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Dubin JA, Bains SS, Moore M, Assayag MA, McClure PK. Outpatient limb lengthening using magnetic intramedullary nails: A single Institution's experience. J Orthop 2024; 53:163-167. [PMID: 38601890 PMCID: PMC11002844 DOI: 10.1016/j.jor.2024.03.021] [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: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 04/12/2024] Open
Abstract
Introduction The advantages of outpatient surgery have been shown in other orthopedic subspecialities to be a means of driving down costs and reducing the average length of hospital stay. However, there is a scarcity of literature examining the utility of a specific, hospital-based facility performing such procedures for limb lengthening. Considering this, we aimed to investigate surgical factors, patient characteristics, and the incidence of outpatient postoperative complications for patients undergoing surgery and subsequent distraction osteogenesis utilizing the Precice® nail, a state-of-the-art magnetic intramedullary nail (MILN). Methods We performed a retrospective review of medical records pertaining to outpatient limb lengthening procedures occurring between January 2012 and September 2023 at a single institution, as performed by three surgeons. Variables of interest included baseline demographics, type of anesthesia, operative bone, laterality, preoperative diagnosis, osteotomy level, procedure performed, prosthesis, point of entry, nail diameter/length, goal length, goal achieved, postoperative complications, and elective nail removal. Results The cohort comprised 20 limbs, with an average age at index surgery of 24.8 (SD 7.96). There were no complications related to the outpatient nature of the procedure. Five of the 20 limbs had postoperative complications, including deep vein thrombosis (DVT), screw backout, and nail breakage. Conclusion Our initial investigation of outpatient limb lengthening at a specific, hospital-based facility demonstrated favorable postoperative outcomes for those patients undergoing limb lengthening procedures with an MILN. The field would certainly benefit from future research assessing outcomes of pediatric surgeries in the outpatient setting on a larger scale, as well as across hospital systems, the country, and globally. With the proven advances and benefits of MILNs, prioritizing examination of their efficacy in an outpatient population is imperative. Furthermore, the success of outpatient procedures in other orthopedic subspecialities, such as total joint arthroplasty, is a logical, driving precedent for this rationale.
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Affiliation(s)
- Jeremy A. Dubin
- Lifebridge Health Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Sandeep S. Bains
- Lifebridge Health Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Mallory Moore
- Lifebridge Health Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Michael A. Assayag
- 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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Geiger EJ, Geffner AD, Rozbruch SR, Fragomen AT. Treatment of Angular Deformity and Limb Length Discrepancy With a Retrograde Femur Magnetic Intramedullary Nail: A Fixator-assisted, Blocking Screw Technique. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00018. [PMID: 37205724 PMCID: PMC10566895 DOI: 10.5435/jaaosglobal-d-23-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Fixator-assisted nailing techniques that incorporate magnetic internal lengthening nails (MILNs) permit acute deformity correction and then gradual limb lengthening without needing postoperative external fixators. PURPOSES We sought to investigate the safety and accuracy of a fixator-assisted, blocking screw technique using retrograde MILNs for the correction of LLD and limb malalignment. METHODS Forty-one patients (13 patients with genu varum and 28 patients with genu valgum) with LLD treated with fixator-assisted, blocking screw retrograde MILN reconstruction were included. Preoperative LLD, mechanical axis deviation, and joint orientation angles were compared with values at the end of treatment, and bone healing indices were calculated. Perioperative complications were tracked. RESULTS Preoperatively, the mean mechanical lateral distal femoral angle of the varus cohort was 98 ± 12°, whereas the mean lateral distal femoral angle of the valgus cohort was 82±4°. Both cohorts had an average 3-cm LLD. 99% of the planned limb lengthening was achieved. Final LDFAs were 91 ± 6° and 89 ± 4° in the varus and valgus cohorts, respectively, and the limb mechanical axis angles were normalized. 10 patients underwent a total of 21 returns to the operating room. Most commonly, this involved percutaneous injection of bone marrow aspirate concentrate to bone regenerate exhibiting delayed union (6 patients). CONCLUSIONS The use of a retrograde MILN with a fixator-assisted, blocking screw technique is an effective means of acute deformity correction and gradual limb lengthening through minimal incisions. The accuracy of deformity correction relies on intraoperative execution of the appropriate nail start site, osteotomy location, and placement of blocking screws.
