in different distraction index and weight-bearing index. Further comparative studies might induce technical progress in intramedullary limb lengthening. How to cite this article Thaller PH, Frankenberg F, Degen N, et al. Complications and Effectiveness of Intramedullary Limb Lengthening: A Matched Pair Analysis of Two Different Lengthening Nails. Strategies Trauma Limb Reconstr 2020;15(1):7-12.
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Affiliation(s)
- Peter H Thaller
- 3DSurgery, Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, LMU, Germany
| | - Felix Frankenberg
- Department Trauma and Reconstructive Surgery, Klinikum München Süd, Germany
| | - Nikolaus Degen
- 3DSurgery, Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, LMU, Germany
| | - Chris Soo
- School of Medicine, Griffith University, Gold Coast, Australia
| | - Florian Wolf
- 3DSurgery, Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, LMU, Germany
| | - Ekkehard Euler
- 3DSurgery, Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, LMU, Germany
| | - Julian Fürmetz
- 3DSurgery, Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, LMU, Germany
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The Effect of External Fixator Configurations on the Dynamic Compression Load: An Experimental and Numerical Study. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app10010003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
(1) Objective: External fixation systems are commonly used by surgeons to ensure stabilization and consolidation of bone fractures, especially in patients who are at high risk for systematic complications. Both rigid and elastic external fixations are important in the fracture healing process. This study aims to evaluate the behavior of the Orthofix Limb Reconstruction System (LRS)® in the dynamic compression mode. (2) Methods: Experimental and numerical setups were developed using a simplified model of a human tibia which consisted of a nylon bar with a diameter of 30 mm. The bone callus was included in both setups by means of a load cell-based system, which consisted of two carbon epoxy laminated composite plates with a final stiffness of 220 N/mm. The system was evaluated experimentally and numerically, considering different numbers of pins and comparing distances between the external fixator frame and the bone, achieving a good correlation between experimental and numerical results. (3) Results: The results identified and quantified the percental load transferred to the fracture and its sensibility to the distance between the external fixator and bone. Additionally, LRS locking stiffness was evaluated which resulted from the clamp-rail clearances. The results show that the blocking effects of the free clamp movement are directly related to the fixator configuration and are responsible for changes in the amount of load that crosses the bone callus. (4) Conclusions: From the biomechanical point of view, the results suggest that the average bending span of Schanz pins and the weights of the patients should be included into clinical studies of external fixators comparisons purpose.
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Krettek C. [MagicTube: new possibilities for completely internal bone segmental transport and optional lengthening : New additional module for motorized lengthening nails for treatment of large bone defects]. Unfallchirurg 2019; 121:884-892. [PMID: 30430224 DOI: 10.1007/s00113-018-0549-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Segmental bone transport is an effective method of treatment for segmental defects but the previous need for external fixation constructs during the transport phase is a great disadvantage, especially in the femur. In order to avoid external fixation, a new cylindrical combitube segmental transport (CKTST, MagicTube) module for combination with a commercially available motorized lengthening nail was developed by the author. This MagicTube module enables completely internal segmental bone transport and also enables optional lengthening if needed. The concept and surgical technique of MagicTube are described, illustrated, discussed and exemplified by clinical cases involving the tibia and femur.
