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Al Ramlawi A, Assayag M, McClure P. PRECICE nail bending in femur lengthening. J Orthop 2024; 56:127-132. [PMID: 38828473 PMCID: PMC11137381 DOI: 10.1016/j.jor.2024.05.018] [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: 04/29/2024] [Accepted: 05/12/2024] [Indexed: 06/05/2024] Open
Abstract
Intro Intramedullary nails (ILNs) are commonly used in orthopedic surgery for the fixation of long bone fractures and limb lengthening. Understanding the structural mechanics (i.e. nail bend) of an ILN device is crucial in determining its performance under various loading conditions. Furthermore, nail diameter was found to play a key role in an ILN's susceptibility to plastic deformity. This study aims to investigate the degree of nail bending and incidence of plastic deformity in patients receiving antegrade femoral ILNs (PRECICE, NuVasive, Inc.). Methods Retrospectively evaluated 130 ILNs (PRECICE, NuVasive, Inc.) in 100 adult patients who underwent limb lengthening done in a single center. Patients who had concomitant osteotomies, tibial lengthening, malunion, non-union, mechanical failure, or revision surgery for any reason were excluded. All nails were inserted through the greater trochanter or piriformis. Patients' age, weight, height, and body mass index (BMI)were extracted. Radiologic assessments involved analyzing long lower limb standing X-rays before, during, and at consolidation for total distraction and nail bend. Naildiameter and patient characteristics were directly sourced from medical records. Results Nail bend at consolidation averaged 2.4° (SD 2.4), ranging from 0 to 9. Additionally, total femoral lengthening was assessed, with a mean value of 5.3 cm (SD 2.1). A significant positive association was observed in the nail bend and weight (weight in kg/nail diameter in mm) coefficient (P < 00.01). Bilateral limb lengthening was also correlated to increase nail bend (P < 00.05). Conclusion Patient's weight to nail diameter ratio and bilateral limb lengthening were found to be significant factors affecting nail bend. These findings advance our understanding of the interrelation between the nail biomechanical profile and the patient's physical attributes, offering important implications for limb lengthening. Level of evidence III.
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Affiliation(s)
- Akram Al Ramlawi
- International Center for Limb Lengthening, Sinai of Baltimore, USA
| | - Michael Assayag
- International Center for Limb Lengthening, Sinai of Baltimore, USA
| | - Philip McClure
- International Center for Limb Lengthening, Sinai of Baltimore, USA
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2
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Bains SS, Dubin JA, Green C, Herzenberg JE, McClure PK. Infection rates and risk factors with magnetic intramedullary lengthening nails. J Orthop 2024; 55:124-128. [PMID: 38706586 PMCID: PMC11063112 DOI: 10.1016/j.jor.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/14/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Surgical site infection (SSI) related to magnetic intramedullary lengthening nails (MILNs) can lead to delayed consolidation or loss of limb function, resulting in deleterious effects to a patient's quality of life. With the rise of MILNs, we sought to determine the incidence rate and risk factors for infection during limb lengthening with MILNs. Methods We reviewed a consecutive series of patients who underwent femoral and/or tibial lengthening with an MILN at a single institution between 2012 and 2020 (n = 420). SSI was defined according to CDC-NHSN criteria (including superficial and deep infections) with postoperative surveillance time of 12 months. Demographic, health metrics, comorbidities, limb- and surgery-related factors, were assessed as potential risk mediators of SSI. Results Incidence of SSI was 3.3 % (14/420). This was divided into superficial (0.5 %,2/420) and deep (2.9 %, 12/420) infections. Of deep infections, 75 % (9/12) were osteomyelitis. Of the 14 limbs that developed SSI, 57 % (8/14) had a history of prior external fixation in the same limb and 38 % (5/14) had a previous infection of the same limb. A subanalysis of patients with a history of prior external fixation in the same bone was associated with SSI, as compared to those without previous external fixation. None of the surgery-related infection risk factors reached statistical significance. Discussion and conclusion The total incidence of infection with MILNs was 3.3 % at 24 months follow-up. The risk of deep infection was 2.9 %. Patients with a history of previous external fixation and prior infection show an independent association with increased rate of infection recurrence in the same bone. These patients could be considered a high-risk group for developing deep tissue infection. Potential algorithms include prolonged oral antibiotics after MILN insertion or simultaneous injection of absorbable antibiotic at the time of the nail insertion.
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Affiliation(s)
- Sandeep S. Bains
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jeremy A. Dubin
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Connor Green
- Children's University Hospital, Temple St, Rotunda, Dublin 1, D01 XD99, Ireland
- Cappagh Kids, National Orthopaedic Hospital Cappagh, Cappagh Rd, Cappoge, Dublin 11, D11 EV29, Ireland
- UCD School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - John E. Herzenberg
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Phillip K. McClure
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
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Sabry AO, Galal S, Menshawey R, Menshawey E, Hegazy M, Farahat M, Nasr N, Boutros Y, Zakaria Y, El Barbary H, Hegazy M. Femoral Lengthening in Children with Congenital Femoral Deficiency: A Systematic Review. JBJS Rev 2024; 12:01874474-202408000-00013. [PMID: 39172878 DOI: 10.2106/jbjs.rvw.24.00088] [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: 08/24/2024]
Abstract
BACKGROUND Congenital femoral deficiency (CFD) presents a significant challenge in pediatric orthopaedics, characterized by a spectrum of congenital anomalies ranging from mild femoral shortening to complete absence of the proximal femur and hip joint. This review aims at reviewing the latest concepts of femoral limb lengthening modalities in treating CFD, to explore the efficacy, complications, and long-term outcomes of various surgical techniques. METHODS A comprehensive search of the literature was performed for clinical studies involving lengthening in patients with proximal focal femoral deficiency (PFFD) in several databases. RESULTS We analyze the evolution of limb lengthening procedures, from the Wagner and Ilizarov methods to the latest advancements in distraction osteogenesis, and assess their role in addressing the functional needs of patients. We also analyze the possible risk factors for the occurrence of complications with each method and alternatives to avoid them. CONCLUSION The review highlights the importance of individualized treatment plans, considering factors such as the degree of femoral deficiency and the potential for achieving a functional limb length; however, it requires a multidisciplinary approach and careful preoperative planning to optimize patient outcomes. The review underlines the need for ongoing research to refine surgical techniques and to compare them and improve the quality of life for individuals with PFFD. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ahmed O Sabry
- Department of Orthopaedic Surgery, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Sherif Galal
- Department of Orthopaedic Surgery, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
- Limb Lengthening and Complex Reconstruction Service, Ministry of Health, Muscat, Oman
| | - Rahma Menshawey
- Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Esraa Menshawey
- Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Mariam Hegazy
- Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Mai Farahat
- Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Nadine Nasr
- Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Youssef Boutros
- Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Youssef Zakaria
- Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Hassan El Barbary
- Department of Orthopaedic Surgery, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Hegazy
- Department of Orthopaedic Surgery, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
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Van Nguyen L, Nguyen GN. The results of femoral lengthening using domestic unilateral external fixation and then plating: the first case series in Vietnam. Ann Med Surg (Lond) 2024; 86:4344-4351. [PMID: 39118726 PMCID: PMC11305785 DOI: 10.1097/ms9.0000000000002172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/07/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction and importance This study aimed to assess the results of femoral lengthening using an external fixator and then plating. Case presentation This prospective case series study enrolled 11 patients who underwent femoral lengthening and then plating (LATP) between January 2019 and April 2023. The average age of patients was 14.45 ± 7.54 years. One patient with a femur was lengthened and plated, and one tibia was lengthened over a nail simultaneously. The average femoral lengthening was 8.41 ± 1.35 cm. Clinical discussion The femoral healing result was excellent in seven femurs and good in four femurs; the functional outcome was excellent in five patients and good in six patients. Pin-track infection occurred in all patients. A limited range of motion of knee flexion occurred in eight patients. Femoral varus and procurvatum deviation occurred during distraction in four and two patients. Femoral LATP was considered an attractive alternative to intramedullary lengthening nails in a low-income country. Conclusion Our research suggests that femoral LATP was an effective method. However, the most common complications were pin-site infection and extensive knee contracture. Further research should be done with a larger sample size and longer follow-up time. Level of evidence Level IV-prospective observational case series study.
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Affiliation(s)
- Luong Van Nguyen
- Institute of Trauma and Orthopaedics, 108 Central Military Hospital, Hanoi, Vietnam
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Vogt B, Biermann C, Gosheger G, Laufer A, Rachbauer A, Antfang C, Lueckingsmeier M, Toporowski G, Tretow H, Roedl R, Frommer A. Simultaneous correction of leg length discrepancy and angular deformity of the distal femur with retrograde Precice nails: a retrospective analysis of 45 patients. Acta Orthop 2024; 95:364-372. [PMID: 39007719 PMCID: PMC11248716 DOI: 10.2340/17453674.2024.40947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/17/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND AND PURPOSE Magnetically controlled motorized intramedullary lengthening nails (ILNs) can be employed for simultaneous correction of angular deformities of the distal femur and leg length discrepancy. This spares typical complications of external fixators but requires precise preoperative planning and exact intraoperative execution. To date, its results are insufficiently reported. We aimed to elucidate the following questions: (i) Is acute angular deformity correction and gradual femoral lengthening via a retrograde ILN a reliable and precise treatment option? (ii) What are the most common complications of treatment? METHODS Acute angular deformity correction and subsequent gradual lengthening of the distal femur with retrograde ILN was retrospectively analyzed in 45 patients (median patient age: 15 years, interquartile range [IQR] 13-19 and median follow-up: 40 months, IQR 31-50). Outcome parameters were accuracy, precision, reliability, bone healing, and complications of treatment. RESULTS The median distraction was 46 mm (IQR 29-49), median distraction and consolidation index 0.9 mm/day (IQR 0.7-1.0) and 29 days/cm (IQR 24-43), respectively. The median preoperative mechanical axis deviation (MAD) was 30 mm (IQR 23-39) in the varus cohort and -25 mm (IQR -29 to -15) in the valgus cohort and reduced to a mean of 8 mm (standard deviation [SD] 8) and -3 (SD 10), respectively. Accuracy, precision, and reliability of lengthening were 94%, 95% and 96%, respectively. Accuracy and precision of deformity correction were 92% and 89%, respectively. In total, 40/45 of patients achieved distraction with a difference of less than 1 cm from the initial plan and a postoperative MAD ranging from -10 mm to +15 mm. In 13/45 patients unplanned additional surgeries were conducted to achieve treatment goal with nonunion being the most frequent (4/45) and knee subluxation (3/45) the most severe complication. CONCLUSION Acute deformity correction and subsequent lengthening of the distal femur with retrograde ILN is a reliable and accurate treatment achieving treatment goal in 89% but unplanned additional surgeries in 29% of patients should be anticipated.
