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Calder PR, Wright J, Goodier WD. An Update on the Intramedullary Implant in Limb Lengthening: A Quinquennial Review Part 2: Extending Surgical Indications and Further Innovation. Injury 2022; 53 Suppl 3:S88-S94. [PMID: 35851475 DOI: 10.1016/j.injury.2022.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 02/02/2023]
Abstract
The use of the intramedullary lengthening nail has gained in popularity over the last decade. The reduction in complications associated with the use of external fixators and excellent patient outcomes has resulted in the largest change in management of limb length discrepancy since the concept of distraction osteogenesis was accepted by the Western world in the 1980s. Success following "simple" limb lengthening has led to surgeons extending the indications for the lengthening nail, including different bone segments, lengthening associated with potential joint instability and lengthening combined with acute deformity correction. There has been a drive for further implant modification to reduce complications, and enable full weight bearing during the lengthening process. This would offer the opportunity to consider simultaneous limb lengthening. The aim of this review is to evaluate the literature published over the last five years and highlight important learning points and technical tips for these expanding indications.
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Affiliation(s)
- Peter R Calder
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, United Kingdom.
| | - Jonathan Wright
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, United Kingdom
| | - W David Goodier
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, United Kingdom
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Lorange JP, Alamiri N, Marwan Y, Alshammari A, Hamdy RC, Bernstein M. Humerus Lengthening with a Motorized Intramedullary Nail: A Systematic Review of Outcomes and Complications. Strategies Trauma Limb Reconstr 2022; 17:165-171. [PMID: 36756294 PMCID: PMC9886034 DOI: 10.5005/jp-journals-10080-1568] [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] [Received: 07/20/2022] [Accepted: 10/10/2022] [Indexed: 01/01/2023] Open
Abstract
Aim In the past decade, internal limb lengthening nails have gained popularity. In this study, we aim to systematically review the literature on humerus limb lengthening with a motorized intramedullary nail (MIN). We intend to assess the outcome and complications of this technique. Materials and methods A systematic review was performed in the following databases: PubMed, Embase, Web of Science, and the Journal of Limb Lengthening and Reconstruction. The inclusion criteria included limb lengthening of the humerus using an intramedullary nail, clinical studies, all levels of evidence, and no restriction to the date of publication. Results Our search yielded 239 journal articles. A total of nine articles remained relevant based on the inclusion and exclusion criteria. The total number of patients was 20, with 22 segments lengthened. The mean age of the patients was 20.8-year-old [standard deviation (SD), 12.0; range, 13-51]. The mean gained length was 5.7 cm (SD, 0.9; range, 5-7.5) with a mean distraction protocol of 0.82 mm/day (SD, 0.2; range, 0.6-1). The average duration of lengthening was 71.6 days (SD, 12.8; range, 50-93), and the mean duration of consolidation was 192.3 days (SD, 40.5; range, 120-228). Reported complications included a range of motion (ROM) limitation, hardware failure, and hypertrophic bone regeneration. Conclusion Humeral lengthening with an MIN provides favourable outcomes with low complication rates. Future high-level studies should focus on comparing long-term outcomes of humeral lengthening utilising internal and external fixation techniques. Clinical significance Humeral lengthening using MIN can be used safely. Each surgical approach and type of nail have different risks and benefits. These should be carefully discussed when planning the surgery. How to cite this article Lorange JP, Alamiri N, Marwan Y, et al. Humerus Lengthening with a Motorized Intramedullary Nail: A Systematic Review of Outcomes and Complications. Strategies Trauma Limb Reconstr 2022;17(3):165-171.
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Affiliation(s)
- Justin-Pierre Lorange
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nawaf Alamiri
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Yousef Marwan
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Abdullah Alshammari
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Reggie Charles Hamdy
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mitchell Bernstein
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Femino JD, Nelson SC, Agulnik M, Zuckerman LM. All-Internal Limb Lengthening with Simultaneous Corrective Osteotomy After Internal Hemipelvectomy: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00029. [PMID: 36099533 DOI: 10.2106/jbjs.cc.22.00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE A 27-year-old woman with a Grade II chondrosarcoma in the right acetabulum underwent a Type II internal hemipelvectomy with an ischiofemoral fusion. She developed a 7.0-cm functional limb-length discrepancy with adduction of the hip at rest. Four years after surgery, she underwent a corrective osteotomy and limb lengthening with a magnetic lengthening nail. Eleven years after tumor resection and a successful pregnancy, she had symmetric leg lengths and ambulated without an assistive device. CONCLUSIONS A magnetic lengthening nail is a viable option for correcting limb-length discrepancies after hemipelvectomy. If necessary, a simultaneous corrective proximal femoral osteotomy can be performed.