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Affiliation(s)
- Christian Krettek
- Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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Calder PR, McKay JE, Timms AJ, Roskrow T, Fugazzotto S, Edel P, Goodier WD. Femoral lengthening using the Precice intramedullary limb-lengthening system. Bone Joint J 2019; 101-B:1168-1176. [DOI: 10.1302/0301-620x.101b9.bjj-2018-1271.r1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aims The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients. Patients and Methods A retrospective review of prospectively collected data was undertaken of a consecutive series of 107 femoral lengthening operations in 92 patients. In total, 73 antegrade nails and 34 retrograde nails were inserted. Outcome was assessed by the regenerate healing index (HI), hip and knee range of movement (ROM), and the presence of any complications. Results The mean lengthening was 4.65 cm (1.5 to 8) in the antegrade group and 4.64 cm (1.6 to 8) in the retrograde group. Of the 107 lengthenings, 100 had sufficient datapoints to calculate the mean HI. This was 31.6 days/cm (15 to 108). There was a trend toward a lower (better) HI with an antegrade nail and better outcomes in adolescent patients, but these were not statistically significant. Hip and knee ROM was maintained and/or improved following commencement of femoral lengthening in 44 patients (60%) of antegrade nails and 13 patients (38%) of retrograde nails. In female patients, loss of movement occurred both earlier and following less total length achieved. Minor implant complications included locking bolt migration and in one patient deformity of the nail, but no implant failed to lengthen and there were no deep infections. Three patients had delayed union, five patients required surgical intervention for joint contracture. Conclusion This study confirms excellent results in femoral lengthening with antegrade and retrograde Precice nails. There is a trend for better healing and less restriction in hip and knee movement following antegrade nails. There are clinical scenarios, that mandate the use of a retrograde nail. However, when these are not present, we recommend the use of antegrade nailing. Cite this article: Bone Joint J 2019;101-B:1168–1176
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Affiliation(s)
| | | | - Anna J. Timms
- The Royal National Orthopaedic Hospital, Stanmore, UK
| | - Tracy Roskrow
- The Royal National Orthopaedic Hospital, Stanmore, UK
| | | | - Penina Edel
- The Royal National Orthopaedic Hospital, Stanmore, UK
| | - W. D. Goodier
- The Royal National Orthopaedic Hospital, Stanmore, UK
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One-stage Surgical Treatment of Simultaneous Osteotomy and Asymmetric Lengthening on Short Femur with Severe Deformity of Genu Valgus. Sci Rep 2019; 9:8602. [PMID: 31197215 PMCID: PMC6565623 DOI: 10.1038/s41598-019-45157-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 05/30/2019] [Indexed: 11/29/2022] Open
Abstract
This study aimed to discuss the effects of one stage surgical treatment by simultaneous osteotomy and asymmetric lengthening by Ilizarov external fixator on short femur with severe deformity of genu valgus. A total of 12 cases with unilateral deformities treated by simultaneous osteotomy and Ilizarov asymmetric lengthening on short femur with severe deformity of genu valgus were retrospectively analyzed from January 2006 to April 2015. The affected limbs were 2.5–11 cm (5.2 cm on average) short, the femorotibial angle was 135°–158° (146.3° on average), and the ankle interval was 15–43 cm (24.7 cm on average). The Paley method was used to determine the osteotomy plane (distal femur) of genu valgus. According to this standard, the bone union results were as follows: 11 had excellent and 1 had good, where 7 patients had excellent and 5 had good functional outcomes. One stage surgical treatment by simultaneous osteotomy and asymmetric lengthening on short femur with severe deformity of genu valgus was considered to be an effective and reliable method with better osteotomy union, less trauma and fewer complications.
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Cost Comparison of Femoral Distraction Osteogenesis With External Lengthening Over a Nail Versus Internal Magnetic Lengthening Nail. J Am Acad Orthop Surg 2019; 27:e430-e436. [PMID: 30278015 DOI: 10.5435/jaaos-d-17-00741] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Femoral lengthening is performed by distraction osteogenesis via lengthening over a nail (LON) or by using a magnetic lengthening nail (MLN). MLN avoids the complications of external fixation while providing accurate and easily controlled lengthening. However, the increased cost of implants has led many to question whether MLN is cost-effective compared with LON. METHODS A retrospective review was performed comparing consecutive femoral lengthenings using either LON (n = 19) or MLN (n = 39). The number of surgical procedures, time to union, and amount of lengthening were compared. Cost analysis was performed using both hospital and surgeon payments. Costs were adjusted for inflation using the Consumer Price Index. RESULTS No difference was observed in the length of femoral distraction. Patients treated with MLN underwent fewer surgeries (3.1 versus 2.1; P < 0.001) and had a shorter time to union (136.7 versus 100.2 days; P = 0.001). Total costs were similar ($50,255 versus $44,449; P = 0.482), although surgeon fees were lower for MLN ($4,324 versus $2,769; P < 0.001). DISCUSSION Although implants are more expensive for MLN than LON, this appears to be offset by fewer procedures. Overall, the two procedures had similar total costs, but MLN was associated with a decreased number of procedures and shorter time to union. LEVEL OF EVIDENCE III.