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Affiliation(s)
- Bjoern Vogt
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany.
| | - Caja Biermann
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital
| | - Georg Gosheger
- General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany
| | - Andrea Laufer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany
| | - Anna Rachbauer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany
| | - Carina Antfang
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany
| | - Milena Lueckingsmeier
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany
| | - Gregor Toporowski
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany
| | - Henning Tretow
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany
| | - Robert Roedl
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital
| | - Adrien Frommer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Germany
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Athanasiou V, Papagiannis S, Antzoulas P, Papathanidis V, Stavropoulos T, Charalampous-Kefalas C, Bitas V. Total Hip Replacement and Femoral Nail Lengthening for Hip Dysplasia and Limb Length Discrepancy: A Literature Review. Cureus 2024; 16:e64638. [PMID: 39149686 PMCID: PMC11326755 DOI: 10.7759/cureus.64638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/17/2024] Open
Abstract
Developmental dysplasia of the hip (DDH) is a serious condition resulting in inadequate acetabular development, distorted bone configuration, and substantially altered hip biomechanics. An extensive leg length discrepancy (LLD) is commonly encountered in such cases, making a total hip arthroplasty (THA) procedure extremely challenging. Although good results in terms of patients' satisfaction, implant survival rates and overall improved quality of life have been reported, complication rates are considerably higher than primary THA procedures performed for idiopathic osteoarthritis. Reconstructing a dysplastic hip arthrosis and equalizing a preexisting LLD is a technically demanding procedure that is associated with significant bone and soft tissue complications. Intramedullary lengthening through motorized nails has become increasingly popular to address difficult cases with extensive LLD following THA in recent years. However, limited data on femoral lengthening procedures implemented following THA are available considering complications, radiological results, and patient-reported outcomes following staged THA and subsequent femoral lengthening using a femoral magnetically-driven intramedullary lengthening nail. We performed a literature review of the past 10 years in PubMed using the terms neglected hip dislocation, DDH, THA, and intramedullary lengthening nail as keywords. A total amount of eight cases addressing LLD through a telescoping intramedullary nail following THA in DDH have been reported in recent literature. All eight patients underwent primary THA for DDH followed by the implantation of the intramedullary lengthening nail. The mean THA was lengthened by 28.9 mm (from 13.0 to 45.0). The mean time for nail implantation after THA was 11.1 months (from 3.5 to 21). The mean time for lengthening per day through the nail was 0.94 mm (from 0.65 to 1.0) from 26 days to 70 days, and the mean lengthening through the nail was 37.6 mm (from 24.0 to 70.0). Good union and consolidation rates were reported by the authors, while there were no complications. The intramedullary distraction osteogenesis method with a telescopic rod can be an effective method to manage leg length discrepancies while avoiding soft tissue complications in challenging cases of DDH.
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Affiliation(s)
- Vasileios Athanasiou
- Department of Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | - Spyridon Papagiannis
- Department of Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | - Panagiotis Antzoulas
- Department of Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | - Vasileios Papathanidis
- Department of Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | - Theodoros Stavropoulos
- Department of Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | | | - Vasileios Bitas
- Department of Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
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Dabash S, Zhang DT, Rozbruch SR, Fragomen AT. Limb salvage reconstruction of the lower limb with complex ankle arthrodesis and magnetic internal lengthening nail. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1877-1882. [PMID: 38441634 DOI: 10.1007/s00590-024-03863-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/16/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE With advances in orthopedic implants, the use of intramedullary lengthening devices has gained increasing popularity as an alternative technique compared to lengthening with external fixators, with alleged comparable or better outcomes. The aim of this study is to report our single-center technique and outcomes of combined ankle arthrodesis and proximal tibial lengthening using external fixator with a motorized intramedullary nail, respectively. METHOD Fourteen patients with post-traumatic advanced ankle arthritis underwent staged ankle arthrodesis with external fixator and proximal tibial lengthening using the PRECICE® ILN. Amount of shortening, length achieved, bone healing index, infection rate, ankle fusion rate, and ASAMI score were evaluated. RESULTS The average age was 44 years old (range, 30-62). The mean follow up is 70 months (range, 43-121.4). The average amount of limb shortening for patients after ankle fusion was 36.7 mm (18-50) while lengthening was 35.9 mm (range, 18-50). Patients had the nail implanted for an average of 479 days (range, 248-730). Ankle fusions were healed in an average of 178.3 days. There were no surgical infections. All osteotomy-lengthening sites healed after an average 202 days (106-365). The mean bone healing index (BHI) was 56.0 days/cm (21.2-123.6) among the whole cohort. There were no cases of nonunion. ASAMI bone scores were excellent or good among all patients. CONCLUSION Ankle arthrodesis with external fixation along with proximal tibial lengthening using motorized IMN yielded high rates of fusion and successful lengthening. This technique could be offered as a reasonable alternative to using external fixation for both purposes. LEVEL OF EVIDENCE Level IV, Retrospective cohort study.
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Affiliation(s)
- Sherif Dabash
- Orthopedic Surgery Department, Ain Shams University Hospitals, Cairo, Egypt.
- Potomac Valley Hospital, WVU Medicine, 100 Pin Oak Ln., Keyser, WV, 26726, USA.
| | - David T Zhang
- Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA
| | - S Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA
| | - Austin T Fragomen
- Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA
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Vogt B, Laufer A, Gosheger G, Toporowski G, Antfang C, Rölfing JD, Rödl R, Frommer A. Evaluation of simultaneous bilateral femoral distraction osteogenesis with antegrade intramedullary lengthening nails in achondroplasia with rhizomelic short stature: a retrospective study of 15 patients with a minimum follow-up of 2 years. Acta Orthop 2024; 95:47-54. [PMID: 38287909 PMCID: PMC10825798 DOI: 10.2340/17453674.2024.35226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 11/07/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND AND PURPOSE Bilateral femoral distraction osteogenesis in patients with achondroplasia is insufficiently reported. We aimed to perform the first study that exclusively analyzed simultaneous bilateral femoral distraction osteogenesis with motorized intramedullary lengthening nails via an antegrade approach in patients with achondroplasia focused on reliability, accuracy, precision, and the evolving complications. PATIENTS AND METHODS In this retrospective singlecenter study we analyzed patients with achondroplasia who underwent simultaneous bilateral femoral lengthening with antegrade intramedullary lengthening nails between October 2014 and April 2019. 15 patients (30 femoral segments) of median age 14 years (interquartile range [IQR] 12-15) were available for analysis. The median follow-up was 29 months (IQR 27-37) after nail implantation. RESULTS The median distraction length per segment was 49 mm (IQR 47-51) with a median distraction index of 1.0 mm/day (IQR 0.9-1.0), and a median consolidation index of 20 days/cm (IQR 17-23). Reliability of the lengthening nails was 97% and their calculated accuracy and precision were 96% and 95%, respectively. The most common complication was temporary restriction of knee range of motion during distraction in 10 of 30 of the lengthened segments. 1 patient was treated with 2 unplanned additional surgeries due to premature consolidation. CONCLUSION The method is reliable and accurate with few complications.
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Affiliation(s)
- Björn Vogt
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Muenster, Germany; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany.
| | - Andrea Laufer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Muenster, Germany; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Georg Gosheger
- General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Gregor Toporowski
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Muenster, Germany; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Carina Antfang
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Muenster, Germany; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Jan Duedal Rölfing
- Children's Orthopedics and Reconstruction, Aarhus University Hospital, Aarhus, Denmark
| | - Robert Rödl
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Muenster, Germany; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Adrien Frommer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Muenster, Germany; General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
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Rosslenbroich SB, Oh CW, Kern T, Mukhopadhaya J, Raschke MJ, Kneser U, Krettek C. Current Management of Diaphyseal Long Bone Defects-A Multidisciplinary and International Perspective. J Clin Med 2023; 12:6283. [PMID: 37834927 PMCID: PMC10573364 DOI: 10.3390/jcm12196283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/14/2023] [Accepted: 09/11/2023] [Indexed: 10/15/2023] Open
Abstract
The treatment of defects of the long bones remains one of the biggest challenges in trauma and orthopedic surgery. The treatment path is usually very wearing for the patient, the patient's environment and the treating physician. The clinical or regional circumstances, the defect etiology and the patient´s condition and mental status define the treatment path chosen by the treating surgeon. Depending on the patient´s demands, the bony reconstruction has to be taken into consideration at a defect size of 2-3 cm, especially in the lower limbs. Below this defect size, acute shortening or bone grafting is usually preferred. A thorough assessment of the patient´s condition including comorbidities in a multidisciplinary manner and her or his personal demands must be taken into consideration. Several techniques are available to restore continuity of the long bone. In general, these techniques can be divided into repair techniques and reconstructive techniques. The aim of the repair techniques is anatomical restoration of the bone with differentiation of the cortex and marrow. Currently, classic, hybrid or all-internal distraction devices are technical options. However, they are all based on distraction osteogenesis. Reconstructive techniques restore long-bone continuity by replacing the defect zone with autologous bone, e.g., with a vascularized bone graft or with the technique described by Masquelet. Allografts for defect reconstruction in long bones might also be described as possible options. Due to limited access to allografts in many countries and the authors' opinion that allografts result in poorer outcomes, this review focuses on autologous techniques and gives an internationally aligned overview of the current concepts in repair or reconstruction techniques of segmental long-bone defects.
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Affiliation(s)
- Steffen Bernd Rosslenbroich
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Münster, Germany;
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu 41944, Republic of Korea;
| | - Thomas Kern
- Department of Trauma Surgery/Murnau, BG Unfallklinik Murnau, 82418 Murnau am Staffelsee, Germany;
| | - John Mukhopadhaya
- Orthopedic and Trauma Department, Paras HMRI Hospital, Patna 800014, Bihar, India;
| | - Michael Johannes Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Münster, Germany;
| | - Ulrich Kneser
- BG Trauma Center Ludwigshafen, Department of Plastic Surgery, University of Heidelberg/Ludwigshafen, 67059 Heidelberg, Germany;
| | - Christian Krettek
- Trauma Department/Hannover, Hannover Medical School, 30625 Hannover, Germany;
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10
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Vogt B, Rölfing JD, Rödl R, Tretow H. [Options and limits of leg length correction in paediatric orthopaedics]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:719-728. [PMID: 37561147 DOI: 10.1007/s00132-023-04420-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/11/2023]
Abstract
For paediatric orthopaedic surgeons treating leg length discrepancy, knowledge of the available procedures and their options and limits is just as important as mastery of the very different surgical methods and implants, as well as the possible complications, in order to be able to advise and treat the children and adolescents and their parents comprehensively and in the best interests. Both the growth inhibiting procedures and the complex bone lengthening procedures require a great deal of experience to successfully guide patients and families through what is often a lengthy and sometimes complicated treatment process. Careful preoperative indications and planning, precise surgical techniques with suitable instruments and implants, and attentive postoperative check-ups are mandatory prerequisites for the desired therapeutic success.
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Affiliation(s)
- Björn Vogt
- Kinderorthopädie, Deformitätenrekonstruktion und Fußchirurgie, Universitätsklinikum Münster, 48149, Münster, Deutschland.
| | - Jan Duedal Rölfing
- Kinderorthopädie, Deformitätenrekonstruktion und Fußchirurgie, Universitätsklinikum Münster, 48149, Münster, Deutschland
- Children's Orthopaedics and Reconstruction, Aarhus University Hospital, Aarhus, Dänemark
| | - Robert Rödl
- Kinderorthopädie, Deformitätenrekonstruktion und Fußchirurgie, Universitätsklinikum Münster, 48149, Münster, Deutschland
| | - Henning Tretow
- Kinderorthopädie, Deformitätenrekonstruktion und Fußchirurgie, Universitätsklinikum Münster, 48149, Münster, Deutschland
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11
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Tran TH, Hanna SM, Gundle KR, Yang S. Femoral Magnetic Lengthening After Distal Femur Endoprosthetic Reconstruction in a Pediatric Patient: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00067. [PMID: 37616419 DOI: 10.2106/jbjs.cc.23.00089] [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: 08/26/2023]
Abstract
CASE A 10-year-old boy with osteosarcoma of the left distal femur underwent resection with compressive osseointegration endoprosthetic reconstruction, gradually resulting in a 4.5-cm leg-length difference with significant predicted progression. Two years after resection, he underwent right distal femur and proximal tibia epiphysiodesis and placement of a left femoral magnetic lengthening nail. At 2 years after lengthening and skeletal maturity, the patient has symmetric limb lengths, no pain, and returned to sports. CONCLUSION A magnetic lengthening nail with contralateral epiphysiodesis is a viable option for correcting limb-length discrepancy after distal femur endoprosthetic reconstruction in a pediatric patient.
