Reamed Intramedullary Nailing has an Adverse Effect on Bone Regeneration During the Distraction Phase in Tibial Lengthening

Tibial Lengthening and Intramedullary Nail Fixation for Hindfoot Charcot Neuroarthropathy

Hindfoot and ankle Charcot neuroarthropathy is a challenging condition to treat, specifically with segmental bone defects secondary to avascular necrosis or infection. Several techniques exist alongside continued challenges of nonunion and complication rates. The authors assert that combining distal tibial distraction osteogenesis with external fixation in tibiocalcaneal or tibiotalocalcaneal arthrodesis should be considered an effective method for management of complex Charcot neuroarthropathy conditions of the ankle. This staged procedure technique resulted in a high rate of union in patients who are often considered a high risk for nonunion, as well as eradication of infection, minimal soft tissue disruption, and improvement in limb length.

Nonunion of the femoral shaft associated with limb shortening treated with a combined technique of external fixation over an intramedullary nail versus the Ilizarov method

INTRODUCTION

Post-traumatic nonunion of the femur remains a challenging problem even for experienced orthopedic surgeons. The main question is the choice of the optimal surgical tool.

MATERIALS AND METHODS

Management of 20 patients with nonunion of the femoral diaphysis associated with anatomical shortening was retrospectively analyzed. Group A (n = 14) was treated with a hybrid technique that combined the Ilizarov external fixation and intramedullary nailing. The Ilizarov bone transport was used in group B (n = 6). Patients of both groups had aseptic post-traumatic nonunion. Mean shortening was 4.5 ± 0.4 cm in group A and 4.8 ± 1.0 cm in group B (p = 0.459959).

RESULTS

Union was achieved in 85.7% of group A and 100% of group B patients. External fixation was repeated in two cases of group A and achieved consolidation. Deep infection developed in one case of group A after 15 months post-frame with the nail in. It was resolved by nail removal, surgical debridement and external fixation. Limb shortening was fully eliminated in eleven cases of group A and four patients of group B. The average duration of distraction was 35.3 ± 1.7 days in group A and 47.8 ± 9.3 days in group B. The total duration of external fixation was 49.1 ± 3.5 and 177.2 ± 21.9 days with an external fixation index of 13.1 ± 1.2 and 52.4 ± 6.4 days/cm, respectively. Distraction regenerate consolidated in all the cases.

CONCLUSION

Hybrid technique provides bone union with compensation of limb shortening and reduces the treatment period as compared with the Ilizarov method used alone. However, deep infection may happen.

Increased Arthrodesis Rates in Charcot Neuroarthropathy Utilizing Distal Tibial Distraction Osteogenesis Principles

Charcot neuroarthropathy of the hindfoot and ankle poses substantial challenges due to deformity, segmental bone loss, chronic infection, and difficulty with bracing. Hindfoot or ankle arthrodesis is often employed at high rates of complications and nonunion. This study reports 15 consecutive patients with Charcot neuroarthropathy who underwent tibiotalocalcaneal or tibiocalcaneal fusion with simultaneous distal tibial distraction osteogenesis with a mean follow-up period of 20.2 ± 5.66 months. Arthrodesis rate was 93.3% (14 patients) with mean time to fusion of 4.75 ± 3.4 months. One hypertrophic nonunion occurred at the arthrodesis site. Complete consolidation of 4 cortices was achieved at the distraction site in 93.3% of patients (14 patients) with a mean duration to consolidation of 9.8 ± 3.3 months. One patient experienced hypertrophic nonunion at the regeneration site. The authors report a technique to enhance arthrodesis rates in Charcot neuroarthropathy by combining distal tibial distraction osteogenesis with simultaneous tibiotalocalcaneal or tibiocalcaneal arthrodesis for hindfoot fusion and salvage. Distraction osteogenesis supports enhanced vascularity to the arthrodesis site.Level of Clinical Evidence: Level 4.

Use of the Pixel Value Ratio Following Intramedullary Limb Lengthening: Uncomplicated Full Weight-bearing at Lower Threshold Values

Aims

The pixel value ratio (PVR) can be used to assess regenerate consolidation after lengthening and guide advice for full weight-bearing (FWB). This study aimed to analyse the PVR in adults having femoral lengthening, the time to FWB and compare findings with the reported values in the literature.