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Zhang X, Shui W, Ni W, Hu Z, Huang W, Luo G, Qiao B, Guo S. Minimally invasive treatment of old femoral fractures in adults. Injury 2019; 50:956-961. [PMID: 30878260 DOI: 10.1016/j.injury.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/02/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Extensive incision associated with large-scale callus exfoliation and internal fixation is the common therapeutic approach employed by the majority of orthopaedists in the treatment of old femoral fractures. Inspired by the surgical techniques of intramedullary fixation and reduction by traction, the present study attempted to treat old femoral fractures with minimally invasive methods utilising the principles of biological osteosynthesis (BO). METHODS A retrospective analysis involving 16 patients with old femoral fractures treated with combined traction, small incision, limited callus treatment, reduction by leverage and intramedullary fixation was conducted. The operative effect was evaluated by the operation time, intraoperative blood loss, bone grafting, healing time of fractures during follow-up, VAS score, and Harris hip score. RESULTS Intraoperative observation revealed an average operation time of 1.53 ± 0.34 h and average blood loss of 268.13 ± 97.29 ml without bone grafting in all patients. All enrolled patients had outcomes resulting in effective fixation restoration of limb alignment. Of the 16 enrolled patients, 13 patients completed follow-up with an average follow-up time of 7.42 ± 3.29 months. The average healing time for proximal femoral fractures was 3 months. The average healing time of femoral shaft fractures was 4 ± 1.09 months; two of these cases took 4 months to heal, whereas 1 case demonstrated a delayed healing time of 6 months. The VAS score was 1.15 ± 1.70, 1 patient experienced sciatica, and the Harris hip score was 92.92 ± 5.42. There were no complications of malunion, nonunion or infection among any of the patients who completed follow-up. CONCLUSIONS Minimally invasive treatment is feasible for most patients with old femoral fractures of the trochanter and femoral shaft. This finding is consistent with BO principles, thereby providing a possible new method for the treatment of old femoral fractures.
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Affiliation(s)
- Xiang Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, China.
| | - Wei Shui
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, China.
| | - Weidong Ni
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, China
| | - Zhenming Hu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, China
| | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, China
| | - Gang Luo
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, China
| | - Bo Qiao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, China
| | - Shuquan Guo
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, China.
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Gaudreau J, Mekhail M, Hamdy R, Villemure I. Remote-controlled internal lengthening plate for distraction osteogenesis in pediatric patients. Expert Rev Med Devices 2019; 16:333-339. [PMID: 30931640 DOI: 10.1080/17434440.2019.1599283] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Limb lengthening by distraction osteogenesis is a technique widely used to treat limb length discrepancy resulting from trauma, congenital limb defects and long bone non-union. For decades, patients have resorted to the Ilizarov apparatus, prone to pin tract infections and scarring. Although implantable lengthening nails have reduced the incidence of complications, they are not applicable in pediatric patients with open growth plates. The aim of this project is to design a remote-controlled internal lengthening device suitable for implantation in children. METHODS The proposed device has the form of an internal remote-controlled telescopic lengthening plate, screwed to the lateral side of the bone with locking screws. This is appropriate for use with pediatric patients. It has been tested on an experimental bench which has the form of a vertically sliding platform, on which were stacked weights simulating soft-tissue resistance forces. RESULTS This internal lengthening plate generated distraction forces of up to 735 N on wooden and synthetic bones (SawbonesTM). Furthermore, it maintained a constant distraction speed over the course of the procedure for a given weight. CONCLUSIONS This device represents a major advancement in the field of pediatric limb-lengthening, addressing a demographic gap left open by current implantable devices.