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Affiliation(s)
- Tina H Tran
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - Sarah M Hanna
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - Kenneth R Gundle
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
- Operative Care Division, Portland VA Medical Center, Portland, Oregon
| | - Scott Yang
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
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12
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Reif TJ, Geffner A, Hoellwarth JS, Fragomen AT, Rozbruch SR. Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms. Strategies Trauma Limb Reconstr 2023; 18:94-99. [PMID: 37942435 PMCID: PMC10628610 DOI: 10.5005/jp-journals-10080-1514] [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: 02/10/2022] [Accepted: 03/11/2023] [Indexed: 11/10/2023] Open
Abstract
Aims The Precice Stryde® internal magnetic lengthening nail allowed many patients a full weight-bearing experience during femur and tibia lengthening, but concerns over corrosion, pain and radiographic changes led to the implant's recall. Despite the recall, it is important to understand the rate of these occurrences and their influence on the overall success of the lengthening procedure. We aimed to investigate radiographic changes, patient-reported symptoms and bone healing indices for our cohort of Stryde lengthening. Materials and methods Our surgical database and electronic medical record system were used to review and document patient demographics, indications for lengthening, length achieved, bone healing index (BHI), location and type of radiographic changes, time until radiographic changes were first visible, presence of pain symptoms (not attributable to surgery or distraction), time to implant removal and if the pain symptoms resolved following implant extraction. Results From January 2019 to February 2021, 90 Stryde nails (78 femur and 12 tibia) were implanted in 63 patients. The cohort included 48 males and 15 females. The average length [± standard deviation (SD)] achieved was 58.4 ± 22.7 mm. The 66 bones (73%) developed radiographic changes and were found to be 58/78 (74%) femurs and 8/12 (67%) tibias. The average time to initial radiographic changes was 168 ± 108.1 days (femur) and 276 ± 126.8 days (tibia). Late-onset pain developed in 10 femur lengthening (11.1% of all nails) surgeries across eight patients (12.7% of all patients). All patients' pain resolved; three instances prior to nail removal and the remaining seven after nail removal. No patients were re-presented with worsening pain or radiographic changes following implant removal. Radiographic or symptomatic abnormalities did not impair bone formation. The BHI for femurs with (29.6 ± 16.6 days/cm, n = 58) vs without (29.4 ± 17.9 days/cm, n = 20) radiographic or symptomatic irregularity were nearly identical (p = 0.961). The difference between BHI for tibias with (39.3 ± 7.8 days/cm, n = 8) vs without (86.1 ± 38.2 days/cm, n = 4) radiographic changes was influenced by outliers and underpowered to draw a conclusion. Conclusion Bone lengthening with the Stryde nail was associated with high rates of radiographic abnormalities, but symptoms were uncommon and resolved with explantation. The radiographic changes did not affect bone healing in the femur. Clinical significance Radiographic changes including bone hypertrophy and osteolysis were common after bone lengthening with the Stryde nail, but the development of pain following consolidation was rare and resolved with implant removal.The BHI in femurs was not affected by radiographic changes. How to cite this article Reif TJ, Geffner A, Hoellwarth JS, et al. Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms. Strategies Trauma Limb Reconstr 2023;18(2):94-99.
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Affiliation(s)
- Taylor J Reif
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States of America
| | - Adam Geffner
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States of America
| | - Jason S Hoellwarth
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States of America
| | - Austin T Fragomen
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, United States of America
| | - S Robert Rozbruch
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, United States of America
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13
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Laufer A, Frommer A, Gosheger G, Toporowski G, Duedal Rölfing J, Antfang C, Roedl R, Vogt B. Antegrade Intramedullary Femoral Lengthening and Distal Temporary Hemiepiphysiodesis for Combined Correction of Leg Length Discrepancy and Coronal Angular Deformity in Skeletally Immature Patients. J Clin Med 2023; 12:jcm12083022. [PMID: 37109358 PMCID: PMC10142902 DOI: 10.3390/jcm12083022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 04/29/2023] Open
Abstract
Leg length discrepancies (LLD) are frequently associated with coronal malalignment. Temporary hemiepiphysiodesis (HED) is a well-established procedure for the correction of limb malalignment in skeletally immature patients. For treatment of LLD > 2 cm, lengthening with intramedullary devices gains increasing popularity. However, no studies have investigated the combined application of HED and intramedullary lengthening in skeletally immature patients. This retrospective single-center study evaluated the clinical and radiological outcomes of femoral lengthening with an antegrade intramedullary lengthening nail combined with temporary HED performed in 25 patients (14 females) between 2014 and 2019. Temporary HED through the implantation of flexible staples of the distal femur and/or proximal tibia was either performed prior (n = 11), simultaneously (n = 10) or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). The median initial LLD was 39.0 mm (35.0-45.0). Twenty-one patients (84%) presented valgus and four (16%) showed varus malalignment. Leg length equalization was achieved in 13 of the skeletally mature patients (62%). The median LLD of the eight patients with residual LLD > 10 mm at skeletal maturity was 15.5 mm (12.8-21.8). Limb realignment was observed in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Combining antegrade femoral lengthening and temporary HED is a viable option to correct LLD and coronal limb malalignment in skeletally immature patients; however, achieving limb length equalization and realignment may be difficult in cases of severe LLD and angular deformity, in particular.
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Affiliation(s)
- Andrea Laufer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, 48149 Muenster, Germany
- General Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Adrien Frommer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, 48149 Muenster, Germany
- General Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Georg Gosheger
- General Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Gregor Toporowski
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, 48149 Muenster, Germany
- General Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Jan Duedal Rölfing
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, 48149 Muenster, Germany
- Children's Orthopedics and Reconstruction, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Carina Antfang
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, 48149 Muenster, Germany
- General Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Robert Roedl
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, 48149 Muenster, Germany
| | - Bjoern Vogt
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, 48149 Muenster, Germany
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14
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Alrabai HM. Breakage of a re-activated PRECICE® nail: A case report. Int J Surg Case Rep 2023; 106:108182. [PMID: 37060767 PMCID: PMC10130627 DOI: 10.1016/j.ijscr.2023.108182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/07/2023] [Accepted: 04/08/2023] [Indexed: 04/17/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Distraction osteogenesis using motorized nails have shown promising results. These high-priced nails are regularly removed following successful lengthening sessions. The internal lengthening mechanism inside such nails is presumably intact and perhaps capable of running additional lengthening. Motorized nails are relatively weaker than conventional nails. This case report presented a broken re-activated PRECICE nail which has not been previously reported. PRESENTATION OF CASE A 21-year-old male patient with right short tibia. He has completed an uneventful lengthening session using tibial PRECICE® nail. A residual length discrepancy persisted despite 4 cm length gain. Attempt of re-lengthening was conducted utilizing the pre-implanted PRECICE® nail. The re-lengthening session run smoothly throughout distraction phase. Late in the consolidation phase, partial nail breakage occurred. The patient acknowledged intermittent gentle weightbearing against the physician's recommendations. The broken nail was removed on emergency basis. Cast immobilization with non-weightbearing continued until achievement of full consolidation clinically and radiographically. CLINICAL DISCUSSION Most of commercially available lengthening motorized nails are considered less rigid compared to conventional nails and hence more susceptible to deformation and metal failure. However, nail breakage has been reported in both conventional and lengthening nails. Re-activation of PRECICE nail for additional lengthening session could carry higher risk of breakage. CONCLUSION Possibility of nail breakage may be higher in re-activated PRECICE® nails relative to newly implanted PRECICE® nails. More studies are required to evaluate behavior of re-activated lengthening nails. Defective lengthening nails must not be re-activated. The patient compliance is essential for successful re-activation of lengthening nails.
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Affiliation(s)
- Hamza M Alrabai
- Department of Orthopedics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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15
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Hafez M, Nicolaou N, Offiah A, Obasohan P, Dixon S, Giles S, Madan S, Fernandes JA. How Much Does Paediatric Femoral Lengthening Cost? A Cost Comparison between Magnetic Lengthening Nails and External Fixators. Strategies Trauma Limb Reconstr 2023; 18:16-20. [PMID: 38033930 PMCID: PMC10682557 DOI: 10.5005/jp-journals-10080-1573] [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: 03/03/2022] [Accepted: 01/23/2023] [Indexed: 12/02/2023] Open
Abstract
Aim Motorised intramedullary lengthening nails are considered more expensive than external fixators for limb lengthening. This research aims to compare the cost of femoral lengthening in children using the PRECICE magnetic lengthening nail with external fixation. Methods Retrospective analysis of 50 children who underwent femoral lengthening. One group included patients who were treated with PRECICE lengthening nails, the other group included patients who had lengthening with external fixation. Each group included 25 patients aged between 11 and 17 years. The patients in both groups were matched for age. Cost analysis was performed following micro-costing and analysis of the used resources during the different phases of the treatments. Results Each group's mean patient age was 14.7 years. Lengthening nails were associated with longer operative times compared with external fixators, both for implantation and removal surgery (p-values of 0.007 and < 0.0001, respectively). Length of stay following the implantation surgery, frequency of radiographs and frequency of outpatient department appointments were all lower with lengthening nails. The overall cost of lengthening nails was £1393 more than external fixators, however, this difference was not statistically significant (p-value = 0.088). Conclusion The difference in the mean costs between femoral lengthening with lengthening nails versus external fixators was not statistically significant. Further research to review the effectiveness of the devices and the quality of life during the lengthening process is crucial for robust health economic evaluation. How to cite this article Hafez M, Nicolaou N, Offiah A, et al. How Much Does Paediatric Femoral Lengthening Cost? A Cost Comparison between Magnetic Lengthening Nails and External Fixators. Strategies Trauma Limb Reconstr 2023;18(1):16-20.
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Affiliation(s)
- Mohamed Hafez
- Department of Paediatric Trauma and Orthopaedic, Sheffield Children's Hospital, Sheffield, England, United Kingdom
| | - Nicolas Nicolaou
- Department of Paediatric Trauma and Orthopaedic, Sheffield Children's Hospital, Sheffield, England, United Kingdom
| | - Amaka Offiah
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Phillips Obasohan
- Department of Medical Statistics, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Simon Dixon
- Department of Health Economics and Decision Science, School of Health and Related Research, Sheffield, United Kingdom
| | - Stephen Giles
- Department of Trauma and Orthopaedics, Sheffield Children's Hospital, Sheffield, England, United Kingdom
| | - Sanjeev Madan
- Department of Paediatric Limb Reconstruction, Sheffield Children's Hospital NHS Trust, Sheffield, England, United Kingdom
| | - James Alfred Fernandes
- Department of Trauma and Orthopaedics, Sheffield Children's Hospital, Sheffield, England, United Kingdom
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16
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Mittal A, Allahabadi S, Jayaram R, Nalluri A, Callahan M, Sabharwal S. Trends and Practices in Limb Lengthening: An 11-year US Database Study. Strategies Trauma Limb Reconstr 2023; 18:21-31. [PMID: 38033925 PMCID: PMC10682549 DOI: 10.5005/jp-journals-10080-1574] [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: 02/10/2022] [Accepted: 03/11/2023] [Indexed: 12/02/2023] Open
Abstract
Aim Over the past couple of decades, limb lengthening has evolved to encompass various implants and techniques. The purpose of this study was to (1) determine trends in the utilisation of various limb lengthening techniques for the femur and tibia in the United States, (2) determine trends in 1-year readmission rate following limb lengthening procedures and (3) to study the relationship of limb lengthening implant used and payment method used with the underlying diagnosis associated with limb shortening. Materials and methods Inpatient data were acquired using the Healthcare Cost and Utilisation Project (HCUP) database from 2005 to 2015 from seven states in the United States. Patients with an International Classification of Diseases (ICD)-9 code for limb lengthening of the femur or tibia were included. A total of 2,563 patients were included. Data were analysed using descriptive statistics, and chi-square test was used for comparison of subcategories. Linear regression analysis was used to examine trends over time. Results There was a strong linear trend towards increasing proportional use of internal lengthening of the femur from 2011 to 2015 (R2 = 0.99) with an increase of 10.2% per year. A similar trend towards increasing proportional use of internal lengthening of the tibia was seen from 2011 to 2015 (R2 = 0.87) with an increase of 4.9% per year. There was a moderate correlation showing a decrease in readmission rate of 1.07% per year from 2005 to 2015 (R2 = 0.55). Patients with short stature had increased use of internal lengthening and self-payment compared to patients with congenital, post-traumatic or other diagnoses. Conclusion There was increasing use of internal lengthening techniques from 2011 to 2015. Patients with short stature had higher use of internal lengthening technique and self-pay for payment method. Clinical significance Intramedullary devices have seen increasing use for limb lengthening procedures. Lengthening technique and payment method may differ by underlying diagnosis. How to cite this article Mittal A, Allahabadi S, Jayaram R, et al. Trends and Practices in Limb Lengthening: An 11-year US Database Study. Strategies Trauma Limb Reconstr 2023;18(1):21-31.