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Affiliation(s)
- Erik J. Geiger
- From the Department of Orthopedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Geiger) and the Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, NY (Mr. Geffner, Dr. Rozbruch, Dr. Fragomen)
| | - Adam D. Geffner
- From the Department of Orthopedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Geiger) and the Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, NY (Mr. Geffner, Dr. Rozbruch, Dr. Fragomen)
| | - S. Robert Rozbruch
- From the Department of Orthopedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Geiger) and the Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, NY (Mr. Geffner, Dr. Rozbruch, Dr. Fragomen)
| | - Austin T. Fragomen
- From the Department of Orthopedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Geiger) and the Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, NY (Mr. Geffner, Dr. Rozbruch, Dr. Fragomen)
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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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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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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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[Translated article] Bone lengthening with magnetic nails. Experience in patients younger than 18. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:T355-T363. [DOI: 10.1016/j.recot.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/18/2021] [Indexed: 11/22/2022] Open
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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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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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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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Hoellwarth J, Tetsworth K, Akhtar M, Oomatia A, Muderis M. Motorized intramedullary lengthening followed by osseointegration for amputees with short residual femurs: An observational cohort study. JOURNAL OF LIMB LENGTHENING & RECONSTRUCTION 2022. [DOI: 10.4103/jllr.jllr_20_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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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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Malkova TA, Borzunov DY. International recognition of the Ilizarov bone reconstruction techniques: Current practice and research (dedicated to 100 th birthday of G. A. Ilizarov). World J Orthop 2021; 12:515-533. [PMID: 34485099 PMCID: PMC8384611 DOI: 10.5312/wjo.v12.i8.515] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/08/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
The Ilizarov method is one of the current methods used in bone reconstruction. It originated in the middle of the past century and comprises a number of bone reconstruction techniques executed with a ring external fixator developed by Ilizarov GA. Its main merits are viable new bone formation through distraction osteogenesis, high union rates and functional use of the limb throughout the course of treatment. The study of the phenomenon of distraction osteogenesis induced by tension stress with the Ilizarov apparatus was the impetus for advancement in bone reconstruction surgery. Since then, the original method has been used along with a number of its modifications developed due to emergence of new fixation devices and techniques of their application such as hexapod external fixators and motorized intramedullary lengthening nails. They gave rise to a relatively new orthopedic subspecialty termed “limb lengthening and reconstruction surgery”. Based on a comprehensive literature search, we summarized the recent clinical practice and research in bone reconstruction by the Ilizarov method with a special focus on its modification and recognition by the world orthopedic community. The international influence of the Ilizarov method was reviewed in regard to the origin country of the authors and journal’s rating. The Ilizarov method and other techniques based on distraction osteogenesis have been used in many countries and on all populated continents. It proves its international significance and confirms the greatest contribution of Ilizarov GA to bone reconstruction surgery.
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Affiliation(s)
- Tatiana A Malkova
- Department of Medical Information and Analysis, Ilizarov National Medical Research Center for Traumatology and Orthopedics, Kurgan 640014, Russia
| | - Dmitry Y Borzunov
- Department of Traumatology and Orthopedics, Ural State Medical University, Ekaterinburg 620109, Russia
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de Pablos J, González Herranz P, Arbeloa-Gutiérrez L, Stéfano E. Bone lengthening with magnetic nails. Experience in patients younger than 18. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021; 66:355-363. [PMID: 34366258 DOI: 10.1016/j.recot.2021.06.006] [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: 02/14/2021] [Revised: 05/21/2021] [Accepted: 06/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND GOAL Bone elongation with magnetic endomedullary nails (MEN) has been proposed as an advantageous alternative to other techniques, by eliminating the drawbacks of external fixation. The aim of this work is to analyze the results and assess the complications in a series of patients under the age of 18. MATERIAL AND METHODS From 2014 to 2019, 31 elongations (23 femurs, 8 tibias) using MEN (Precice2™) have been performed in 28 patients younger than 18 (15 males and 13 females). In this observational retrospective study, only patients with follow-up longer than 18 months have been included. The average age has been 14.4 years (8-18). The most relevant aspects analyzed have been: previous shortening/deformity, elongation/correction achieved and time to full weight bearing. Complications and re-interventions have also been assessed. RESULTS The elongation achieved has been 5.5cm on average (3-8). In 28 elongations (90.3%) the planned goal of lengthening was achieved. The mean healing index was 1.1months/cm. More than half of elongations (55%) presented complications. Although they produced permanent sequelae in only two patients (7.1%), a total of 9 patients required re-intervention (13 operations). No infections were detected. CONCLUSIONS Bone lengthening with MEN in individuals younger than 18 has achieved its goal in more than 90% of patients in an effective, accurate and safe manner. The use of MEN in this series has eliminated the need for external fixators and has successfully tutorized the operated segment. The high number of complications detected in this study remains a concern.