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Affiliation(s)
- Jérémie Gaudreau
- a Department of Mechanical Engineering , École Polytechnique of Montreal , Montréal , Québec , Canada
| | - Mina Mekhail
- b Department of Surgery , Shriners Hospital for Children , Montréal , Québec , Canada
| | - Reggie Hamdy
- b Department of Surgery , Shriners Hospital for Children , Montréal , Québec , Canada
| | - Isabelle Villemure
- a Department of Mechanical Engineering , École Polytechnique of Montreal , Montréal , Québec , Canada.,c Research Center , Sainte-Justine University Hospital Center , Montréal , Québec , Canada
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Horn J, Hvid I, Huhnstock S, Breen AB, Steen H. Limb lengthening and deformity correction with externally controlled motorized intramedullary nails: evaluation of 50 consecutive lengthenings. Acta Orthop 2019; 90:81-87. [PMID: 30371122 PMCID: PMC6366464 DOI: 10.1080/17453674.2018.1534321] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Joachim Horn
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital;; ,Correspondence:
| | - Ivan Hvid
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital;;
| | - Stefan Huhnstock
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital;;
| | - Anne B Breen
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital;;
| | - Harald Steen
- Biomechanics Lab, Division of Orthopaedic Surgery, Oslo University Hospital, Norway
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Wright J, Bates P, Heidari N, Vris A. All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss. Strategies Trauma Limb Reconstr 2019; 14:94-101. [PMID: 32742421 PMCID: PMC7376584 DOI: 10.5005/jp-journals-10080-1431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
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.
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Affiliation(s)
- Jonathan Wright
- Department of Paediatric Orthopaedics and Limb Reconstruction, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Peter Bates
- Department of Trauma and Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Nima Heidari
- Department of Trauma and Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexandros Vris
- Department of Trauma and Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Lopes M, Nunes B, Couto A, Freitas J, Martins R, Coutinho J, Costa G. Electromagnetic Rod in Lower Limb Lengthening: A Technical Note for Shaft Osteotomy. Strategies Trauma Limb Reconstr 2019; 14:139-141. [PMID: 32742429 PMCID: PMC7368354 DOI: 10.5005/jp-journals-10080-1444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Long bone lengthening procedures are paramount in the treatment of limb length discrepancies. We witnessed a revolution in the treatment paradigm of this pathology with the development of expandable intramedullary rods. Endomedular nailing might be technically demanding and some steps are critical for success. The aim of authors is to describe a technical note of the PRECICE system that may ease femoral nailing and fixation: the nail can be advanced through the femur and proximal and distal fixation performed previous to complete femoral osteotomy. Materials and methods The authors present a case series of XX patients in which the limb lengthening has been performed with partial osteotomy with Gigli saw, nail advancement, proximal and distal fixation, and osteotomy completion at the end of the procedure. Results After 18 consecutive limb (femoral) lengthening operations with this technical variation in PRECICE, nail patients presented no significant lower limb length discrepancy. There were no records of rotational deformities, nonunion, or infection. Material failure was not reported. Conclusion This technical note is another positive variable that can help to ease the procedure, minimise possible complications, and confirm magnetic expandable nails as the gold standard technique in limb lengthening procedures and it might be applied to other nailing systems for limb lengthening procedures. How to cite this article Lopes M, Nunes B, Couto A, et al. Electromagnetic Rod in Lower Limb Lengthening: A Technical Note for Shaft Osteotomy. Strategies Trauma Limb Reconstr 2019;14(3):139–141.