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Affiliation(s)
- Ashish Mittal
- Department of Orthopedic Surgery, St. Mary's Medical Center, San Francisco, California, United States of America
| | - Sachin Allahabadi
- Department of Orthopedic Surgery, University of California, San Francisco, California, United States of America
| | - Rishab Jayaram
- Department of Orthopedic Surgery, University of Rochester, Rochester, New York, United States of America
| | - Abhinav Nalluri
- Department of Orthopedic Surgery, St. Mary's Medical Center, San Francisco, California, United States of America
| | - Matt Callahan
- Department of Orthopedic Surgery, University of California, San Francisco, California, United States of America
| | - Sanjeev Sabharwal
- Department of Orthopedic Surgery, University of California, San Francisco; UCSF Benioff Children's Hospital, Oakland, California, United States of America
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17
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Tremblay JO, Bernstein JM, Schoenleber SJ. Lower Extremity Malformations. Pediatr Rev 2022; 43:704-713. [PMID: 36450641 DOI: 10.1542/pir.2020-001180] [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: 12/05/2022]
Affiliation(s)
| | - Jessica M Bernstein
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
| | - Scott J Schoenleber
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR
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18
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Frommer A, Roedl R, Vogt B. Reply to the Letter to the Editor: What Are the Potential Benefits and Risks of Using Magnetically Driven Antegrade Intramedullary Lengthening Nails for Femoral Lengthening to Treat Leg Length Discrepancy? Clin Orthop Relat Res 2022; 480:2463-2464. [PMID: 36190491 PMCID: PMC10538866 DOI: 10.1097/corr.0000000000002439] [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: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Adrien Frommer
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany
| | - Robert Roedl
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany
| | - Bjoern Vogt
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany
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19
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Egea-Gámez RM, Galán-Olleros M, Alonso-Hernández J, Miranda-Gorozarri C, Martínez-Caballero I, Palazón-Quevedo Á, González-Díaz R. Improvement of the sagittal alignment of the spine in patients with achondroplasia after subtrochanteric femoral lengthening. Spine Deform 2022; 10:1443-1452. [PMID: 35653063 DOI: 10.1007/s43390-022-00523-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 05/07/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Limb-lengthening surgery to treat short stature has undergone great development in recent years with the use of intramedullary telescopic nails (TIMNs). A limited number of studies have explored the impact of lower limb lengthening on the spine, though their conclusions are not consistent. The aim of this research is to analyze changes in spinopelvic sagittal alignment and balance after lower limb lengthening in achondroplastic patients. METHODS Prospective study of patients with achondroplasia treated with bilateral femoral lengthening using an TIMN. Different sagittal spinal and pelvic plane parameters were measured on pre- and 2 year postoperative lateral spine radiographs: cervical lordosis, thoracic kyphosis, TL junction, lumbar lordosis (LL), pelvic incidence, pelvic tilt (PT), sacral slope (SS), and sagittal vertebral axis (SVA). Similarly, information regarding the elongation procedure was recorded. RESULTS A total of 10 patients were included (60% male), with a median age of 13.39 (2.32) years at first surgery and a median height of 120.3 (5.75) cm. A 10 cm elongation was performed in all patients through femoral subtrochanteric osteotomy. Statistically significant changes were found in LL -15.2 (7.4-17.9)º (p = 0.028), PT 11.7 (10.3-13.4)º (p = 0.018), SS - 11.6 (- 13.4 to - 10.4)º (p = 0.018) and |SVA| - 34.3 (- 39.10 to - 1.7) mm (p = 0.043). CONCLUSION Bilateral lower limb lengthening in patients with achondroplasia not only increases their size, but also improves sagittal spinopelvic alignment and balance. This may be due to retroversion of the pelvis and subsequent decrease in SS and LL as a result of the increased tightness of the gluteus maximus and hamstring muscles after femoral lengthening through subtrochanteric osteotomy. LEVEL OF EVIDENCE II, prospective comparative cohort study, before and after intervention.
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Affiliation(s)
- Rosa M Egea-Gámez
- Spinal Unit, Pediatric Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Av. de Menéndez Pelayo, 65, 28009 JCR, Madrid, Spain.
| | - María Galán-Olleros
- Pediatric Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Javier Alonso-Hernández
- Pediatric Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Carlos Miranda-Gorozarri
- Pediatric Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Ignacio Martínez-Caballero
- Neuro-Orthopaedic Unit, Pediatric Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Ángel Palazón-Quevedo
- Pediatric Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Rafael González-Díaz
- Spinal Unit, Pediatric Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Av. de Menéndez Pelayo, 65, 28009 JCR, Madrid, Spain
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20
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Calder PR, Wright J, Goodier WD. An update on the intramedullary implant in limb lengthening: A quinquennial review Part 1: The further influence of the intramedullary nail in limb lengthening. Injury 2022; 53 Suppl 3:S81-S87. [PMID: 35768325 DOI: 10.1016/j.injury.2022.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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 goal of limb lengthening is to restore length to bone, safely stretch soft tissues and improve quality of life with minimal complications. Traditionally this was achieved with the use of external fixators, associated with complications related to pin site tethering and infections, joint stiffness and regenerate deformity and fracture following frame removal. The duration of treatment also impacts on patient mental health and well-being. In order to reduce external fixator time, intramedullary nails have been introduced as an adjunct, either at the initial surgery or after completion of lengthening. Complications related to the external fixator still remained and innovation has led to the popularisation of the intramedullary lengthening nail. The lengthening mechanism of the nail can be divided into those with ratchet systems and those driven by motors. In the ratchet group, patients are required to manually rotate their limb, with movement at the osteotomy site, in order to create forward movement. This was often associated with pain, and in some cases led to the requirement of general anaesthesia to enable rotation and continuation of lengthening. Further issues were reported related to lengthening rate control. Once the nail had lengthened sufficiently for the osteotomy to disengage, rapid lengthening termed a 'runaway' nail could occur. The nails were limited to forward movement, and once length was gained it could not be retracted, leading to poor regenerate formation and soft tissue contractures. The introduction of the Fitbone implant utilised a transcutaneous electrical conduit, powered by a high frequency electrical signal, enabling more control over the lengthening. The Precice intramedullary lengthening system is controlled by the use of an external device with two rotating neodymium magnets, which produce rotation of a third magnet in the nail. By altering the direction of the magnet rotation, the lengthening can be controlled both forwards and backwards with sub-millimetre precision. Following initial excellent outcomes published, the use of the lengthening intramedullary nail has become accepted by many as the implant of choice in limb lengthening. The aim of this article comes in two parts. The first to highlight the latest research and clinical results in the last five years using an intramedullary implant during limb lengthening, and the second to report the outcome in extended surgical indications and further implant innovation.
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Affiliation(s)
- Peter R Calder
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK.
| | - Jonathan Wright
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK
| | - W David Goodier
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK
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21
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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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22
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Mittal A, Allahabadi S, Jayaram R, Nalluri A, Callahan M, Sabharwal S. What Factors Correlate With Length of Stay and Readmission After Limb Lengthening Procedures? A Large-database Study. Clin Orthop Relat Res 2022; 480:1754-1763. [PMID: 35353078 PMCID: PMC9384914 DOI: 10.1097/corr.0000000000002201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures. QUESTIONS/PURPOSES (1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission? METHODS Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses. RESULTS Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only. CONCLUSION When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Ashish Mittal
- Department of Orthopaedic Surgery, St. Mary’s Medical Center, San Francisco, CA, USA
| | - Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Abhinav Nalluri
- Department of Orthopaedic Surgery, St. Mary’s Medical Center, San Francisco, CA, USA
| | - Matt Callahan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Sanjeev Sabharwal
- Department of Orthopaedic Surgery, University of California, San Francisco. UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
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Gigi R, Hemo Y, Danino B, Ovadia D, Segev E. Changes in the femoral osteotomy level coefficient and neck shaft angle during limb lengthening with an intramedullary magnetic nail. Arch Orthop Trauma Surg 2022; 142:1739-1742. [PMID: 33555401 DOI: 10.1007/s00402-020-03740-9] [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: 05/05/2020] [Accepted: 12/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The intramedullary magnetic IM nail enables bone graduated distraction. Proximal femur osteotomies for ante grade IM lengthening nails have a tendency towards varus-procurvatum malalignment. We examined the effect of the level of the osteotomy and of trochanteric versus piriformis entry points on the neck shaft angle (NSA) during lengthening with the PRECICE IM magnetic nail. METHODS A novel parameter, the osteotomy level coefficient (OLC), was introduced as a guide to determine the level of an osteotomy at the proximal femur. The OLC was defined as the ratio between the distances from the tip of the greater trochanter to the osteotomy divided by the full length of the femur. A retrospective review of all femoral lengthening procedures with the PRECICE ante grade IM lengthening nail between 2013 and 2018 was carried out. RESULTS 31 femurs were lengthened in 30 patients (16 males and 14 females, mean age at surgery years 17.1. The average amount of lengthening was 4.4 cm. Trochanteric entry points were used in 24 femurs, and piriformis entry points in seven femurs. The OLC values ranged from 0.16 to 0.34 (average 0.25). The average follow-up period was 10.15 months. The distraction index average 10.5 days/cm (Range 8.6-11.9), Consolidation index 32.1 days/cm (14.3-51.9). The average post-operative NSA was significantly reduced from 133.5º to 128.5º [t (31) = 5.57, p = 0.000]. There was no correlation between the OLC and the change in the NSAs. The trochanteric entry point showed a greater tendency to reduce the NSA (Mdif = - 6, SD = 4.8) compared to the piriformis entry point (Mdif = - 0.86, SD = 2.27) [t (31) = -3.96, p = 0.001]. CONCLUSION Proximal femur lengthening with the PRECICE IM nail significantly reduced the NSA and might cause Varus deformity. The level of osteotomy by OLC did not influence the amount of NSA reduction. The trochanteric entry points have a greater tendency to reduce the NSA compared to the piriformis entry points.
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Affiliation(s)
- Roy Gigi
- Department of Pediatric Orthopedic Surgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Yoram Hemo
- Department of Pediatric Orthopedic Surgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Baruch Danino
- Department of Pediatric Orthopedic Surgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Dror Ovadia
- Department of Pediatric Orthopedic Surgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Eitan Segev
- Department of Pediatric Orthopedic Surgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel.
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Alonso-Hernández J, Galán-Olleros M, Miranda-Gorozarri C, Egea-Gámez RM, Palazón-Quevedo Á. Two-stage Bone Lengthening With Reuse of a Single Intramedullary Telescopic Nail in Patients With Achondroplasia. J Pediatr Orthop 2022; 42:e616-e622. [PMID: 35250019 DOI: 10.1097/bpo.0000000000002133] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with achondroplasia may benefit from limb-lengthening surgery with telescopic intramedullary nails (TIMNs). However, the 5-cm maximum length of the nails used in these patients in their original design may be insufficient. The aim of this research is to analyze the outcomes and complications after reusing the same TIMN for a second consecutive 5-cm lengthening in patients with achondroplasia. METHODS Retrospective study of 26 bones (16 femurs and 10 tibias) in 9 patients with achondroplasia treated for bilateral 2-stage sequential lengthening reusing the same TIMN. On completion of a first stage of 5 cm of elongation, the nail was unlocked, retracted, and re-locked; a second stage of 5 cm of distraction followed. Radiologic and clinical parameters were measured preoperatively and postoperatively, and complications were recorded. RESULTS The median age of patients at first surgery was 13.54 (12.9 to 16.3) years; 55% were males. The median preoperative height was 121 (117.5 to 127) cm, and the median healing index was 18.12 (14.5 to 32.8) and 26.96 (23.3 to 31.6) d/cm, while time to weight bearing was 185.5 (144.8 to 308.5) and 242.5 (208.5 to 293.8) days for femurs and tibias, respectively. Major complications included 3 cases of moderate ankle equinus, 2 cases of hardware failure (failure to relengthen), 2 premature consolidations, 1 common peroneal neurapraxia, and 2 valgus deformities. Femoral procedures had significantly fewer complications than tibial interventions (7 vs. 15, P=0.03), whereas patients who underwent lengthening of both the femur and tibia did not have significantly higher complication rates (14 vs. 8, P=0.6). CONCLUSIONS This study analyzes lower-limb lengthening in a series of achondroplastic patients using TIMN with the novelty of nail reuse to relengthen the bone. The complication rate found is acceptable, among which, potential damage to the internal lengthening mechanism must be considered, though this complication can usually be easily resolved. Overall, nail reuse seems advisable in cases where bone elongation is indicated, and the size and design of the nail limits the extent of lengthening. LEVEL OF EVIDENCE Level III, retrospective comparative study, before and after intervention.