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Affiliation(s)
- J de Pablos
- Unidad de Reconstrucción Ósea, Hospital San Juan de Dios, Pamplona, España.
| | | | - L Arbeloa-Gutiérrez
- Servicio de Traumatología, Hospital García Orcoyen, Estella, Navarra, España
| | - E Stéfano
- Ortopedia Infantil, Hospital de Niños Gutiérrez, Buenos Aires, Argentina
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Nichols LRB. Has the Threshold for Epiphysiodesis Versus Lengthening Changed in the Era of Magnetically Controlled Nails? J Pediatr Orthop 2021; 41:S24-S32. [PMID: 34096534 DOI: 10.1097/bpo.0000000000001801] [Citation(s) in RCA: 3] [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
INTRODUCTION Limb length discrepancy (LLD) is common in both the pediatric and adult population. Length inequalities can be due to a multitude of etiologies including congenital, developmental, and acquired causes. There has been little consensus on the morbidity of LLD and, as a result, the threshold necessary for treatment of LLD to prevent morbidity. Advances in magnetically controlled lengthening devices achieve greater accuracy and patient satisfaction and create an opportunity to lower the threshold for limb lengthening. DISCUSSION Asymptomatic LLD is relatively common in both pediatric and adult populations. Only ~10% of the population has equal leg length. LLD of <5 cm may lead to long-term morbidities such as scoliosis, lower back pain, gait abnormalities, stress on hip or knee joint, and lower extremity symptomatic versus asymptomatic osteoarthritis. The teaching in most orthopaedic textbooks is to adjust the shoe if symptomatic for discrepancies up to 2 cm; consider an orthotic, epiphysiodesis, or skeletal shortening for 2.5 to 5 cm; and possible limb reconstruction for >5 cm. The assumption is that there are no long-term consequences of mild LLD. However, data in recent literature show that small discrepancies may contribute to pathologic changes such as pain, gait abnormalities, and osteoarthritis. Major advances have been made in limb lengthening over the past 40 years. The increased accuracy and superior patient satisfaction of the magnetically controlled lengthening nail versus external fixation methods argue for including lengthening for LLD of <5 cm. CONCLUSION If mild LLD can cause long-term pathology, it is important to counsel families on the full range of options for limb equalization no matter the size of the discrepancy. The evolution in technology and understanding of limb lengthening has provided additional safe surgical options. Therefore, the historic treatment protocol for addressing limb differences may need to include lengthening for smaller discrepancies even <2 cm.
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Affiliation(s)
- L Reid Boyce Nichols
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
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15
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Kuruoglu D, Sems SA, Sampson BP, Carlsen BT. Internal Magnetic Lengthening and Reconstruction with Free TRAM Flap After Traumatic Transfemoral Amputation: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00121. [PMID: 34129536 DOI: 10.2106/jbjs.cc.20.00967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE This is a case of a 41-year-old man who sustained a traumatic proximal transfemoral amputation with loss of adductor function and inadequate soft tissue. Wound closure was achieved with split-thickness skin grafting. Subsequently, femoral lengthening was achieved with an internal magnetic lengthening nail. He underwent a free transverse rectus abdominis myocutaneous (TRAM) flap to resurface the limb and provide more stable soft tissue, adductor repair, and further lengthening because of his prominent abduction contracture and inadequate soft tissue. This allowed independent ambulation with a prosthetic. CONCLUSION Femoral lengthening with soft-tissue reconstruction improved prosthetic function and ambulation in a patient with a short transfemoral amputation.
