Leg lengthening over an intramedullary nail

Simpson, A. H. R. W.; Cole, Andrew S.; Kenwright, J

doi:10.1302/0301-620x.81b6.9359

Cited by 95 publications

(61 citation statements)

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“…A different strategy for the distraction and consolidation phases aims at reducing the total fixator time by simultaneously placing an intramedullary solid nail at the time of osteotomy and by removing the external device at the end of distraction [50,60,138]. This concept was introduced in 1956 by Bost and Larsen [11].…”

Section: Lengthening Over Nail (Lon Monorail Method)mentioning

confidence: 99%

“…2 cm to max. 17.4 cm) for Ilizarov ring fixators (IRF) [48,57,58] and intramedullary nails [16,46,50,[59][60][61][62][63][64] and around 2.5-3 cm (min. 8 mm to max.…”

Section: Indications For Leg Lengtheningmentioning

confidence: 99%

“…Though callotasis and complex deformity correction is predominantly a paediatric orthopaedic field, the age of patients ranges from as young as 2 years up to 70 years (!). Patients treated with ring fixators and unilateral external fixators have an average age of around 12-16 years [48,49,65], whereas m'g [50,53,[59][60][61] or by solid nails [16, 46, 51-56, 60, 62, 63, 65] constitute young adults around the age of 18-25 years.…”

Section: Indications For Leg Lengtheningmentioning

confidence: 99%

“…Plain radiography-weekly to bi-weekly during distraction, monthly in the consolidation phase and 3-4 monthly after consolidation-is still the most useful methodology to monitor the fragment alignment, as well as the quantity and quality of bone formation [60]. More than a typical central 4-6-mm-thick radiolucent zone corresponds to an exaggerated rate of distraction and vice versa [38,92,[108][109][110][111].…”

Section: Osteotomy Techniques and Biology Of Callotasismentioning

confidence: 99%

“…A nail protects the regenerate and provides enough rotational and axial stability to then allow return to normal activities. Diminishing knee stiffness issues by preserving the soft tissue envelope and the risk of refracture after hardware removal are further benefits [60]. Ilizarov's core Fig.…”

Section: Intramedullary Fixation: General Considerationsmentioning

confidence: 99%

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Current concepts of leg lengthening

Hasler

Krieg

2012

Journal of Children's Orthopaedics

101

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Any lower limb discrepancy may be equalised by conservative means (insoles, prosthesis and orthosis). However, their long-term acceptance is low in regard to function, costs, expenditure and appearance. Timely epiphysiodesis is the best option in uniplanar deformities with adequate remaining growth and for patients whose predicted final body height is above the 50th percentile. However, many patients present late or with multi-planar deformities, which warrant more sophisticated operative approaches. The history of surgical bone lengthening comprises 100 exciting years of struggling, development and ongoing learning. The initial strategy of acute or rapid incremental distraction had lasted almost half a century until Ilizarov recognised the benefits of biological periosteum-preserving osteotomies and incremental lengthening at slow rates (1 mm/day) at a 4 × 0.25-mm daily rhythm, well appreciated as callotasis. In parallel, ring and wire constructs made complex three-dimensional axial, translational and rotational bone moulding possible. Taylor Spatial Frames—built on hexapod strut-linked platform technology as known from flight simulators—took limb correction to a more reliable, more precise and aesthetical level, all the more that the whole process became web-based. It represents state-of-the-art methodology and technology for complex, multi-plane deformities. Due to the significant risk of secondary malalignment, indications for lengthening by unilateral fixation have shrunken to moderate amounts of length disparity and uni- to bi-planar deformities in patients with still open physes. Mechanical or motorised, minimally invasively placed nails prevent muscle fixation and, therefore, ease rehabilitation, increase patient comfort and potentially shorten the overall time of sick leave and refrain from sports activities. Hence, they offer a valuable alternative for low-grade complexity situations. It remains to be proved if the significantly higher implant costs are compensated by lower treatment costs. Overall, limb lengthening, particularly in combination with multi-planar deformity correction, can still be an arduous endeavour. In any case, wise judgement of the patient’s deformity, medical and biological situation, psychosocial environment, selection of the appropriate method and hardware, as well as meticulous operating technique by an experienced surgeon are the cornerstones of successful outcomes.

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Section: Lengthening Over Nail (Lon Monorail Method)mentioning

confidence: 99%

“…2 cm to max. 17.4 cm) for Ilizarov ring fixators (IRF) [48,57,58] and intramedullary nails [16,46,50,[59][60][61][62][63][64] and around 2.5-3 cm (min. 8 mm to max.…”

Section: Indications For Leg Lengtheningmentioning

confidence: 99%

Section: Indications For Leg Lengtheningmentioning

confidence: 99%

Section: Osteotomy Techniques and Biology Of Callotasismentioning

confidence: 99%

Section: Intramedullary Fixation: General Considerationsmentioning

confidence: 99%

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Current concepts of leg lengthening

Hasler

Krieg

2012

Journal of Children's Orthopaedics

101

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Preliminary investigations on a new gentamicin and vancomycin‐coated PMMA nail for the treatment of bone and intramedullary infections: An experimental study in the rabbit