Materials and methods

A retrospective database review identified 100 eligible patients who underwent lengthening using the PRECICE nail (68 antegrade and 32 retrograde). The PVR was calculated in each cortex on plain radiographs at every visit. The ratio between the regenerate and an average from the adjacent normal bone was calculated and plotted against the clinical decision to allow FWB.

Results

Eighty-seven patients (58 men and 29 women) were assessed; eleven had bilateral lengthening and two patients underwent lengthening twice. The median age was 30.5 years. The underlying cause of shortening was post-traumatic in 46%, with the remaining due to a wide variety of causes, including congenital 16%, syndromic 12% and other causes. The median lengthening achieved was 45 mm, at a median of 57.5 days. The PVR increased with each visit (p <0.0001). FWB was allowed at a median of 42 days after the last day of lengthening, with PVR values of 0.83, 0.84, 0.93 and 0.84 for the anterior, posterior, medial and lateral cortex noted, respectively (average 0.85). There were no implant failures, shortening or regenerate fractures. No differences were detected between antegrade and retrograde nails or with lengthening greater or less than 45 mm. One surgeon allowed earlier FWB at median 31 days with no nail failures.

Conclusion

PVR is a valuable tool that quantifies regenerate maturity and provides objectivity in deciding when to allow FWB after intramedullary lengthening with the PRECICE nail. FWB was permitted at an earlier time point, corresponding with lower PVR values than have been reported in the literature and with no mechanical failure or regenerate deformation.

How to cite this article

Elsheikh AA, Wright J, Stoddart MT, et al. Use of the Pixel Value Ratio Following Intramedullary Limb Lengthening: Uncomplicated Full Weight-bearing at Lower Threshold Values. Strategies Trauma Limb Reconstr 2022;17(1):14–18.

Novel approach to estimate distraction forces in distraction osteogenesis and application in the human lower leg

PURPOSE

In distraction osteogenesis (DO) of long bones, new bone tissue is distracted to lengthen limbs or reconstruct bone defects. However, mechanical boundary conditions in human application such as arising forces are mainly based on limited empirical data. Our aim was the numerical determination of the callus distraction force (CDF) and the total distraction force (TDF) during DO in the tibia of adults to advance the understanding of callus tissue behavior and optimize DO procedures.

METHOD

We implemented a mathematical model based on an animal experiment to enable the calculation of forces arising while distracting callus tissue, excluding the influence of surrounding soft tissue (muscles, skin etc.). The CDF progression for the distraction period was calculated using the implemented model and varying distraction parameters (initial gap, area, step size, time interval, length). Further, we estimated the CDF based on reported forces in humans and compared the results to our model predictions. In addition, we calculated the TDF based on our CDF predictions in combination with reported resisting forces due to soft tissue presence in human cadavers. Finally, we compared the progressions to in vivo TDF measurements for validation.

RESULTS

Due to relaxation, a peak and resting CDF is observable for each distraction step. Our biomechanical results show a non-linear degressive increase of the resting and peak CDF at the beginning and a steady non-linear increase thereafter. The calculated resting and peak CDF in the tibial metaphysis ranged from 0.00075 to 0.0089 N and 0.22-2.6 N at the beginning as well as 20-25 N and 70-75 N at the end of distraction. The comparison to in vivo data showed the plausibility of our predictions and resulted in a 10-33% and 10-23% share of resting CDF in the total resting force for bone transport and elongation, respectively. Further, the percentage of peak CDF in total peak force was found to be 29-58% and 27-55% for bone transport and elongation, respectively. Moreover, our TDF predictions were valid based on the comparison to in vivo forces and resulted in a degressive increase from 6 to 125 N for the peak TDF and from 5 to 76 N for the resting TDF.

CONCLUSION

Our approach enables the estimation of forces arising due to the distraction of callus tissue in humans and results in plausible force progressions as well as absolute force values for the callus distraction force during DO. In combination with measurements of resisting forces due to the presence of soft tissue, the total distraction force in DO may also be evaluated. We thus propose the application of this method to approximate the behavior of mechanical callus properties during DO in humans as an alternative to in vivo measurements.

