Clinical Orthopaedics and Related Research

, Volume 466, Issue 12, pp 2923–2932

Limb Lengthening and Then Insertion of an Intramedullary Nail: A Case-matched Comparison

  • S. Robert Rozbruch
  • Dawn Kleinman
  • Austin T. Fragomen
  • Svetlana Ilizarov
Symposium: Advances in Limb Lengthening and Reconstruction

Abstract

Distraction osteogenesis is an effective method for lengthening, deformity correction, and treatment of nonunions and bone defects. The classic method uses an external fixator for both distraction and consolidation leading to lengthy times in frames and there is a risk of refracture after frame removal. We suggest a new technique: lengthening and then nailing (LATN) technique in which the frame is used for gradual distraction and then a reamed intramedullary nail inserted to support the bone during the consolidation phase, allowing early removal of the external fixator. We performed a retrospective case-matched comparison of patients lengthened with LATN (39 limbs in 27 patients) technique versus the classic (34 limbs in 27 patients). The LATN group wore the external fixator for less time than the classic group (12 versus 29 weeks). The LATN group had a lower external fixation index (0.5 versus 1.9) and a lower bone healing index (0.8 versus 1.9) than the classic group. LATN confers advantages over the classic method including shorter times needed in external fixation, quicker bone healing, and protection against refracture. There are also advantages over the lengthening over a nail and internal lengthening nail techniques.

Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

References

  1. 1.
    Bhandari M, Schemitsch EH. Bone formation following intramedullary femoral reaming is decreased by indomethacin and antibodies to insulin-like growth factors. J Orthop Trauma. 2002;16:717–722.PubMedCrossRefGoogle Scholar
  2. 2.
    Blachut PA, Meek RN, O’Brien PJ. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol. J Bone Joint Surg Am. 1990;72:729–735.PubMedGoogle Scholar
  3. 3.
    Brinker MR, O’Connor DP. Exchange nailing of ununited fractures. J Bone Joint Surg Am. 2007;89:177–188.PubMedCrossRefGoogle Scholar
  4. 4.
    Carvalho RS, Einhorn TA, Lehmann W, Edgar C, Al-Yamani A, Apazidis A, Pacicca D, Clemens TL, Gerstenfeld LC. The role of angiogenesis in a murine tibial model of distraction osteogenesis. Bone. 2004;34:849–861.PubMedCrossRefGoogle Scholar
  5. 5.
    Cole JD, Justin D, Kasparis T, DeVlught D, Knobloch C. The intramedullary skeletal kinetic distractor (ISKD): first clinical results of a new intramedullary nail for lengthening of the femur and tibia. Injury. 2001;32(4):SD129–SD139.PubMedGoogle Scholar
  6. 6.
    Cosco F, Risi M, Pompili M, Boriani S. External fixation and sequential nailing in the treatment of open diaphyseal fractures of the tibia. Chir Organi Mov. 2001;86:191–197.PubMedGoogle Scholar
  7. 7.
    Danckwardt-Lilliestrom G. Reaming of the medullary cavity and its effect on diaphyseal bone. A fluorochromic, microangiographic and histologic study on the rabbit tibia and dog femur. Acta Orthop Scand Suppl. 1969;128:1–153.PubMedGoogle Scholar
  8. 8.
    Danziger MB, Kumar A, DeWeese J. Fractures after femoral lengthening using the Ilizarov method. J Pediatr Orthop. 1995;15:220–223.PubMedGoogle Scholar
  9. 9.
    Fischgrund J, Paley D, Suter C. Variables affecting time to bone healing during limb lengthening. Clin Orthop Relat Res. 1994;301:31–37.PubMedGoogle Scholar
  10. 10.
    Giannoudis PV, Smith RM, Bellamy MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br. 1999;81:356–361.PubMedCrossRefGoogle Scholar
  11. 11.
    Green SA, Garland DE, Moore TJ, Barad SJ. External fixation for the uninfected angulated nonunion of the tibia. Clin Orthop Relat Res. 1984;190:204–211.PubMedGoogle Scholar
  12. 12.
    Hak DJ, Lee SS, Goulet JA. Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma. 2000;14:178–182.PubMedCrossRefGoogle Scholar
  13. 13.
    Hankemeier S, Gosling T, Pape HC, Wiebking U, Krettek C. Limb lengthening with the Intramedullary Skeletal Kinetic Distractor (ISKD). Oper Orthop Traumatol. 2005;17:79–101.PubMedCrossRefGoogle Scholar
  14. 14.
    Ilizarov GA. Tranosseous Osteosynthesis. 1st ed. Berlin, Germany: Springer-Verlag; 1992.Google Scholar
  15. 15.
    Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res. 1990;250:8–26.PubMedGoogle Scholar
  16. 16.
    Kessler SB, Hallfeldt KK, Perren SM, Schweiberer L. The effects of reaming and intramedullary nailing on fracture healing. Clin Orthop Relat Res. 1986;212:18–25.PubMedGoogle Scholar
  17. 17.
    Klezl Z, Rennirt G, Seligson D. Secondary intramedullary nailing of complicated fractures of lower extremities. Acta Chir Orthop Traumatol Cech. 1993;60:88–92.PubMedGoogle Scholar
  18. 18.
    Kocaoglu M, Eralp L, Kilicoglu O, Burc H, Cakmak M. Complications encountered during lengthening over an intramedullary nail. J Bone Joint Surg Am. 2004;86:2406–2411.PubMedGoogle Scholar
  19. 19.
    Lai KA, Lin CJ, Chen JH. Application of locked intramedullary nails in the treatment of complications after distraction osteogenesis. J Bone Joint Surg Br. 2002;84:1145–1149.PubMedCrossRefGoogle Scholar
  20. 20.
    Leidinger B, Winkelmann W, Roedl R. Limb lengthening with a fully implantable mechanical distraction intramedullary nail [in German]. Z Orthop Ihre Grenzgeb. 2006;144:419–426.PubMedCrossRefGoogle Scholar
  21. 21.
    Lowenberg DW, Feibel RJ, Louie KW, Eshima I. Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defects. Clin Orthop Relat Res. 1996;332:37–51.PubMedCrossRefGoogle Scholar
  22. 22.
    Maurer DJ, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. J Bone Joint Surg Am. 1989;71:835–838.PubMedGoogle Scholar
  23. 23.
    Mercado EM, Lim EV, Stern PJ, Aquino NJ. Exchange nailing for failure of initially rodded tibial shaft fractures. Orthopedics. 2001;24:757–762.PubMedGoogle Scholar
  24. 24.