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Affiliation(s)
- Doga Kuruoglu
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Stephen A Sems
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Brian T Carlsen
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
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16
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Abstract
BACKGROUND Limb lengthening by distraction osteogenesis is now achievable via motorized intramedullary devices, mitigating many complications of lengthening by external fixation. In young patients, antegrade intramedullary nailing of the femur risks avascular necrosis of the femoral head. A method of extramedullary placement of a motorized expandable intramedullary nail has been employed by the senior author to safely achieve femoral lengthening without the use of an external fixator in young patients. METHODS Eleven skeletally immature patients with lower limb length discrepancy were reviewed who underwent extramedullary placement of a magnetic, expandable intramedullary nail for lengthening of the femur. Surgical details, lengthening parameters, and complications were reviewed and classified according to the modified Clavien-Dindo Classification. RESULTS Average lengthening was 32.3 mm (range: 27 to 40 mm) comprising an average 14.8% of femoral segment length. The average lengthening duration was 6.3 weeks, and average full weight-bearing began at 12.6 weeks. All but 1 patient underwent early removal of the device at an average of 4.5 months, and 5 had immediate plating of the femur. Complications rates were comparable to other methods of femoral lengthening, including varus or procurvatum through the regenerate, and unplanned reoperation in 3 of 11 cases. Preoperative considerations included careful planning of implant length due to short femoral segments and protection of the knee joint from contracture or iatrogenic instability. CONCLUSIONS Extramedullary placement of a magnetic expandable intramedullary lengthening nail can achieve lengthening of the femur without the use of external fixation. Considerations with this technique include careful planning of implant length relative to trochanteric-physeal distance, protection against knee subluxation during lengthening, and mitigating deformity of the regenerate. Off-label, extramedullary use of these devices can be considered to decrease the burdens of external fixation in young children. The technique begs the advent of future all-internal technology specifically designed for safe limb lengthening in this age group. LEVEL OF EVIDENCE Level IV-retrospective case series.
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Abstract
PURPOSE OF REVIEW Premature Physeal Closure (PPC) is the most common consequence of a mostly posttraumatic, physeal injury. They are of utmost importance because they can significantly alter physeal function and lead to disorders such as limb length discrepancies and angular deformities. RECENT FINDINGS The type of physeal fracture has not demonstrated a solid predictive value in the formation of PPC, especially in the knee where almost any type of fracture can produce it. The detection of physeal damage with imaging tests (simple radiology and MRI) is very accurate; however, their predictive capacity to foretell which injury will generate a physeal bridge is still poor. For this reason, it is not advisable to make surgical decisions at the first medical assessment. Direct surgical management of PPC's (resection-interposition technique) has generally shown high unpredictability. Nevertheless, the latest interposition materials (chondrocytes and mesenchymal stem cells) showed promising results. SUMMARY PPC is an often devastating consequence of physeal injury and as such deserves further research. To date little is known about etiopathogenesis, risk factors and natural history among other aspects. Until direct surgery offers more consistent results, acute osteotomies and bone distraction for progressive correction continue to be the most widespread treatments for PPCs.
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Dvorzhinskiy A, Zhang DT, Fragomen AT, Rozbruch SR. Cost Comparison of Tibial Distraction Osteogenesis Using External Lengthening and Then Nailing vs Internal Magnetic Lengthening Nails. Strategies Trauma Limb Reconstr 2021; 16:14-19. [PMID: 34326897 PMCID: PMC8311750 DOI: 10.5005/jp-journals-10080-1513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective Tibial lengthening can be performed by distraction osteogenesis via lengthening and then nailing (LATN) or by using a magnetic lengthening nail (MLN). MLN avoids the complications of external fixation while providing accurate and easily controlled lengthening. Concerns exist still regarding the high upfront cost of the magnetic nail, which serves to limit its use in resource-poor areas and decrease adoption among cost-conscious surgeons. The purpose of this study was to compare the hospital, surgeon, and total cost between LATN and MLN when used for tibial lengthening. Materials and methods A retrospective review was performed comparing consecutive tibial lengthening using either LATN (n = 17) or MLN (n = 15). The number of surgical procedures and time to union were compared. Surgeon and hospital payments were used to perform cost analysis after adjusting for inflation using the consumer price index (CPI). Results Patients treated with MLN underwent fewer surgeries (3.6 vs 2.8; p < 0.001) but had a longer time to union as compared with patients treated with LATN (19.79 vs 27.84 weeks; p = 0.006). Total costs were similar ($50,345 vs $46,162; p = 0.249) although surgeon fees were lower for MLN as compared with LATN ($6,426 vs $4,428; p < 0.001). Conclusion LATN and MLN had similar overall costs in patients undergoing tibial lengthening. MLN was associated with fewer procedures but a longer time to union as compared with LATN. Clinical significance Despite an increased upfront cost in MLN, there was no difference in total cost between LATN and MLN when used for tibial lengthening. Thus, in cases where either method is feasible, cost may not be a deciding factor when selecting the appropriate treatment. How to cite this article Dvorzhinskiy A, Zhang DT, Fragomen AT, et al. Cost Comparison of Tibial Distraction Osteogenesis Using External Lengthening and Then Nailing vs Internal Magnetic Lengthening Nails. Strategies Trauma Limb Reconstr 2021;16(1):14-19.