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Affiliation(s)
- Javier Alonso-Hernández
- Limb Lengthening and Reconstruction Unit, Orthopaedic Surgery and Traumatology Department
- Department of Orthopaedic Surgery and Traumatology
| | | | - Carlos Miranda-Gorozarri
- Limb Lengthening and Reconstruction Unit, Orthopaedic Surgery and Traumatology Department
- Department of Orthopaedic Surgery and Traumatology
| | - Rosa M Egea-Gámez
- Department of Orthopaedic Surgery and Traumatology
- Spinal Unit, Department of Orthopaedic Surgery and Traumatology
| | - Ángel Palazón-Quevedo
- Department of Orthopaedic Surgery and Traumatology
- Hip Unit, Department of Orthopaedic Surgery and Traumatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Affiliation(s)
- Shao-Ting J. Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nando Ferreira
- Division Orthopaedic Surgery Department of Surgical Sciences, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
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Femoral Lengthening in Children: A Comparison of Motorized Intramedullary Nailing Versus External Fixation Techniques. J Pediatr Orthop 2022; 42:253-259. [PMID: 35180729 DOI: 10.1097/bpo.0000000000002120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoral lengthening is associated with high complication rates often related to the type of surgical device used to perform the lengthening. The advent of intramedullary lengthening devices has promised a reduction in complications when compared with external fixation systems. The purpose of this study was to compare the clinical outcomes of femoral lengthening in children using a motorized intramedullary nail (Precice) versus an external fixation system (Taylor Spatial Frame-TSF; or Monolateral Rail System-MRS) at a single institution, single surgeon practice. METHODS This study is a retrospective comparison of pediatric patients who had previously undergone femoral lengthening (±deformity correction). Patients ages 8 to 18 years of age were included and grouped based on whether they had undergone Precice nailing or external fixation (TSF or MRS) between 2010 and 2019. RESULTS Twenty-seven patients (32 femurs) were included. Thirteen patients (15 femurs) had undergone Precice nailing and 14 patients (17 femurs) had undergone external fixation. The Precice group had significantly fewer problems, obstacles, and complications than the external fixation group, Precice 6.6%, 0%, 0%, respectively, and external fixation 47.1%, 29.4%, 0% respectively (P<0.01). Unplanned return to the operating room occurred in 4 cases, solely in the external fixation group. There were no differences in percentage of goal length achieved, Precice (mean 93.6%, range: 66.7% to 114.3%), external fixation (mean 96%, range: 76.9% to 117.5%) P=0.31 and total length achieved, Precice (mean: 44 mm, range: 20 to 80 mm), external fixation (mean: 46 mm, range: 10 to 70 mm) P=0.72. There was no difference in consolidation index, Precice (24.1 d/cm), external fixation (28.5 d/cm) P=0.36. The Precice group had a significantly shorter length of stay (mean: 2.2 d, range: 1 to 4 d), compared with the external fixation group (mean: 3.7 d, range: 2 to 8), P=0.01. CONCLUSIONS Femoral lengthening in children using a motorized intramedullary nail was associated with a markedly reduced rate of complications and shorter length of stay compared with external fixation. LEVEL OF EVIDENCE Level III.
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Pain levels during distraction osteogenesis with lengthening nails in 168 cases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1167-1172. [PMID: 35476026 PMCID: PMC10125921 DOI: 10.1007/s00590-022-03266-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To firstly examine the pain levels during distraction osteogenesis (DO) with lengthening nails (LN) in a large sample. METHODS A total of 168 cases underwent DO of the tibia or femur with five different models of LN. Under a standardized medical regime, daily pain levels were noted as nominal rating scale (NRS) score (0-10) during the distraction phase. NRS scores and several potential influence factors (LN model, bone, approach, side, age, gender) were evaluated. RESULTS The mean distraction length was 39.1 ± 14.4 mm. The average NRS score decreased from postoperative day 1 with 2.84 nonlinearly by 1.03 points (36.3%) over the course of 62 days to an average score of 1.81. The mean decrease during the first thirty days was 0.67(23.6%). Subgroup analysis did not reveal any influence factors. CONCLUSION Pain levels during the distraction phase are overall low, continuously decreasing, and well manageable with mostly non-opioid analgesics.
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Hafez M, Nicolaou N, Offiah A, Offorha B, Giles S, Madan S, Fernandes JA. Quality of life of children during distraction osteogenesis: a comparison between intramedullary magnetic lengthening nails and external fixators. INTERNATIONAL ORTHOPAEDICS 2022; 46:1367-1373. [PMID: 35385976 PMCID: PMC9117380 DOI: 10.1007/s00264-022-05399-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/31/2022] [Indexed: 12/01/2022]
Abstract
Background Distraction osteogenesis is a very demanding process. For decades, external fixation was the only reliable option for gradual deformity correction. Recently, intramedullary magnetic nails have gained popularity. This research aimed to assess the quality of life in children during gradual deformity correction using intramedullary lengthening nails compared to external fixation. Method Prospective analysis included children who had gradual lower limb deformity correction between 2017 and 2019. Group A included children who had magnetic lengthening nails; patients in group B had external fixation devices. Child health utility 9D (CHU- 9D) and EuroQol 5D youth (EQ- 5D-Y) were used to measure the quality of life at fixed points during the distraction osteogenesis process. The results were used to calculate the utility at each milestone and the overall quality of life adjusted years (QALYs). Results Thirty-four children were recruited, group A had 16 patients, whilst group B had 18 patients. The average ages were 16.0 years and 14.7 years for groups A and B, respectively. Group A patients reported significantly better utility compared to group B. This was observed during all stages of treatment (P = 0.00016). QALYs were better for group A (0.44) compared to group B (0.34) (P < 0.0001). Conclusion The quality of life was generally better in group A compared to group B. In most patients, the health utility progressively improved throughout treatment. In the same way, QALYs were better with the lengthening nails compared to external fixators. The magnetic lengthening devices (PRECICE nails) which were used in this research were recently relabelled to restrict their applications in children; this study was conducted before these restrictions.
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Affiliation(s)
- Mohamed Hafez
- Paediatric Limb Reconstruction Unit, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK. .,Oncology and Metabolism Department, Medical School, Sheffield University, Sheffield, UK.
| | - Nicolas Nicolaou
- Paediatric Limb Reconstruction Unit, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.,Sheffield University, Sheffield, UK
| | - Amaka Offiah
- Oncology and Metabolism Department, Medical School, Sheffield University, Sheffield, UK
| | - Bright Offorha
- School of Health and Related Research, Sheffield University, Sheffield, UK
| | - Stephen Giles
- Paediatric Limb Reconstruction Unit, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.,Sheffield University, Sheffield, UK
| | - Sanjeev Madan
- Paediatric Limb Reconstruction Unit, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.,Sheffield University, Sheffield, UK
| | - James A Fernandes
- Paediatric Limb Reconstruction Unit, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.,Sheffield University, Sheffield, UK
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Frommer A, Roedl R, Gosheger G, Niemann M, Turkowski D, Toporowski G, Theil C, Laufer A, Vogt B. What Are the Potential Benefits and Risks of Using Magnetically Driven Antegrade Intramedullary Lengthening Nails for Femoral Lengthening to Treat Leg Length Discrepancy? Clin Orthop Relat Res 2022; 480:790-803. [PMID: 34780384 PMCID: PMC8923575 DOI: 10.1097/corr.0000000000002036] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Limb lengthening with magnetically driven intramedullary lengthening nails is a fast-developing field and represents an alternative to external fixators. Although previous studies have assessed the application of magnetically driven intramedullary lengthening nails, these studies have been heterogenous regarding the nailing approach, the bone treated, and the implant type; they also have analyzed relatively small patient groups at short follow-up durations. QUESTIONS/PURPOSES (1) Is femoral lengthening with magnetically driven antegrade intramedullary lengthening nails accurate and precise? (2) What are the most common complications of treatment? (3) What factors are associated with unplanned additional surgery? METHODS We retrospectively analyzed the longitudinally maintained database of our orthopaedic teaching hospital to identify all patients who underwent surgery for leg length discrepancy (LLD) between October 2014 and April 2019. In total, we surgically treated 323 patients for LLD of 2 cm or more. Of those 55% (177 of 323) were treated with distraction osteogenesis with magnetically driven intramedullary lengthening nails, 18% (59 of 323) with external fixation, and 27% (87 of 323) with epiphysiodesis around the knee. Based on that, 29% (93 of 323) of patients underwent unilateral femoral distraction osteogenesis with magnetically driven antegrade femoral lengthening nails and were eligible for analysis. No patient was excluded, and 3% (3 of 93) were lost before the minimum study follow-up of 2 years, leaving 97% (90 of 93) for analysis. Patients with a distal femoral deformity were treated via a retrograde femoral approach (10% [33 of 323]) or with external fixators (3% [10 of 323]) and were not included in this study. Distraction osteogenesis with magnetically driven intramedullary lengthening nails was not considered for patients with deep tissue infection, those with bone dimensions considered to be too small in relation to the available implants, and for patients younger than 8 years. This study included 90 patients (44 females, 43 left femora) treated for a median (interquartile range) preoperative LLD of 39 mm (32 to 52) at a median age of 15 years (14 to 17). The same limb lengthening system was applied in all patients. The median (IQR) follow-up was 35 months (24 to 78). Data were acquired through a chart review performed by someone not involved in the surgical care of the included patients. Data acquisition was supervised and curated by two of the involved surgeons. Accuracy was calculated as 100 - [(achieved distraction in mm - planned distraction in mm) / (planned distraction in mm) x 100] and precision as 100 - (relative standard deviation of accuracy). Treatment-associated complications were summarized descriptively and characterized as complications resulting in unplanned additional surgery or those not resulting in unplanned surgery. To analyze the risk of unplanned additional surgery by entity, we calculated odds ratios (ORs) comparing the incidence of unplanned additional surgery in the different entity cohorts with the idiopathic LLD cohort as a reference. By calculating ORs, we analyzed the risk for unplanned additional surgery depending on sex, age, surgery time, and previous lengthening. Due to the lack of long-term evidence about motorized lengthening nails remaining in situ and concerns about potential implant-related adverse effects, removal was routinely scheduled 1 year after consolidation. For implant removal, 92% (83 of 90) of patients underwent planned additional surgery, which was not recorded as an adverse event of the treatment. Ninety-seven percent (87 of 90) of patients completed lengthening with the implant remaining in situ until the end of distraction. The median (IQR) distraction length was 37 mm (30 to 45) with a median distraction index of 0.9 mm/day (0.7 to 1.0) and median consolidation index of 31 days/cm (25 to 42). RESULTS The calculated accuracy and precision were 94% and 90%, respectively. In total, 76% (68 of 90) of our patients experienced complications, which resulted in 20% (18 of 90) of patients undergoing unplanned additional surgery. The most common complication overall was adjustment of the distraction rate in 27% (24 of 90) of patients (faster: 16% [14 of 90]; slower: 11% [10 of 90]) and temporary restriction of knee motion, which occurred in 20% (18 of 90) of our patients and resolved in all patients who experienced it. The most serious complications were bacterial osteomyelitis and knee subluxation, which occurred in 3% (3 of 90) and 1% (1 of 90) of our patients, respectively. With the numbers available, we found only one factor associated with an increased likelihood of unplanned additional surgery: Patients with postinfectious LLD had higher odds of unplanned additional surgery than patients with idiopathic LLD (7% [1 of 15] versus 50% [3 of 6], OR 14.0 [95% CI 1.06 to 185.49]; p = 0.02). However, we caution readers this finding is fragile, and the confidence interval suggests that the effect size estimate is likely to be imprecise. CONCLUSION Femoral distraction osteogenesis with magnetically driven antegrade intramedullary lengthening nails appears to be an accurate and reliable treatment for femoral lengthening. However, depending on the etiology, a high risk of unplanned additional surgery should be anticipated, and a high proportion of patients will experience temporary joint stiffness. We recommend close orthopaedic follow-up and physiotherapy during treatment. This treatment of LLD can be considered alongside other nails, external fixators, and epiphysiodesis. Multicenter studies comparing this with other approaches are needed. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Adrien Frommer