    Nho SJ, Helfet DL, Rozbruch SR. Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame. J Orthop Trauma. 2006;20:419–424.PubMedCrossRefGoogle Scholar
  25. 25.
    Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82:781–788.PubMedCrossRefGoogle Scholar
  26. 26.
    O’Carrigan T, Paley D, Herzenberg JE. Obstacles in limb lengthening: fractures. In: Rozbruch SR, Ilizarov S, eds. Limb Lengthening and Reconstruction Surgery. New York, NY: Informa Healthcare; 2007:675–679.Google Scholar
  27. 27.
    Pacicca DM, Patel N, Lee C, Salisbury K, Lehmann W, Carvalho R, Gerstenfeld LC, Einhorn TA. Expression of angiogenic factors during distraction osteogenesis. Bone. 2003;33:889–898.PubMedCrossRefGoogle Scholar
  28. 28.
    Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening. J Bone Joint Surg Am. 1997;79:1464–1480.PubMedGoogle Scholar
  29. 29.
    Pugh K, Rozbruch SR. Nonunions and malunions. In: Baumgaertner MR, Tornetta P, eds. Orthopaedic Knowledge Update Trauma 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:115–130.Google Scholar
  30. 30.
    Rozbruch SR. Post-traumatic reconstruction of the ankle using the Ilizarov method. J Hosp Special Surg. 2005;1:68–88.Google Scholar
  31. 31.
    Rozbruch SR, DiPaola M, Blyakher A. Fibula lengthening using a modified Ilizarov method. Orthopedics. 2002;25:1241–1244.PubMedGoogle Scholar
  32. 32.
    Rozbruch SR, Fragomen AT, Ilizarov S. Correction of tibial deformity with use of the Ilizarov-Taylor spatial frame. J Bone Joint Surg Am. 2006;88(4):156–174.PubMedCrossRefGoogle Scholar
  33. 33.
    Rozbruch SR, Ilizarov S, Blyakher A. Knee arthrodesis with simultaneous lengthening using the Ilizarov method. J Orthop Trauma. 2005;19:171–179.PubMedCrossRefGoogle Scholar
  34. 34.
    Rozbruch SR, Paley D, Bhave A, Herzenberg JE. Ilizarov hip reconstruction for the late sequelae of infantile hip infection. J Bone Joint Surg Am. 2005;87:1007–1018.PubMedCrossRefGoogle Scholar
  35. 35.
    Rozbruch SR, Weitzman AM, Watson JT, Freudigman P, Katz HV, Ilizarov S. Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method. J Orthop Trauma. 2006;20:197–205.Google Scholar
  36. 36.
    Siebenrock KA, Schillig B, Jakob RP. Treatment of complex tibial shaft fractures. Arguments for early secondary intramedullary nailing. Clin Orthop Relat Res. 1993;290:269–274.Google Scholar
  37. 37.
    Simpson AH, Kenwright J. Fracture after distraction osteogenesis. J Bone Joint Surg Br. 2000;82:659–665.PubMedCrossRefGoogle Scholar
  38. 38.
    Smith RM, Giannoudis PV, Bellamy MC, Perry SL, Dickson RA, Guillou PJ. Interleukin-10 release and monocyte human leukocyte antigen-DR expression during femoral nailing. Clin Orthop Relat Res. 2000;373:233–240.PubMedCrossRefGoogle Scholar
  39. 39.
    Song HR, Oh CW, Mattoo R, Park BC, Kim SJ, Park IH, Jeon IH, Ihn JC. Femoral lengthening over an intramedullary nail using the external fixator: risk of infection and knee problems in 22 patients with a follow-up of 2 years or more. Acta Orthop. 2005;76:245–252.PubMedCrossRefGoogle Scholar
  40. 40.
    Templeman D, Thomas M, Varecka T, Kyle R. Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia. Clin Orthop Relat Res. 1995;315:169–175.PubMedGoogle Scholar
  41. 41.
    Utvag SE, Grundnes O, Reikeras O. Graded exchange reaming and nailing of non-unions. Strength and mineralisation in rat femoral bone. Arch Orthop Trauma Surg. 1998;118:1–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Watanabe K, Tsuchiya H, Sakurakichi K, Yamamoto N, Kabata T, Tomita K. Tibial lengthening over an intramedullary nail. J Orthop Sci. 2005;10:480–485.PubMedCrossRefGoogle Scholar
  43. 43.
    Wu CC, Shih CH, Chen WJ, Tai CL. High success rate with exchange nailing to treat a tibial shaft aseptic nonunion. J Orthop Trauma. 1999;13:33–38.PubMedCrossRefGoogle Scholar
  44. 44.
    Zelle BA, Gruen GS, Klatt B, Haemmerle MJ, Rosenblum WJ, Prayson MJ. Exchange reamed nailing for aseptic nonunion of the tibia. J Trauma. 2004;57:1053–1059.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons 2008

Authors and Affiliations

  • S. Robert Rozbruch
    • 1
  • Dawn Kleinman
    • 1
  • Austin T. Fragomen
    • 1
  • Svetlana Ilizarov
    • 1
  1. 1.Institute for Limb Lengthening and Reconstruction, Limb Lengthening and Deformity Service, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA

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