International recognition of the Ilizarov bone reconstruction techniques: Current practice and research (dedicated to 100th birthday of G. A. Ilizarov)

The Ilizarov method is one of the current methods used in bone reconstruction. It originated in the middle of the past century and comprises a number of bone reconstruction techniques executed with a ring external fixator developed by Ilizarov GA. Its main merits are viable new bone formation through distraction osteogenesis, high union rates and functional use of the limb throughout the course of treatment. The study of the phenomenon of distraction osteogenesis induced by tension stress with the Ilizarov apparatus was the impetus for advancement in bone reconstruction surgery. Since then, the original method has been used along with a number of its modifications developed due to emergence of new fixation devices and techniques of their application such as hexapod external fixators and motorized intramedullary lengthening nails. They gave rise to a relatively new orthopedic subspecialty termed “limb lengthening and reconstruction surgery”. Based on a comprehensive literature search, we summarized the recent clinical practice and research in bone reconstruction by the Ilizarov method with a special focus on its modification and recognition by the world orthopedic community. The international influence of the Ilizarov method was reviewed in regard to the origin country of the authors and journal’s rating. The Ilizarov method and other techniques based on distraction osteogenesis have been used in many countries and on all populated continents. It proves its international significance and confirms the greatest contribution of Ilizarov GA to bone reconstruction surgery.

Ilizarov bone transport using an intramedullary cable transportation system in the treatment of tibial bone defects

INTRODUCTION

Segmental tibia defects remain challenging for orthopedic surgeons to treat. The aim of this study was to demonstrate bone-related and functional outcomes after treatment of complex tibial bone defects using Ilizarov bone transport with a modified intramedullary cable transportation system (CTS).

PATIENTS AND METHODS

We conducted a single-center, retrospective study including all 42 patients treated for tibial bone loss via Ilizarov bone transport with CTS between 2005 and 2018. Bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. Complication and failure rates were determined by the patients' medical files.

RESULTS

Patients had a mean age of 45.5 ± 15.1 years. The mean bone defect size was 7.7 ± 3.4 cm, the average nonunion scoring system (NUSS) score was 59 ± 9.5 points, and the mean follow-up was 40.8 ± 24.4 months (range, 13-139 months). Complete bone and soft tissue healing occurred in 32/42 patients (76.2%). These patients had excellent (10), good (17), fair (2), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 19 patients had excellent, 10 good, and 3 fair results. In total, 37 minor complications and 62 major complications occurred during the study. In 7 patients, bone and soft tissue healing occurred after CTS failure with either an induced membrane technique or classic bone transport; 3 patients underwent lower leg amputation. Patients with treatment failure were significantly older (57.6 vs. 41.8 years; p = 0.003). Charlson score and treatment failure had a positive correlation (Spearman's rho 0.43; p = 0.004).

CONCLUSION

Bone transport using both intramedullary CTS and Ilizarov ring fixation is viable for treating patients with bone loss of the tibia and complex infection or soft tissue conditions. However, a high number of complications and surgical revisions are associated with the treatment of this severe clinical entity and should be taken into account.

Cost Comparison of Tibial Distraction Osteogenesis Using External Lengthening and Then Nailing vs Internal Magnetic Lengthening Nails

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.

Treatment of segmental tibial defects by bone transport with circular external fixation and a locking plate

Objective

To evaluate the effectiveness of bone transport involving circular external fixation and locking plate application for the treatment of segmental tibial defects.

Methods

A retrospective review of 12 patients with segmental tibial defects who underwent bone transport with circular external fixation and locking plate application. We evaluated external fixation time, external fixation index, time to achieve union, and complications. Clinical results were assessed using the Association for the Study and Application of the Methods of Ilizarov (ASAMI) score. Generic health-related outcome was assessed using the 36-Item Short-Form Health Survey questionnaire (SF-36).

Results

The mean follow-up was 25.8 months, and the mean defect size was 6.7 cm. All of the patients achieved union at the distraction callus and docking site. The average external fixation time was 299.5 days. The mean external fixation index was 16.5 days/cm, and the mean healing index was 44.9 days/cm. The functional outcomes were excellent in eight cases and good in four. The average SF-36 score was 92.

Conclusion

Bone transport with external fixation and locking plate application may be a promising method for the treatment of segmental tibial defects.

