All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss

Abstract

Background Variety of techniques for management of segmental femoral bone loss have been described, each with different advantages and challenges during treatment. The development of motorized lengthening nails has provided a potential for all internal bone transport, avoiding some of the difficulties with external fixation in the femur. At present, there is limited published literature on experiences in this technique. Aim The development of this technique aimed to overcome the difficulties previously reported for internal bone transport in the femur, particularly varus deformity and joint stiffness. Technique We describe the technique of double plating with bone transport utilizing a magnetic lengthening nail to manage segmental femoral bone loss. The benefits of the technique are discussed, along with specific challenges and lessons that have been learned through experience of internal bone transport. Conclusion Use of a magnetic lengthening nail and double plating as a method of all internal bone transport provides an option for the management of massive femoral bone loss, while avoiding some of the challenges that have been reported with the existing techniques. Clinical significance This technique provides an additional method in the armamentarium of the trauma or limb reconstruction surgeon treating massive femoral bone loss. How to cite this article Wright J, Bates P, Heidari N, et al. All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss. Strategies Trauma Limb Reconstr 2019;14(2):94–101.

Bone transport with magnetic intramedullary nails in long bone defects

“…2 AP (a, b, c) and lateral (d, e, f) radiographs of Patient 3 showing the defect at the start, during the retrograde bone transport and at the final stage. This demonstrates plate bending, as seen in two of our patients post-tumour resection while Wright et al [13] and Barinaga et al [11] reported exclusively traumatic bone loss. Any differences have not been clearly detected and stated, but it is conceivable that a bone tumour pathology would result in longer follow-up due to the additional use of adjuvants.…”

“…Similarly, Olesen et al [ 12 ] treaded on the same boundary with a mean femoral defect of 9.3 cm (range 7–11.5) and a mean tibial defect of 8.9 cm (range 4.8–15). Wright et al [ 13 ] reported a mean femoral defect size of 10.3 cm (range 7–16). Barinaga et al [ 11 ] reported on a traumatic tibial fracture of 3.0 cm when PABST was indicated, after previous IM nail failure when the initial defect was 4.2 cm.…”

“…PRE-CICE nails (NuVasive) are the latest development and have been reported to achieve accurate and precise limb lengthening [7][8][9][10]. Plate-assisted bone segment transport (PABST) is principally used in bone transport [11,12], but modifications of this technique have been described to improve varus deformity such as by double-plating [13]. The PRECICE nail is controlled using an ERC which, when placed over the nail on the skin, causes magnet rotation which in turn activates a motor that extends or retracts the extendible rod [5].…”

“…The direction of lengthening is determined by the pattern of bone loss, although some other factors to consider are the age of the patient, size of the intramedullary canal and proximal soft tissue, and the need for deformity correction. Distal bone loss mandates the use of retrograde nails for better control of the final docking position [ 13 ]. On the contrary, anterograde nails have the tendency to shift the transport fragment anteriorly towards the docking site if not correctly fixed initially, resulting in missing the docking point.…”

“…After the initial treatment, the bone transport surgery is delayed by 6 weeks for any signs of spontaneous bone regeneration [ 17 ]. Although there is no clear guideline on the appropriate length of delay, they are not usually less than 3–4 weeks and Wright et al had allowed for 8–10 weeks to address associated injuries and any active infection [ 13 ].…”