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
| | - Robert Roedl
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
| | - Georg Gosheger
- General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Maike Niemann
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
| | - Dominik Turkowski
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
| | - Gregor Toporowski
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
| | - Christoph Theil
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
| | - Andrea Laufer
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
| | - Bjoern Vogt
- Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
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Hafez M, Nicolaou N, Offiah A, Giles SN, Madan SS, Fernandes JA. Femoral Lengthening in Children-A Comparison Between Magnetic Intramedullary Lengthening Nails and External Fixators. J Pediatr Orthop 2022; 42:e290-e294. [PMID: 34967804 DOI: 10.1097/bpo.0000000000002039] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoral lengthening can be achieved using external fixators or intramedullary lengthening nails. The purpose of this research was to compare the outcome of femoral lengthening in children using PRECICE magnetic lengthening nails with lengthening external fixators. METHODS Retrospective analysis of 50 children who had femoral lengthening. Group A included patients who had lengthening with external fixation, patients in Group B had lengthening with PRECICE intramedullary lengthening nails. Each group included 25 patients. The sample strictly included children aged between 11 and 17 years. Patients in each group were matched according to age and indication for lengthening whether congenital or acquired conditions. The outcomes focused on the ability to achieve target length, healing index, residual malalignment, length of hospitalization following the osteotomy surgery, and encountered complications. RESULTS Mean patient age was 14.7 years for each group. The length gain was 42±12 mm for Group A and 41.6±8 mm for Group B (P=0.84). Lengthening nails achieved the target length more accurately compared with external fixation (P=0.017). The healing index was significantly higher in group A with 53.2±19 days/cm compared with 40.2±14 days/cm in group B (P=0.03). Group A had significantly higher complications than group B (P<0.0001). There was no statistically significant difference in the final coronal malalignment between the 2 groups (P=0.2). The mean length of stay was 9.2±5.8 days for group A and 4.2±3.3 days for group B (P=0.0005). CONCLUSION Magnetic lengthening nails are clinically effective for femoral lengthening in the pediatric population. Compared with external fixation, healing index and complications were more favorable with PRECICE nails. Further research is required to study the cost-effectiveness of this technique. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Mohamed Hafez
- Department of Oncology and Metabolism, Medical School, Sheffield University
- Paediatric Limb Reconstruction Unit
| | - Nicolas Nicolaou
- Department of Oncology and Metabolism, Medical School, Sheffield University
- Paediatric Limb Reconstruction Unit
| | - Amaka Offiah
- Department of Oncology and Metabolism, Medical School, Sheffield University
- Radiology Department, Sheffield Children's Hospital, Sheffield, UK
| | - Stephen N Giles
- Department of Oncology and Metabolism, Medical School, Sheffield University
- Paediatric Limb Reconstruction Unit
| | - Sanjeev S Madan
- Department of Oncology and Metabolism, Medical School, Sheffield University
- Paediatric Limb Reconstruction Unit
| | - James A Fernandes
- Department of Oncology and Metabolism, Medical School, Sheffield University
- Paediatric Limb Reconstruction Unit
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Rehan Youssef A, Gumaa M, Hosny GA. Are internal lengthening devices effective and associated with less complications compared to other lengthening devices? A systematic review and meta-analysis. J Pediatr Orthop B 2022; 31:e219-e226. [PMID: 34456287 DOI: 10.1097/bpb.0000000000000913] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Internal lengthening devices became more popular than external fixators. This was attributed to their effectiveness and lower complication rates. However, this is an assumption that is not on the basis of solid scientific evidence. Therefore, this study systematically reviewed the quality and strength of evidence supporting femoral internal lengthening devices' effectiveness and their associated complications. Six electronic databases (PubMed, Cochrane, Sage, Embase, Web of Science and Scopus) were searched from inception until 20 June 2020. Further, all included articles' bibliographies were searched manually. After screening of retrieved articles, five studies were eligible for qualitative and quantitative synthesis. Studies were assessed by two independent assessors using a modified 'assessment of the methodological quality both of randomized and nonrandomized studies of health care interventions'. Further, meta-analysis was conducted to compare the procedure's effectiveness, in terms of healing index and major complications incidence. Our findings showed internal validity as the major source of bias whereas external validity was the least. For healing index, there is limited evidence that internal lengthening devices lower healing index by 0.45 months/cm (95% CI, -0.62 to -0.28; P < 0.01) compared to LON/external fixators. The incidence of major complications, that were directly related to the procedures, did not differ between internal lengthening devices and other fixators (risk ratio=0.97; 95% CI, 0.39-2.44; P < 0.95). This review provides evidence that supports lower healing index and similar complications associated with internal lengthening devices compared to other procedures of femoral lengthening. However, the evidence is very limited to draw a solid conclusion.
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Affiliation(s)
- Aliaa Rehan Youssef
- Physical Therapy for Musculoskeletal Disorders and Surgery, Faculty of Physical Therapy, Cairo University
- Physical Therapy for Musculoskeletal Disorders and Surgery, Faculty of Physical Therapy, Ahram Canadian University, Giza
| | - Mohammed Gumaa
- Physical Therapy for Musculoskeletal Disorders and Surgery, Faculty of Physical Therapy, Cairo University
- TRUST Research Center, Cairo
| | - Gamal A Hosny
- Orthopaedic Department, Benha University Hospitals, Benha, Egypt
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Functional outcomes and complications of tibial lengthening using unilateral external fixation and then plating. A prospective case series. Ann Med Surg (Lond) 2022; 74:103262. [PMID: 35127065 PMCID: PMC8792419 DOI: 10.1016/j.amsu.2022.103262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/09/2022] [Accepted: 01/13/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Material and methods Results Conclusion Level of evidence Patients with a narrow intramedullary cavity, joint contracture, pediatric patients are not suitable for LON or motorized nail. Tibial lengthening using external fixater then plating was safe and effective provided complications were kept in check. Equinus contracture, pin-site infection, and valgus alignment were the most common complications. Tibial lengthening then plating should be widely employed in patients who were not suitable for limb lengthening over a nail.
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Abstract
BACKGROUND The Precice intramedullary bone lengthening nail has been used in our department since 2013. We sought to determine the efficacy and safety of intramedullary limb lengthening with Precice nails in children and adolescents. METHODS We retrospectively investigated patients 18 years and younger who underwent lower-limb lengthening using the Precice nail. Radiologic and clinical outcome data were obtained from a prospective database. The minimum postimplantation follow-up was 12 months. Between March 2013 and March 2020, 161 patients underwent limb lengthening with a Precice nail; 76 patients met the inclusion criteria. RESULTS We used 84 nails in 76 patients (68 femurs and 16 tibias). Femoral nails were inserted using an antegrade approach in 57 patients and a retrograde approach in 11. The mean age at surgery was 16 years (range, 9 to 18 y). The mean lengthening was 33 mm (range, 14 to 80 mm) with additional acute axial or rotational malalignment correction in 16 segments. At the last follow-up (mean=2.1, years; range, 1 to 5 y), all regenerates had healed and all patients were mobile with full weight-bearing. Complications that necessitated surgical revision occurred in 6 patients (8%), and the desired lengthening was not achieved in 2 patients. Postlengthening malalignment occurred in 4 patients (5 tibial nails). The weight-bearing index, defined as days from surgery to full weight-bearing/cm of lengthening, was a mean of 45 days (range, 7 to 127 d/cm). CONCLUSIONS The Precice nail facilitated reliable and safe bone lengthening and was associated with a low complication rate. Correction of additional malalignment was possible by applying intraoperative acute correction or guided growth. LEVEL OF EVIDENCE Level IV-therapeutic study investigating the results of treatment.
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Lu V, Zhang J, Krkovic M. Management of femoral non-union with post-traumatic bone defect using second-generation PRECICE® nail - A case report. Trauma Case Rep 2022; 37:100585. [PMID: 35005162 PMCID: PMC8718650 DOI: 10.1016/j.tcr.2021.100585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2021] [Indexed: 11/26/2022] Open
Abstract
The management of post-traumatic bone defects with non-union remains a surgical challenge. Current techniques are often fraught with complications, posing a functional, economical, and psychological challenge for the patient. A 57 year-old gentlemen suffered an open femoral fracture after a motorcycle accident. Having previously undergone open reduction internal fixation, he presented to us with atrophic non-union and bone defects, which were simultaneously treated with a second-generation PRECICE nail. Our treatment protocol was based on the strain theory, and involved initial distraction by ~5 mm at the non-union site, compression of the non-union site, followed by distraction osteogenesis at the non-union site. The patient achieved union and the initially planned limb lengthening regime was achieved with minimal complications. Self-lengthening, magnetically-driven PRECICE nails can successfully restore union and manage limb length discrepancies with reasonable patient satisfaction and minimal complications.
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Affiliation(s)
- Victor Lu
- School of Clinical Medicine, University of Cambridge, CB2 0SP, United Kingdom
| | - James Zhang
- School of Clinical Medicine, University of Cambridge, CB2 0SP, United Kingdom
| | - Matija Krkovic
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, CB2 0QQ, United Kingdom
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Abstract
Intramedullary magnetic lengthening nails represents a marked advance in the process of limb lengthening, reducing the complications associated with other methods, and improving patient's comfort. However, one important limitation is its lengthening ability, especially when it comes to short bones. Previous reports have shown techniques that may allow further lengthening but at a cost of having to carry out repeated procedures, requiring the use of other devices, and submitting the patient to long-winded surgical procedures. This report presents a novel technique to achieve lengthening beyond the initial reach of the nail, in a simple and quick procedure, without the need of implanting any additional devices.
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Pietrzak S, Grzelecki D, Parol T, Czubak J. Comparison of Intramedullary Magnetic Nail, Monolateral External Distractor, and Spatial External Fixator in Femur Lengthening in Adolescents with Congenital Diseases. J Clin Med 2021; 10:jcm10245957. [PMID: 34945254 PMCID: PMC8706718 DOI: 10.3390/jcm10245957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 11/25/2022] Open
Abstract
The aim of this study is to evaluate the course of the treatment and clinical and functional outcomes of femur lengthening in adolescents with congenital disorders by the application of different surgical methods. This retrospective study comprised 35 patients (39 procedures). A total of 11 patients underwent femur lengthening with the use of the intramedullary magnetic nail (IMN) Precise 2 (NuVasive, San Diego, CA, USA), 7 patients (11 procedures) with the use of the monolateral external distractor Modular Rail System (MRS) (Smith and Nephew, Memphis, TN, USA), and 17 with the use of the computer-assisted external fixator Taylor Spatial Frame (TSF) (Smith and Nephew, Memphis, TN, USA). The inclusion criteria were as follows: (1) congenital femoral length deficiency without any axial deformities and (2), independently of the finally applied treatment, the technical possibility of use of each of the analyzed methods. The distraction index did not differ significantly between the groups (p = 0.89). The median lengthening index was the lowest in the IMN group (24.3 d/cm; IQR 21.8–33.1) and statistically different in comparison to the MRS (44.2 d/cm; IQR 42–50.9; p < 0.001) and the TSF groups (48.4 d/cm; IQR 38.6–63.5; p < 0.001). Similarly, the consolidation index in the IMN group (12.9 d/cm; IQR 10.7–21.3) was statistically lower than that in the MRS (32.9 d/cm; IQR 30.2–37.6; p < 0.001) and the TSF (36.9 d/cm; IQR 26.6–51.5; p < 0.001) groups. This study indicates that IMN is a more valuable method of treatment for femoral length discrepancy without axial deformity than MRS and TSF in complication rate and indexes of lengthening and consolidation.