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Affiliation(s)
- Miguel Lopes
- Department of Orthopaedic and Traumatology, Centro Hospitalar de São João, Porto, Portugal
| | - Bernardo Nunes
- Department of Orthopaedic and Traumatology, Centro Hospitalar de São João, Porto, Portugal
| | - André Couto
- Department of Orthopaedic and Traumatology, Centro Hospitalar de São João, Porto, Portugal
| | - Joana Freitas
- Department of Orthopaedic and Traumatology, Centro Hospitalar de São João, Porto, Portugal
| | - Rui Martins
- Department of Orthopaedic and Traumatology, Centro Hospitalar de São João, Porto, Portugal
| | - Jorge Coutinho
- Department of Orthopaedic and Traumatology, Centro Hospitalar de São João, Porto, Portugal
| | - Gilberto Costa
- Department of Orthopaedic and Traumatology, Centro Hospitalar de São João, Porto, Portugal
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Two consecutive limb lengthenings with the same PRECICE nail: a technical note. Strategies Trauma Limb Reconstr 2018; 13:199-204. [PMID: 30232655 PMCID: PMC6249150 DOI: 10.1007/s11751-018-0317-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 09/11/2018] [Indexed: 01/14/2023] Open
Abstract
Purpose The most significant advance in our time about limb lengthening is the magnetic lengthening nail, as the first reports appeared to show good results with accurate lengthening rates and good regenerate bone formation. The described complication rate is generally low. They avoid external fixation elements, and are activated transcutaneously, so the patient’s pain and discomfort are reduced and the rehabilitation is faster and more effective. The aim of authors is to describe a special technical issue of the PRECICE system: the nail can be extended inside the patient limb (after the osteotomy), but it also can be retracted inside the limb after achieving the bone union. Methods The authors present a case in which the limb lengthening has been performed in consecutive lengthening periods using the same nail. The nail was extended and retracted by altering the settings on the external remote control as well as accurately setting the rate of distraction. Results After two consecutive femoral lengthening with the same PRECICE nail, the patient no longer has a significant lower limb length discrepancy and patient satisfaction was high. During this clinical case, we were not confronted with any type of complications. Conclusion This technique utilizes the principles and advantages of lengthening over an magnetic lengthening nail, avoids the necessity of nail removal and minimizes the complication rates and the overall time for complete recovery. Level of evidence Level IV.
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Panagiotopoulou VC, Davda K, Hothi HS, Henckel J, Cerquiglini A, Goodier WD, Skinner J, Hart A, Calder PR. A retrieval analysis of the Precice intramedullary limb lengthening system. Bone Joint Res 2018; 7:476-484. [PMID: 30123497 PMCID: PMC6076355 DOI: 10.1302/2046-3758.77.bjr-2017-0359.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES The Precice nail is the latest intramedullary lengthening nail with excellent early outcomes. Implant complications have led to modification of the nail design. The aim of this study was to perform a retrieval study of Precice nails following lower-limb lengthening and to assess macroscopical and microscopical changes to the implants and evaluate differences following design modification, with the aim of identifying potential surgical, implant, and patient risk factors. METHODS A total of 15 nails were retrieved from 13 patients following lower-limb lengthening. Macroscopical and microscopical surface damage to the nails were identified. Further analysis included radiology and micro-CT prior to sectioning. The internal mechanism was then analyzed with scanning electron microscopy and energy dispersive x-ray spectroscopy to identify corrosion. RESULTS Seven male and three female patients underwent 12 femoral lengthenings. Three female patients underwent tibial lengthening. All patients obtained the desired length with no implant failure. Surface degradation was noted on the telescopic part of every nail design, less on the latest implants. Microscopical analysis confirmed fretting and pitting corrosion. Following sectioning, black debris was noted in all implants. The early designs were found to have fractured actuator pins and the pin and bearings showed evidence of corrosive debris. The latest designs showed evidence of biological deposits suggestive of fluid ingress within the nail but no corrosion. CONCLUSION This study confirms less internal corrosion following modification, but evidence of titanium debris remains. We recommend no change to current clinical practice. However, potential reuse of the Precice nail, for secondary limb lengthening in the same patient, should be undertaken with caution.Cite this article: V. C. Panagiotopoulou, K. Davda, H. S. Hothi, J. Henckel, A. Cerquiglini, W. D. Goodier, J. Skinner, A. Hart, P. R. Calder. A retrieval analysis of the Precice intramedullary limb lengthening system. Bone Joint Res 2018;7:476-484. DOI: 10.1302/2046-3758.77.BJR-2017-0359.R1.