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Affiliation(s)
- Joseph D Femino
- Division of Orthopaedic Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Scott C Nelson
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California
- Department of Surgery, Hopital Adventiste d'Haiti, Port-au-Prince, Haiti
| | - Mark Agulnik
- Department of Medical Oncology and Therapeutics, City of Hope National Medical Center, Duarte, California
| | - Lee M Zuckerman
- Division of Orthopaedic Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, California
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Rivera JC, McClure PK, Fragomen AT, Mehta S, Rozbruch SR, Conway JD. Intramedullary Antibiotic Depot Does Not Preclude Successful Intramedullary Lengthening or Compression. J Orthop Trauma 2021; 35:e309-e314. [PMID: 33395176 PMCID: PMC8253503 DOI: 10.1097/bot.0000000000002054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
SUMMARY The challenging problem of long bone infection and limb length difference cannot be addressed using only an antibiotic-coated nonmagnetic static nail. The combined use of resorbable calcium sulfate and magnetic lengthening nails offers a possible solution to this dilemma, as well as for infected nonunions that require compression. We present a combined technique to treat or prevent infection using femoral or tibial intramedullary antibiotic delivery with an absorbable calcium sulfate depot and concomitant internal lengthening or compression using a nail. Adequate débridement is required in cases of established infection and is a prerequisite for this technique.
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Affiliation(s)
- Jessica C. Rivera
- Louisiana State University Health Science Center, New Orleans, LA
- Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD
| | - Philip K. McClure
- Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD
| | | | | | | | - Janet D. Conway
- Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD
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Galal S, Shin J, Principe P, Mehta R, Khabyeh-Hasbani N, Hamilton A, Fragomen A, Rozbruch SR. Humerus Lengthening: A Comparison of the Internal Lengthening Nail to External Fixation. HSS J 2021; 17:207-212. [PMID: 34421432 PMCID: PMC8361582 DOI: 10.1177/1556331621996334] [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: 11/10/2020] [Accepted: 11/27/2020] [Indexed: 11/16/2022]
Abstract
Introduction: Magnetic internal lengthening nails (MILNs) have been used for humeral lengthening to avoid complications associated with external fixation. Purpose/Questions: We compared the 1-year Disabilities of the Arm, Shoulder and Hand (DASH) score, adjacent joint range of motion (ROM), bone healing index (BHI), length achieved, distraction rate, and complications when lengthening the humerus using MILN vs using external fixation. Methods: We conducted a retrospective cohort study of 18 patients (22 humeri) from January 2001 to March 2020 divided into 2 groups, the MILN group (7 patients, 7 humeri) and the mono-lateral fixator group (11 patients, 15 humeri). Results: The MILN group showed larger improvement of DASH scores (average 26.8 and 8 for MILN and fixator groups, respectively), less loss of elbow ROM (average 5° and 7° for MILN and fixator groups, respectively), and shorter time to full recovery of elbow ROM (average 39 days and 122 days for MILN and fixator groups, respectively). In the MILN group, there was slower distraction rate (average 0.66 mm/day and 0.86 mm/day for MILN and fixator groups, respectively), less lengthening achieved (average 5.2 cm and 7 cm for MILN and fixator group, respectively), and a lower lengthening percentage (average 19% and 41% for MILN and fixator group, respectively). Bone healing index (BHI) of 0.94 and 0.99 months/cm for the MILN and the fixator groups were similar. Conclusion: Humeral lengthening using the MILN allowed for early full recovery of joint ROM with comparable functional and radiographic outcomes compared with using external fixators.
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Affiliation(s)
- Sherif Galal
- Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA,Department of Orthopaedic Surgery, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt,Sherif Galal, MD, PhD, Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021-4898, USA.