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Affiliation(s)
- Szymon Pietrzak
- Department of Orthopedics, Pediatric Orthopedics and Traumatology, Centre of Postgraduate Medical Education, Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, 05-400 Otwock, Poland; (T.P.); (J.C.)
- Correspondence: ; Tel.: +48-(22)-788-91-97
| | - Dariusz Grzelecki
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, 05-400 Otwock, Poland;
| | - Tomasz Parol
- Department of Orthopedics, Pediatric Orthopedics and Traumatology, Centre of Postgraduate Medical Education, Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, 05-400 Otwock, Poland; (T.P.); (J.C.)
| | - Jarosław Czubak
- Department of Orthopedics, Pediatric Orthopedics and Traumatology, Centre of Postgraduate Medical Education, Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, 05-400 Otwock, Poland; (T.P.); (J.C.)
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Mierke A, Shields TG, Williams NL, Zuckerman LM. Comparison of forces generated using compression plating versus a magnetic lengthening nail in a sawbones femur model. Clin Biomech (Bristol, Avon) 2021; 90:105508. [PMID: 34700236 DOI: 10.1016/j.clinbiomech.2021.105508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 09/29/2021] [Accepted: 10/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study is to compare compression generated by a Precice magnetic lengthening intramedullary nail and a 5.0 mm limited contact dynamic compression plate. METHODS Transverse osteotomy sites were created in the femoral shaft of ten Sawbones fourth generation composite femurs. Antegrade 10-degree trochanteric Precice nails and 8-hole, 5.0 mm plates were used for fixation. The plates were compressed by placing a neutral screw and three eccentrically drilled compression screws on alternating sides of the osteotomy. Average compression and distribution of compression were compared, and P-values <0.05 were considered statistically significant. FINDINGS The Precice nail generated an average of 2.38 megapascal across the osteotomy sites. The plate generated an average of 0.70 megapascal (P < 0.001) with the initial compression screw, 0.93 megapascal (P < 0.001) after the second screw, and 1.04 megapascal (p < 0.001) after the final screw. The distribution of compression was assessed utilizing a polar transformation to compare pressure values. We found that the distribution of compression was more circumferentially uniform in the Precice nail group (P = 0.046). INTERPRETATION This study demonstrates that an electromagnetic intramedullary device is capable of generating significantly higher compression, in a more uniform distribution, than a 5.0 mm limited contact dynamic compression plate in a Sawbones model. The results indicate that electromagnetic intramedullary nail systems may be an ideal alternative to compression plating for treatment of at-risk fractures, nonunions, delayed unions, and intercalary allograft reconstruction.
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Affiliation(s)
- Alex Mierke
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Troy G Shields
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Nadine L Williams
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Lee M Zuckerman
- Division of Orthopaedic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
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Hafez M, Nicolaou N, Offiah AC, Giles S, Madan S, Fernandes JA. Femoral lengthening in young patients: An evidence-based comparison between motorized lengthening nails and external fixation. World J Orthop 2021; 12:909-919. [PMID: 34888151 PMCID: PMC8613692 DOI: 10.5312/wjo.v12.i11.909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/07/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Femoral lengthening is a procedure of great importance in the treatment of congenital and acquired limb deficiencies. Technological advances have led to the latest designs of fully implantable motorized intramedullary lengthening nails. The use of these nails has increased over the last few years.
AIM To review and critically appraise the literature comparing the outcome of femoral lengthening in children using intramedullary motorized lengthening nails to external fixation.
METHODS Electronic databases (MEDLINE, CINAHL, EMBASE, Cochrane) were systematically searched in November 2019 for studies comparing the outcome of femoral lengthening in children using magnetic lengthening nails and external fixation. The outcomes included amount of gained length, healing index, complications and patient reported outcomes.
RESULTS Of the 452 identified studies, only two (retrospective and non-randomized) met the inclusion criteria. A total of 91 femora were included. In both studies, the age of patients treated with nails ranged from 15 to 21 years compared to 9 to 15 years for patients in the external fixation group. Both devices achieved the target length. Prevalence of adverse events was less in the nail (60%-73%) than in the external fixation (81%-100%) group. None of the studies presented patient reported outcomes.
CONCLUSION The clinical effectiveness of motorized nails is equivalent or superior to external fixation for femoral lengthening in young patients. The available literature is limited and does not provide evidence on patient quality of life or cost effectiveness of the interventions.
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Affiliation(s)
- Mohamed Hafez
- Department of Oncology and Metabolism, Sheffield University, Sheffield S10 2TN, United Kingdom
- Department of Paedaiatric Limb Reconstruction, Sheffield Children Hospital, Sheffield S10 2TH, United Kingdom
| | - Nicolas Nicolaou
- Department of Paedaiatric Limb Reconstruction, Sheffield Children Hospital, Sheffield S10 2TH, United Kingdom
| | - Amaka C Offiah
- Department of Radiology, Sheffield Children Hospital, Sheffield S10 2TH, United Kingdom
| | - Stephen Giles
- Department of Paedaiatric Limb Reconstruction, Sheffield Children Hospital, Sheffield S10 2TH, United Kingdom
| | - Sanjeev Madan
- Department of Paedaiatric Limb Reconstruction, Sheffield Children Hospital, Sheffield S10 2TH, United Kingdom
| | - James A Fernandes
- Department of Paedaiatric Limb Reconstruction, Sheffield Children Hospital, Sheffield S10 2TH, United Kingdom
- Department of Trauma and Orthopaedics, Sheffield Children Hospital, Sheffield S10 2Th, United Kingdom
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Use of a Motorized Intramedullary Bone Transport Nail for Trauma: Tips, Tricks, Corticotomy Techniques, and Rate and Rhythm. J Orthop Trauma 2021; 35:S31-S38. [PMID: 34533484 DOI: 10.1097/bot.0000000000002121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
The introduction of internal magnetic nails (IMNs) for bone lengthening and bone transport has given us exciting new tools with which to treat segmental bone loss. Distraction osteogenesis has a long record of success in recreating even large segments of bone, but the availability of IMNs now offers the possibility of performing distraction osteogenesis without the drawbacks of external fixation. However, there are aspects of treatment with IMNs that are critical to understand to achieve success and minimize complications. These include assessment of feasibility in relation to available bone stock and segment configuration, the condition of the soft tissue envelope, and the presence of contamination or infection. They also include execution aspects such as bone end preparation, nail placement, need for and positioning of adjuvant fixation, corticotomy techniques, rate and rhythm of distraction, staged screw exchange, docking site preparation, and nail extraction. We discuss these issues in detail and introduce some novel techniques not previously described including the comminuted wedge osteotomy, testing of the nail with initial compression, and retention plug application for nail extraction to assist in optimizing success in certain clinical situations.
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40
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Hothi H, Bergiers S, Henckel J, Iliadis AD, Goodier WD, Wright J, Skinner J, Calder P, Hart AJ. Analysis of retrieved STRYDE nails. Bone Jt Open 2021; 2:599-610. [PMID: 34352183 PMCID: PMC8384447 DOI: 10.1302/2633-1462.28.bjo-2021-0126] [Citation(s) in RCA: 6] [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] [Indexed: 11/06/2022] Open
Abstract
Aims The aim of this study was to present the first retrieval analysis findings of PRECICE STRYDE intermedullary nails removed from patients, providing useful information in the post-market surveillance of these recently introduced devices. Methods We collected ten nails removed from six patients, together with patient clinical data and plain radiograph imaging. We performed macro- and microscopic analysis of all surfaces and graded the presence of corrosion using validated semiquantitative scoring methods. We determined the elemental composition of surface debris using energy dispersive x-ray spectroscopy (EDS) and used metrology analysis to characterize the surface adjacent to the extendable junctions. Results All nails were removed at the end of treatment, having achieved their intended lengthening (20 mm to 65 mm) and after regenerate consolidation. All nails had evidence of corrosion localized to the screw holes and the extendable junctions; corrosion was graded as moderate at the junction of one nail and severe at the junctions of five nails. EDS analysis showed surface deposits to be chromium rich. Plain radiographs showed cortical thickening and osteolysis around the junction of six nails, corresponding to the same nails with moderate – severe junction corrosion. Conclusion We found, in fully united bones, evidence of cortical thickening and osteolysis that appeared to be associated with corrosion at the extendable junction; when corrosion was present, cortical thickening was adjacent to this junction. Further work, with greater numbers of retrievals, is required to fully understand this association between corrosion and bony changes, and the influencing surgeon, implant, and patient factors involved. Cite this article: Bone Jt Open 2021;2(8):599–610.
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Affiliation(s)
- Harry Hothi
- The Royal National Orthopaedic Hospital, London, UK
| | | | | | | | | | - Jonathan Wright
- The Royal National Orthopaedic Hospital, London, UK.,The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - John Skinner
- The Royal National Orthopaedic Hospital, London, UK
| | - Peter Calder
- The Royal National Orthopaedic Hospital, London, UK
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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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Efficacy of PRECICE Nail in Treatment of Adult Patients With Posttraumatic Femoral Leg Length Discrepancy. J Orthop Trauma 2021; 35:e304-e308. [PMID: 33512857 DOI: 10.1097/bot.0000000000002000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 02/02/2023]
Abstract
Posttraumatic, limb length discrepancy in adults is a challenge to treat, and multiple treatment protocols over the years have shown varying levels of success and complications. Before the introduction of the PRECICE nail in 2011, our preferred method of limb lengthening used an Ilizarov or Taylor Spatial frame. To assess the PRECICE nail, we evaluated the accuracy and complications during treatment in a series of skeletally mature patients with posttraumatic femoral limb length discrepancy. The surgical technique along with a case series of 8 patients are described in detail. On average, the target lengthening for the PRECICE nail was 44 mm, and all patients achieved lengthening within 2 mm and complete bony consolidation. The only observed complication in our series was a broken screw 1 year after the patient started weight-bearing. The PRECICE nail demonstrated promising results and was useful for bone regeneration and consolidation without the need for additional procedures. The rate of complications was low compared with previous methods, making this device an excellent treatment option.
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Frommer A, Roedl R, Gosheger G, Hasselmann J, Fuest C, Toporowski G, Laufer A, Tretow H, Schulze M, Vogt B. Focal osteolysis and corrosion at the junction of Precice Stryde intramedullary lengthening device : preliminary clinical, radiological, and metallurgic analysis of 57 lengthened segments. Bone Joint Res 2021; 10:425-436. [PMID: 34269599 PMCID: PMC8333033 DOI: 10.1302/2046-3758.107.bjr-2021-0146.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aims This study aims to enhance understanding of clinical and radiological consequences and involved mechanisms that led to corrosion of the Precice Stryde (Stryde) intramedullary lengthening nail in the post market surveillance era of the device. Between 2018 and 2021 more than 2,000 Stryde nails have been implanted worldwide. However, the outcome of treatment with the Stryde system is insufficiently reported. Methods This is a retrospective single-centre study analyzing outcome of 57 consecutive lengthening procedures performed with the Stryde nail at the authors’ institution from February 2019 until November 2020. Macro- and microscopic metallographic analysis of four retrieved nails was conducted. To investigate observed corrosion at telescoping junction, scanning electron microscopy (SEM) and energy dispersive x-ray spectroscopy (EDX) were performed. Results Adjacent to the nail’s telescoping junction, osteolytic changes were observed in bi-planar radiographs of 20/57 segments (35%) after a mean of 9.5 months (95% confidence interval 7.2 to 11.9) after surgery. A total of 8/20 patients with osseous alterations (40%) reported rest and ambulation pain of the lengthened segment during consolidation. So far, 24 Stryde nails were retrieved and in 20 (83%) macroscopic corrosion was observed at the nail’s telescoping junction. Before implant removal 11/20 radiographs (55%) of lengthened segments with these 20 nails revealed osteolysis. Implant retrieval analysis by means of SEM showed pitting and crevice corrosion. EDX detected chromium as the main metallic element of corrosion. Conclusion Patients are exposed to the risk of implant-related osteolysis of unclear short- and long-term clinical consequences. The authors advocate in favour of an early implant removal after osseous consolidation. Cite this article: Bone Joint Res 2021;10(7):425–436.