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Affiliation(s)
- V. C. Panagiotopoulou
- Institute of Orthopaedics and Musculoskeletal Science, University College London, London, UK and The Royal National Orthopaedic Hospital, Stanmore, UK
| | - K. Davda
- Limb Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, UK
| | - H. S. Hothi
- Institute of Orthopaedics and Musculoskeletal Science, University College London, London, UK
| | - J. Henckel
- Institute of Orthopaedics and Musculoskeletal Science, University College London, London, UK and The Royal National Orthopaedic Hospital and Stanmore, UK
| | - A. Cerquiglini
- Institute of Orthopaedics and Musculoskeletal Science, University College London, London, UK
| | - W. D. Goodier
- Limb Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, UK
| | - J. Skinner
- Limb Reconstruction Unit, Institute of Orthopaedics and Musculoskeletal Science, University College London, London, UK and The Royal National Orthopaedic Hospital, Stanmore, UK
| | - A. Hart
- Limb Reconstruction Unit, Institute of Orthopaedics and Musculoskeletal Science, University College London, London, UK and The Royal National Orthopaedic Hospital, Stanmore, UK
| | - P. R. Calder
- Limb Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, UK
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82
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Harkin E, Rozbruch SR, Liskutin T, Hopkinson W, Bernstein M. Total hip arthroplasty and femoral nail lengthening for hip dysplasia and limb-length discrepancy. Arthroplast Today 2018; 4:279-286. [PMID: 30186905 PMCID: PMC6123321 DOI: 10.1016/j.artd.2018.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 02/08/2023] Open
Abstract
The application of distraction osteogenesis through the use of magnet-operated, remote-controlled intramedullary lengthening continues to provide new opportunities for accurate limb equalization. While limb-length discrepancy and deformity can be addressed by total hip arthroplasty alone, the magnitude of correction is limited by the soft-tissue envelope and complications such as sciatic nerve palsy. This 3-patient case series presents the combination of staged ipsilateral total hip arthroplasty and retrograde intramedullary femoral nail lengthening for the correction of both deformity and limb-length discrepancy. Our results report leg-length equalization, independent ambulation without assistive devices, and excellent bone and functional outcomes without complications, demonstrating that this combined technique can be used to achieve targeted lengthening and deformity correction.
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Affiliation(s)
- Elizabeth Harkin
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - S Robert Rozbruch
- Hospital for Special Surgery; Limb Lengthening and Complex Reconstruction Service (LLCRS); Limb Salvage and Amputation Reconstruction Center (LSARC); Clinical Orthopaedic Surgery, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Tomas Liskutin
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - William Hopkinson
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Mitchell Bernstein
- Departments of Surgery and Pediatric Surgery, McGill University, Montreal, Quebec, Canada
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83
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Abstract
Aims The management of a significant bony defect following excision of a diaphyseal atrophic femoral nonunion remains a challenge. We present the outcomes using a combined technique of acute femoral shortening, stabilized with a long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis with a temporary monolateral fixator. Patients and Methods Eight men and two women underwent the ‘rail and nail’ technique between 2008 and 2016. Proximal locking of the nail and removal of the external fixator was undertaken once the length of the femur had been restored and prior to full consolidation of the regenerate. Results The mean lengthening was 7 cm (3 to 11). The external fixator was removed at a mean of 127 days (57 to 220). The mean bone healing index was 28 days/cm and the mean external fixation index was 20 days/cm (11 to 18). There were no superficial or deep infections. Conclusion This small retrospective study shows encouraging results for a combined technique, enabling compression of the femoral osteotomy, alignment, and controlled lengthening. Removal of the fixator and proximal locking of the nail reduces the risk of complications and stabilizes the femur with the maximum working length of the nail. Cite this article: Bone Joint J 2018;100-B:634–9.