| | - Jonggu Shin
- Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Peter Principe
- Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Rena Mehta
- Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Nathan Khabyeh-Hasbani
- Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Amber Hamilton
- Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Austin Fragomen
- Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - S. Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Early outcomes of magnetic intramedullary compression nailing for humeral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:23-31. [PMID: 32638124 DOI: 10.1007/s00590-020-02735-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The optimal treatment protocol for humeral shaft fractures at risk for nonunions is controversial. Here, we aim to describe magnetic intramedullary compression nailing as an option for these challenging scenarios and to evaluate its clinical and radiographic outcomes. METHODS This retrospective case series was performed at an urban university-based level-1 trauma center. Patients aged 18-65 who underwent fixation of their at-risk humerus shaft fracture using the PRECICE nail were included in this investigation. These fractures are characterized by a persistent distraction gap, minimal callous formation, or malalignment greater than 20 degrees. The study data were collected through a retrospective chart review and review of the radiographic studies. Primary outcome measure was radiographic union. Secondary outcome measures included mechanical failure, nonunion, malunion, medical, and surgical complications. Functional outcome was determined by range of motion and restoration of rotator cuff strength. RESULTS A total of six patients were included who underwent treatment of their humeral shaft fracture with a NuVasive PRECICE nail after failure of conservative management. After nail placement along with our compression protocol, all patients achieved bony union and experienced favorable outcomes with return to their previous working status. Two complications included a superficial incisional infection treated with antibiotics and a backing out of proximal screw which did not cause discomfort. No other mechanical failures, surgical complications, or medical complications occurred. CONCLUSIONS Early results of controlled compression nailing for humeral shaft fracture demonstrated favorable clinical outcomes. This technique may be utilized for these challenging situations.
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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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Abstract
The new technology of motorized intramedullary telescopic nails has simplified the treatment for upper limb lengthening surgery. Improved patient comfort, low infection rates and absence of fractures in the regenerated bone are contrasted by the limitations of the methods, such as a current maximum distraction of 5cm and the fact that they cannot be used when the growth plates are still open.
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Zak L, Tiefenboeck TM, Wozasek GE. Innovative Technique in Extended Intramedullary Humeral Lengthening: A Case Report. JBJS Case Connect 2019; 9:e0174. [PMID: 31425164 DOI: 10.2106/jbjs.cc.18.00174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
CASE Intramedullary humeral lengthening is still a very uncommon procedure to treat humeral limb length discrepancy (LLD). This approach has various advantages compared with external devices but is limited in its ability to lengthen bones because of the length of the telescopic nail. This case report describes a middle-aged patient with a short right humerus secondary to a childhood growth plate injury that was successfully lengthened with an off-label application of a tibial distracting device. Hereby, a novel treatment technique with unlocking, backwinding, and reinterlocking of the telescopic nail for extended humeral distraction was performed. CONCLUSIONS Extended intramedullary humeral lengthening with unlocking, backwinding, and reinterlocking of the nail is a cost-effective, minimally invasive procedure in cases of massive humeral LLD with limitations in the distraction capacity of the telescopic nail.
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Affiliation(s)
- Lukas Zak
- Department of Trauma Surgery, Medical University of Vienna, Vienna, Austria
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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 2018; 100:1436-1442. [PMID: 30106829 DOI: 10.2106/jbjs.18.00584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Reggie C Hamdy
- Shriners Hospital for Children, Montreal, Quebec, Canada
| | - Mitchell Bernstein
- Shriners Hospital for Children, Montreal, Quebec, Canada.,McGill University Health Center, Montreal, Quebec, Canada
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Abstract
BACKGROUND Different types of external fixators have been used for humeral lengthening with successful outcomes reported in literature. Motorized intramedullary (IM) lengthening nails have been developed as an alternative to external fixators for long bone lengthening in the lower extremity. QUESTIONS/PURPOSES This case series reports on using the new technology of IM lengthening nails for humeral lengthening. We assessed the radiological healing and functional outcomes after using the PRECICE IM nail for humeral lengthening. METHODS This multicenter retrospective study included a total of six humeri in five patients (mean age was 20 years) that underwent lengthening with the magnetic IM PRECICE nail in two centers in the USA. The etiology was humeral growth arrest post-bone cyst (two segments), post-septic growth arrest (two segments), and multiple hereditary exostosis (bilateral segments in one patient). The outcomes measured were the length achieved, distraction index (DI; the length achieved in mm divided by the duration of lengthening in days), consolidation index (CI; number of days from surgery until consolidation divided by the length of the regenerate in cm), complications encountered, and functional outcomes (shoulder and elbow range of motion, the upper extremity functional index (UEFI), and QuickDASH functional scores). RESULTS The mean follow-up period was 1.8 years (0.9 to 2.4 years). All segments achieved the goal of lengthening; the mean was 5.1 cm (4.5 to 5.8 cm). Mean DI was 0.7 mm/day (0.5 to 0.8). Mean CI was 36 days/cm (25 to 45 days/cm). No complications were observed. At the last follow-up, all patients maintained their preoperative range of motion (ROM) except one patient had reduced shoulder ROM. QuickDASH score and upper extremity functional index showed postoperative improvement compared to the preoperative scores. CONCLUSION IM lengthening nails can provide successful and safe humeral lengthening. Specifically, the PRECICE nail has accurate control over the lengthening process.
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