Giavaresi¹,

Borsari²,

Fini³

et al. 2008

Journal Orthopaedic Research

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To evaluate a new gentamicin-vancomycin-impregnated (2:1) PMMA coating nail as a drug delivery device to treat bone and intramedullary infections, methicillin-resistant Staphylococcus aureus (MRSA) was used to induce femoral osteomyelitis in 20 New Zealand male rabbits. Four weeks after inoculum, the animals were submitted to debridement of infected femur canal, divided into four groups of five animals each and treated according to the following protocols: Group 1, insertion of a steel AISI316 intramedullary nail; Group 2, insertion of a gentamicin-vancomycin-impregnated PMMA nail; Group 3, no therapy; and Group 4 no fixation device and 1-week systemic antibiotic therapy with teicoplanin i.m. At 7 weeks after inoculum, the femurs were explanted sterilely. The radiological score showed that the lowest and best radiological score was observed in Group 2 that was significantly different from the other groups. The highest bacterial load in the femoral canal was found in Group 1, which was significantly different from Group 2 and Group 4 (p < 0.05). Histology showed that Group 2 produced a marked improvement (p < 0.005) of the bone injuries induced by the osteomyelitis in comparison with the other groups (Smeltzer score). The current findings showed that tested device might effectively lead to MRSA infection healing after surgical debridement and immediate implantation. Keywords: PMMA nail; gentamicin-vancomycin coating; intramedullary infections Bone and intramedullary infections are severe complications of fracture management (0-1% for closed fractures and 0-11% for open fractures) 1 and surgical repair (intramedullary nailing 2,3 and lengthening over nails with external fixation 4,5 ) of long bones. A prevalence of methicillin-resistant or gentamicin-resistant Staphyloccous aureus (SA) has been observed, and bone infection with methicillin-resistant SA (MRSA) has increased among patients with implanted orthopedic devices. The current management of these forms of osteomyelitis has two main aims: (a) to limit and resolve the infective process, by removing all foreign material (fixation device), followed by a meticulous debridement of the necrotic and infected area, and by administering systemically prolonged (4-6 weeks) high doses of antibiotics; 6-8 (b) to stabilize the fracture with alternative treatments, mainly external fixators, which are also not without complications. 1,9 The rationale for the long treatment time is based on the observation that revascularization of bone after debridement takes about 4 weeks. 10

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Callus patterns in femoral lengthening over an intramedullary nail

Muzaffar¹,

Hafeez²,

Modi

et al. 2011

Journal Orthopaedic Research

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Our objectives were to evaluate callus patterns seen in femoral lengthening over an intramedullary nail by Li classification regarding shape and type and to predict the result while using the nail to reduce the external fixation period and its complications. Eight hundred digital radiographs of 15 patients with 15 segments of femur shortening who underwent femoral lengthening with a monolateral external fixator over an intramedullary nail were analyzed retrospectively by four observers. Each radiograph was studied for callus shape, feature type, and callus density using pixel values. The classification was tested for concurrence and reproducibility by interobserver studies and callus patterns were compared with treatment indices to evaluate how they correlated with the outcome. Mean length gained was 4.5 cm (range: 2-8 cm). External fixator index (EFI) was 21.68 days/cm. Average distraction consolidation index (DCI) was 48.49 days/cm. Fusiform callus was seen in three cases, cylindrical in seven, and lateral in five. The homogenous pathway had higher DCI (43.7) than the heterogeneous pathway (32.9), and mixed pathways making up the rest had a DCI of 50.1. Pixel value of callus showed gradual increase in density until 20-24 weeks, then density gradually fell for 8 weeks, again increased after 32 weeks, again gradually fell, and was comparable to adjacent normal bone by 44-48 weeks. Our results suggest that the Li classification can be satisfactorily applied to lengthening procedures over intramedullary nails. The radiologic pattern and pixel value of regenerate can be correlated with the clinical outcome and can be an aid of prognostic value for the surgeon. Keywords: callus pattern; femoral lengthening; intramedullary nail; callus density; healing pathwayThe most common dilemma of any orthopedic surgeon doing distraction osteogenesis is the reproducible method of ascertaining the progression of osteogenesis and the eventual timing of removal of the external fixator.1,2 Since the constant presence of the fixator has been a source of irritation, pain, and stiffness for most patients, the lengthening done over an intramedullary nail is an aesthetic and biomechanically stable option for early removal. Better patient compliance, rapid improvement in range of joint movement, additional construct stability, and reduced incidence of deformities are advantages of such a procedure.3 Routinely, the consolidation phase is two to four times the duration of the distraction phase. Hence, accurate assessment of the mineralization of the regenerate assumes significance considering that inaccurate timing of removal may lead to stiffness and pin tract infection or deformity, shortening, and non union. Li et al. 4 developed a classification based on the shape and pattern of regenerate that, according to them, can help the surgeon to diagnose a particular abnormal callus pattern to determine its etiology, and with early intervention improve the end result. In the Li et al. 4 study, callus patterns were described in the adu...

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Leg lengthening over an intramedullary nail

Cited by 95 publications

References 0 publications

Current concepts of leg lengthening

Current concepts of leg lengthening

Preliminary investigations on a new gentamicin and vancomycin‐coated PMMA nail for the treatment of bone and intramedullary infections: An experimental study in the rabbit

Callus patterns in femoral lengthening over an intramedullary nail

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