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Affiliation(s)
- K. Davda
- Limb Reconstruction Unit, Royal National
Orthopaedic Hospital, London, UK
| | - N. Heidari
- The Royal London Hospital, Whitechapel, London, UK
| | - P. Calder
- Limb Reconstruction Unit, Royal National
Orthopaedic Hospital, London, UK
| | - D. Goodier
- Limb Reconstruction Unit, Royal National
Orthopaedic Hospital, London, UK
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84
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All Internal Segmental Bone Transport and Optional Lengthening With a Newly Developed Universal Cylinder-Kombi-Tube Module for Motorized Nails-Description of a Surgical Technique. J Orthop Trauma 2017; 31 Suppl 5:S39-S41. [PMID: 28938391 DOI: 10.1097/bot.0000000000000986] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Segmental transport is an effective method of treatment for segmental defects, but the need for external fixation during the transport phase is a disadvantage. To avoid external fixation, we have developed a Cylinder-Kombi-Tube Segmental Transport (CKTST) module for combination with a commercially available motorized lengthening nail. This CKTST module allows for an all-internal segmental bone transport and also allows for optional lengthening if needed. The concept and surgical technique of CKTST are described and illustrated with a clinical case.
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85
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Fragomen AT, Rozbruch SR. Retrograde magnetic internal lengthening nail for acute femoral deformity correction and limb lengthening. Expert Rev Med Devices 2017; 14:811-820. [PMID: 28893094 DOI: 10.1080/17434440.2017.1378092] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The Precice magnetic internal lengthening intramedullary nail is being used with great success in femur lengthening and deformity correction with a retrograde approach. Areas Covered: Our personal history of limb lengthening and the Precice nail will be reviewed. Several technical aspects are discussed including design updates, pre operative planning, selection of nail length, the use of blocking screws and intra operative temporary external fixation, osteotomy practice, post operative management, and cost analysis. Expert Commentary: The phenomenal bone healing ability for the retrograde Precice nail after femoral osteotomy for lengthening, even after acute deformity correction, is recognized throughout the growing body of scientific publications on this topic. The few failures that have occurred appear to be attributable to excessive loading of the femur and implant during a vulnerable time of bone healing. Further studies with more uniform outcome criteria need to be conducted to better standardize user's experiences. The higher one time cost of the implant is offset by the reduced number of surgeries needed when compared with the gold standard of lengthening-over-nail-technique, and we suspect that patients return to work sooner due to the ability to wear normal clothing and the reduction in pain throughout the entire lengthening process.
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Affiliation(s)
- Austin T Fragomen
- a Clinical Orthopaedics , Weill Medical College of Cornell University , New York , NY , USA.,b Limb Lengthening & Complex Reconstruction Service , Hospital for Special Surgery , New York , NY , USA
| | - S Robert Rozbruch
- c Orthopaedic Surgery , Weill Medical College of Cornell University , New York , NY , USA.,d Orthopedic Surgery, Limb Lengthening & Complex Reconstruction Service , Hospital for Special Surgery , New York , NY , USA
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86
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Hamdy RC, Bernstein M, Fragomen AT, Rozbruch SR. What's New in Limb Lengthening and Deformity Correction. J Bone Joint Surg Am 2017; 99:1408-1414. [PMID: 28816903 DOI: 10.2106/jbjs.17.00464] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Reggie C Hamdy
- 1Shriners Hospital for Children, Montreal, Quebec, Canada 2Loyola University Stritch School of Medicine, Maywood, Illinois 3Hospital for Special Surgery, New York, NY
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87
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Abstract
Limb equalization using the Ilizarov method has evolved and adapted the use of internal lengthening devices. One of the newest devices, termed "PRECICE," is a magnetically controlled telescoping nail. Complications such as pin site infection and skin irritation are eliminated. Despite trauma surgeons' familiarity with intramedullary nailing, the Ilizarov method requires sound knowledge of deformity analysis and awareness of specific complications associated with distraction osteogenesis. This manuscript discusses some of the practical preoperative and intraoperative components of limb lengthening.
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