Limb lengthening and deformity correction in children with abnormal bone

Flexible intramedullary nailing (FIN) provides multiple advantages in limb lengthening and progressive deformity correction in combination with external fixation. The article presents brief literature review and authors' experience in limb lengthening of abnormal bone (Ollier's disease, fibrous dysplasia, osteogenesis imperfecta). Titanium and, especially, hydroxyapatite-coated bent elastic nails in combination with external fixator are appropriate in limb lengthening of abnormal bone in children. FIN left in situ after lengthening procedure and external frame removal should be applied for long-term reinforcement of lengthened bone in patients with abnormal bone (metabolic bone disorders, skeletal dysplasias with compromised bone tissue development). The FIN respects bone biology, which is mandatory for good bone consolidation. Osteoactive properties of intramedullary elastic implants are favorable for bone formation and as well as for stable position of nails without risks of migration in long-term follow-up.

Intramedullary Metatarsal Fixation for Treatment of Delayed Regenerate Bone in Lengthening of Brachymetatarsia

Delayed regenerate healing after distraction osteogenesis can be a challenging problem for patients and surgeons alike. In the present study, we retrospectively reviewed the data from a cohort of patients with delayed regenerate healing during gradual lengthening treatment of brachymetatarsia. Additionally, we present a novel technique developed by 1 of us (B.M.L.) for the management of delayed regenerate healing. We hypothesized that application of intramedullary metatarsal fixation would safely and effectively promote healing of poor quality, atrophic regenerate during bone lengthening in brachymetatarsia correction. We formulated a study to retrospectively review the data from a cohort of patients with delayed regenerate healing after gradual lengthening for brachymetatarsia. All patients underwent temporary placement of intramedullary fixation after identification of delayed regenerate healing. Patient-related variables and objective measurements were assessed. We identified 10 patients with 13 metatarsals treated with intramedullary fixation for delayed regenerate healing. All 10 patients were female, with 6 (46.2%) right metatarsals and 7 (53.8%) left metatarsals treated. No complications developed with the use of this technique. All subjects progressed to successful consolidation of the regenerate bone at a mean of 44.5 ± 30.2 days after placement of intramedullary metatarsal fixation. No regenerate fracture or reoperations were noted. In conclusion, intramedullary metatarsal fixation is a safe and effective method for managing delayed regenerate healing encountered during distraction osteogenesis correction of brachymetatarsia.

Functional recovery of daily living and sports activities after cosmetic bilateral tibia lengthening

PURPOSE

The aims of this study were to evaluate the recovery of physical function and to investigate whether there are factors that adversely affect functional recovery after cosmetic bilateral lengthening of the tibia.

METHODS

One hundred twenty-five healthy individuals who had undergone bilateral cosmetic tibia lengthening by the lengthening and then nail (LATN) method, lengthening over intramedullary nail (LON) method or intramedullary skeletal kinetic distractor (ISKD) were included in the study. Functional outcomes were evaluated using the Sports Activity Rating Scale (SARS), International Knee Documentation Committee (IKDC) Subjective Knee Form and patient self-reported ability scores.

RESULTS

SARS and IKDC scores decreased at post-operative one year and improved significantly at post-operative two years. SARS and IKDC scores recovered similarly to pre-operative levels. Average patient self-reported ability scores at post-operative two years were 94.6 and 89.9 for daily living and light sports, respectively. However, the average score for moderate-to-strenuous sports was 68.1 and 39 patients (31.2%) recorded below average score for the moderate-to-strenuous sports.

CONCLUSIONS

Patients who had undergone bilateral cosmetic tibial lengthening may expect almost full recovery of daily and light sports activities at post-operativetwo years. However, several patients may feel some limitation in moderate-to-strenuous sports activities.

‘Rail and Nail’ bifocal management of atrophic femoral nonunion

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.

Segmental Bone Loss Reconstruction Using Ring Fixation

Ring fixation is a powerful tool in the treatment of bone defects. The ability to create high-quality, biologically normal new bone of even massive proportions using distraction osteogenesis is a major reason for its success. In addition, ring fixation provides the ability to limit the risk of deep infection, improves flexibility in limb length control and alignment, and increases soft tissue coverage options. The drawbacks of ring fixation include long frame times, pin problems, risk of joint contractures, and difficult usage in areas with a large soft tissue envelope such as the thigh. Significant advancements such as hydroxyapatite coated pins, internal cable transport, multifocal transport, and combined techniques with internal fixation have helped increase the effectiveness of ring fixator use by minimizing many of the drawbacks. At present, ring fixation provides the most effective means of treatment for large bone defects in many clinic situations.