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Affiliation(s)
- Aleksey Dvorzhinskiy
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States
| | - David T Zhang
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States
| | - Austin T Fragomen
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States
| | - S Robert Rozbruch
- Department of Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, United States
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19
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How should we lengthen post-traumatic limb defects? a systematic review and comparison of motorized lengthening systems, combined internal and external fixation and external fixation alone. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:1015-1022. [PMID: 33222112 DOI: 10.1007/s00590-020-02831-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/10/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Various external fixation systems for lower extremity long bone deformities have been used to various degrees of success, while newer mechanical lengthening nail (MLN) systems offer the potential for improved patient outcomes. Proponents of MLNs argue that they reduce the number of operations, infectious complications, and improve quality of life; however, the evidence to support these claims is scant. This systematic review aims to evaluate the optimal lengthening system for treating post-traumatic long bone deformity. METHODS The systematic review was conducted in accordance with PRISMA guidelines. PUBMED, EMBASE, CINAHL, and the Cochrane Library were searched for comparative studies of lengthening techniques among adult patients with axial deformities. Studies were screened and data extracted in duplicate. Treatment groups were pooled into external fixation (EF) alone, combined internal and external fixation (CIF), and mechanical lengthening nail (MLN). Outcomes were mean lengthening achieved, lengthening index, and reported complications. RESULTS Thirteen studies with 725 patients (mean age: 29.6 years, 74% male) were included. Nearly all of the studies were either prospective or retrospective cohort studies (n = 12), with one randomized controlled trial of moderate study quality. The mean limb lengthening achieved, lengthening index, and rate of reoperation were similar among the MLN, EF, and CIF groups. CONCLUSION The purported decreased the duration of lengthening and the risk of reoperation associated with MLNs was not demonstrated in this review. Patients with post-traumatic leg length deformities remain a challenging patient population to treat, with intervention being associated with high rates of infectious complications and need for revision operations.
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21
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The Economics of New Technology. Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Early outcomes of magnetic intramedullary compression nailing for humeral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:23-31. [PMID: 32638124 DOI: 10.1007/s00590-020-02735-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The optimal treatment protocol for humeral shaft fractures at risk for nonunions is controversial. Here, we aim to describe magnetic intramedullary compression nailing as an option for these challenging scenarios and to evaluate its clinical and radiographic outcomes. METHODS This retrospective case series was performed at an urban university-based level-1 trauma center. Patients aged 18-65 who underwent fixation of their at-risk humerus shaft fracture using the PRECICE nail were included in this investigation. These fractures are characterized by a persistent distraction gap, minimal callous formation, or malalignment greater than 20 degrees. The study data were collected through a retrospective chart review and review of the radiographic studies. Primary outcome measure was radiographic union. Secondary outcome measures included mechanical failure, nonunion, malunion, medical, and surgical complications. Functional outcome was determined by range of motion and restoration of rotator cuff strength. RESULTS A total of six patients were included who underwent treatment of their humeral shaft fracture with a NuVasive PRECICE nail after failure of conservative management. After nail placement along with our compression protocol, all patients achieved bony union and experienced favorable outcomes with return to their previous working status. Two complications included a superficial incisional infection treated with antibiotics and a backing out of proximal screw which did not cause discomfort. No other mechanical failures, surgical complications, or medical complications occurred. CONCLUSIONS Early results of controlled compression nailing for humeral shaft fracture demonstrated favorable clinical outcomes. This technique may be utilized for these challenging situations.