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Affiliation(s)
- Adrien Frommer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster, Muenster, Germany
| | - Robert Roedl
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster, Muenster, Germany
| | - Georg Gosheger
- General Orthopedics and Tumor Orthopedics, University Hospital of Muenster, Muenster, Germany
| | - Julian Hasselmann
- Materials Technology Laboratory at the Department of Mechanical Engineering, Muenster University of Applied Sciences, Muenster, Germany
| | - Cordula Fuest
- Materials Technology Laboratory at the Department of Mechanical Engineering, Muenster University of Applied Sciences, Muenster, Germany
| | - Gregor Toporowski
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster, Muenster, Germany
| | - Andrea Laufer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster, Muenster, Germany
| | - Henning Tretow
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster, Muenster, Germany
| | - Martin Schulze
- General Orthopedics and Tumor Orthopedics, University Hospital of Muenster, Muenster, Germany
| | - Bjoern Vogt
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, University Hospital of Muenster, Muenster, Germany
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Iliadis AD, Wright J, Stoddart MT, Goodier WD, Calder P. Early results from a single centre's experience with the STRYDE nail : a cause for concern? Bone Joint J 2021; 103-B:1168-1172. [PMID: 34058877 DOI: 10.1302/0301-620x.103b6.bjj-2020-2165.r1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited regarding outcomes and potential problems. We report on our early experience and raise awareness for the potential of adverse effects from this device. METHODS This is a retrospective review of prospective data collected on all patients treated in our institution using this implant. We report the demographics, nail accuracy, reliability, consolidation index, and cases where concerning clinical and radiological findings were encountered. There were 14 STRYDE nails implanted in nine patients (three male and six female) between June 2019 and September 2020. Mean age at surgery was 33 years (14 to 65). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies. RESULTS At the time of reporting, eight patients (13 implants) had completed lengthening. Osteolysis and periosteal reaction at the junction of the telescopic nail was evident in nine implants. Five patients experienced localized pain and swelling. Macroscopic appearances following retrieval were consistent with corrosion at the telescopic junction. Tissue histology was consistent with effects of focal metallic wear debris. CONCLUSION From our early experience with this implant we have found the process of lengthening to be accurate and reliable with good regenerate formation and consolidation. Proposed advantages of early load bearing and the ability for bilateral lengthening are promising. We have, however, encountered concerning clinical and radiological findings in several patients. We have elected to discontinue its use to allow further investigation into the retrieved implants and patient outcomes from users internationally. Cite this article: Bone Joint J 2021;103-B(6):1168-1172.
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Affiliation(s)
| | - Jonathan Wright
- Limb Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | | | | | - Peter Calder
- Limb Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, UK
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45
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Zhang J, Zhang Y, Wang C, Qin S. [Research progress of intramedullary lengthening nail technology]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:642-647. [PMID: 33998220 DOI: 10.7507/1002-1892.202012084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the research progress of intramedullary lengthening nail technology. Methods The foreign literature on the development history, types, advantages and disadvantages, indications and contraindications, complications, and effectiveness of intramedullary lengthening nail were reviewed and analyzed. Results The intramedullary lengthening nail system mainly includes mechanical type, electric motor drive type, and magnetic drive type. Compared with traditional external fixation and lengthening technology, the intramedullary lengthening nail technology has certain advantages in incidence of complications, bone healing, postoperative functional rehabilitation, incision aesthetics, convenience, and patient satisfaction. However, there are also shortcomings, such as pain, uncontrollable distraction rate, device failure, etc. In the clinical application of intramedullary lengthening nails for limb lengthening, the indications should be grasped reasonably, and the related complications should be prevented and treated. Conclusion Intramedullary lengthening nails provide a new option for limb lengthening, and the initial effectiveness is good. It is one of the development direction of limb lengthening technology.
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Affiliation(s)
- Jin Zhang
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P.R.China
| | - Yonghong Zhang
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P.R.China
| | - Chaoqi Wang
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P.R.China
| | - Sihe Qin
- Department of Orthopaedics, Rehabilitation Hospital of the National Research Center for Rehabilitation Technical Aids, Beijing, 100176, P.R.China
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Nguyen Van L, Le Van D. Complications and functional, psychological outcomes of bilateral tibial lengthening over intramedullary nail: evidence from Vietnam. INTERNATIONAL ORTHOPAEDICS 2021; 45:2007-2015. [PMID: 33978783 DOI: 10.1007/s00264-021-05059-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The purpose of this study was to assess the functional, psychological outcomes and complications of bilateral tibial lengthening over intramedullary nail. The intramedullary nail in this study was the Surgical Implant Generation Network (SIGN) nail. MATERIAL AND METHODS We enrolled patients desiring stature lengthening at the 108 Military Central Hospital (Hanoi, Vietnam) from October 2011 to January 2019. A total of 104 people have been enrolled in the study and underwent the bilateral tibial lengthening procedure. RESULTS Average tibial lengthening was 7.1 ± 0.8 cm in men and 6.5 ± 0.6 cm in women. Percentage of tibial lengthening as compared with tibia length at the time of pre-operation was 23.9 ± 3.5% for male patients and 21.5 ± 3.7% for female patients. The outcome was excellent in 85 patients (81.7%) and good in 19 (18.3%). All patients experienced improved self-esteem and enhanced quality of life. CONCLUSION Our study suggests that bilateral tibial lengthening over nail was safe and effective provided complications are looked for and kept in check. Equinus contracture, pin tract infection, and valgus deviation were the most common complications. Valgus deviation occurs during distraction period. In patient who had neutral or valgus alignment, we recommend to use a blocking screw at the proximal segment post-operatively and use a blocking screw at the valgus distal segment at the end of distraction period to maintain the mechanical axis of both tibias. Bilateral tibial lengthening over nail should be widely employed in low-income countries.
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Affiliation(s)
- Luong Nguyen Van
- Institute of Trauma and Orthopaedics, 108 Military Central Hospital, No. 01 Tran Hung Dao Street, Hanoi, Vietnam.
| | - Doan Le Van
- Institute of Trauma and Orthopaedics, 108 Military Central Hospital, No. 01 Tran Hung Dao Street, Hanoi, Vietnam
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Johnson MA, Karkenny AJ, Arkader A, Davidson RS. Dissociation of a Femoral Intramedullary Magnetic Lengthening Nail During Routine Hardware Removal: A Case Report. JBJS Case Connect 2021; 11:01709767-202103000-00046. [PMID: 33684083 DOI: 10.2106/jbjs.cc.20.00950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
CASE A 15-year-old boy with a right femur length discrepancy secondary to infection underwent hardware removal 1-year status-post right femur osteotomy with placement of an antegrade intramedullary magnetic lengthening nail after successful lengthening of 4.2 cm. During hardware removal, dissociation between the proximal (outer) and distal (inner) components of the device was observed. The distal component was removed using an endoscopic pituitary rongeur after considering multiple possible techniques. CONCLUSIONS In the event of nail disconnection during removal of an intramedullary implant, we recommend use of a long pituitary rongeur to retrieve the distal nail component.
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Affiliation(s)
- Mitchell A Johnson
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Frost MW, Rahbek O, Traerup J, Ceccotti AA, Kold S. Systematic review of complications with externally controlled motorized intramedullary bone lengthening nails (FITBONE and PRECICE) in 983 segments. Acta Orthop 2021; 92:120-127. [PMID: 33106069 PMCID: PMC7919879 DOI: 10.1080/17453674.2020.1835321] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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 - In recent years motorized intramedullary lengthening nails have become increasingly popular. Complications are heterogeneously reported in small case series and therefore we made a systematic review of complications occurring in lower limb lengthening with externally controlled motorized intramedullary bone lengthening nails.Methods - We performed a systematic search in PubMed, EMBASE, and the Cochrane Library with medical subject headings: Bone Nails, Bone Lengthening, and PRECICE and FITBONE nails. Complications were graded on severity and origin.Results - The search identified 952 articles; 116 were full text screened, and 41 were included in the final analysis. 983 segments were lengthened in 782 patients (age 8-74 years). The distribution of nails was: 214 FITBONE, 747 PRECICE, 22 either FITBONE or PRECICE. Indications for lengthening were: 208 congenital shortening, 305 acquired limb shortening, 111 short stature, 158 with unidentified etiology. We identified 332 complications (34% of segments): Type I (minimal intervention) in 11% of segments; Type II (substantial change in treatment plan) in 15% of segments; Type IIIA (failure to achieve goal) in 5% of segments; and Type IIIB (new pathology or permanent sequelae) in 3% of segments. Device and bone complications were the most frequent.Interpretation - The overall risk of complications was 1 complication for every 3 segments lengthened. In 1 of every 4 segments, complications had a major impact leading to substantial change in treatment, failure to achieve lengthening goal, introduction of a new pathology, or permanent sequelae. However, as no standardized reporting method for complications exists, the true complication rates might be different.
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Affiliation(s)
- Markus W Frost
- Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg; ,Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark,Correspondence:
| | - Ole Rahbek
- Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg; ,Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Jens Traerup
- Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg;
| | | | - Søren Kold
- Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg; ,Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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Jardaly A, Gilbert SR. Combined antegrade femur lengthening and distal deformity correction: a case series. J Orthop Surg Res 2021; 16:60. [PMID: 33451359 PMCID: PMC7809855 DOI: 10.1186/s13018-020-02168-6] [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] [Received: 10/12/2020] [Accepted: 12/25/2020] [Indexed: 11/12/2022] Open
Abstract
Background Leg length discrepancy is often associated with distal femur angular deformities such as valgus or flexion. This study aims to report a new technique for simultaneous limb lengthening and acute distal femoral angular correction. Methods A retrospective chart review of patients undergoing a single procedure was conducted. Patients included had a single operation where they underwent distal femur osteotomy stabilized with a plate followed by antegrade nailing with a magnetically controlled intramedullary lengthening nail (PRECICE, Ellipse Technologies, Inc., Irvine, CA, USA) using a trochanteric entry. Results Seven femurs from 7 patients were included. The average age at operation was 13.6 years, and the leg length difference was 51 mm (range 30–105 mm). Associated deformities were valgus (4), knee flexion contracture (2), and both valgus and flexion contracture (1). Lengthening achieved was 43 mm (P = 0.0036), with a consolidation index of 27 days/cm and reliability of 0.87 (6/7). The 5 patients with angulation had an improvement of valgus from 12 to 4° (P = 0.006) and of the mechanical axis deviation from 34 to 3 mm (P = 0.0001). The range of motion also improved in the 3 patients with contractures. Preoperative gait disturbance, hip and knee pain, and functional scoliosis resolved after the limb deformities were corrected. Conclusion Combining a magnetic internal lengthening nail with a second distal osteotomy stabilized with a plate can successfully correct limb length and distal femur deformity acutely without altering the expected result of each procedure.
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Affiliation(s)
- Achraf Jardaly
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon.,Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shawn R Gilbert
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA. .,Department of Pediatric Orthopaedics, ACC Suite 316, Children's Hospital of Alabama, 1600 7th Avenue South, Birmingham, AL, 35233, USA.
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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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