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Elastic Modulus of Woven Bone: Correlation with Evolution of Porosity and X-ray Greyscale. Ann Biomed Eng 2020; 49:180-190. [PMID: 32388799 DOI: 10.1007/s10439-020-02529-6] [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: 12/05/2019] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
The woven bone created during the healing of bone regeneration processes is characterized as being extremely inhomogeneous and having a variable stiffness that increases with time. Therefore, it is important to study how the mechanical properties of woven bone are dependent on its microarchitecture and especially on its porosity and mineral content. The porosity and the x-ray greyscale of specimens taken from bone transport studies in sheep were assessed by means of ex vivo imaging. Our study demonstrates that the porosity of the woven bone in the distraction area diminishes during the healing process from 73.3% 35 days after surgery to 31.9% 525 days after surgery. In addition, the woven bone's porosity is negatively correlated with its Young's modulus. The x-ray greyscale, was measured as an indicator of the level of mineralization of the woven bone. Greyscale index has been demonstrated to be inversely proportional to porosity and to increase to up to 60-80% of the level in cortical bone. The results of this study may contribute to the development of micromechanical models of woven bone and improvements in in silico modelling.
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Compression of Nonunions With the PRECICE Magnetic Intramedullary Compression Nail. Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000457] [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: 11/26/2022]
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Sheridan GA, Falk DP, Fragomen AT, Rozbruch SR. Motorized Internal Limb-Lengthening (MILL) Techniques Are Superior to Alternative Limb-Lengthening Techniques. JB JS Open Access 2020. [DOI: 10.2106/jbjs.oa.20.00115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Dahl MT, Morrison SG, Georgiadis AG, Huser AJ. What's New in Limb Lengthening and Deformity Correction. J Bone Joint Surg Am 2019; 101:1435-1439. [PMID: 31436650 DOI: 10.2106/jbjs.19.00584] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Mark T Dahl
- Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,University of Minnesota, Minneapolis, Minnesota
| | - Stewart G Morrison
- Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,University of Minnesota, Minneapolis, Minnesota
| | - Andrew G Georgiadis
- Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,University of Minnesota, Minneapolis, Minnesota
| | - Aaron J Huser
- Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,University of Minnesota, Minneapolis, Minnesota
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Fragomen AT, Wellman D, Rozbruch SR. The PRECICE magnetic IM compression nail for long bone nonunions: a preliminary report. Arch Orthop Trauma Surg 2019; 139:1551-1560. [PMID: 31218436 PMCID: PMC6797666 DOI: 10.1007/s00402-019-03225-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The magnetic intramedullary (IM) compression nail is capable of providing sustained compression for the treatment of nonunions of long bones. This ability was previously only possible with the use of external fixation. We asked the following questions: How effective is the IM compression nail at achieving union? How do we know when adequate compression has been attained? Which types of nonunions are good candidates for this treatment? MATERIALS AND METHODS Fourteen patients with nonunions of the tibia (5) or femur (9) were treated with the PRECICE IM compression nail. The average age was 49 years number of previous surgeries was 1.9, 7 were atrophic and 7 normotrophic, 3 were metaphyseal and 11 diaphyseal. All PRECICE IM nails were pre-distracted prior to implantation. Compression was applied post-operatively until the locking bolts were seen on X-ray to be bending or the nail was no longer shortening despite applying the external magnet. RESULTS Union was achieved in 13/14 cases. The time to union was 24.5 weeks (range 11-60). The two proximal tibia metaphyseal nonunions, both deformed into varus (4°) and flexion (10°) after compression was applied with one failing to unite. The distal tibia metaphyseal and diaphyseal nonunions did not deform upon compression. Three patients had positive cultures and were treated with IV antibiotics for 6 weeks followed by 3 months of oral suppression without subsequent infection. No mechanical nail failures were seen. CONCLUSIONS The IM compression nail was successful at applying compression, preventing deformity, and obtaining union in all diaphyseal and in distal tibia metaphyseal nonunions. Signs of active compression are bending of the locking bolts and failure of the nail to shorten. Proximal tibia metaphyseal nonunion may not be suited for this treatment.
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Affiliation(s)
- Austin T. Fragomen
- grid.5386.8000000041936877XWeill Medical College of Cornell University, New York, USA ,grid.239915.50000 0001 2285 8823Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, USA
| | - David Wellman
- grid.5386.8000000041936877XWeill Medical College of Cornell University, New York, USA ,grid.239915.50000 0001 2285 8823Orthopaedic Trauma Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - S. Robert Rozbruch
- grid.5386.8000000041936877XWeill Medical College of Cornell University, New York, USA ,grid.239915.50000 0001 2285 8823Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, USA
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