Clinical Orthopaedics and Related Research®

, Volume 470, Issue 6, pp 1771–1781 | Cite as

Does Lengthening and Then Plating (LAP) Shorten Duration of External Fixation?

  • Ryhor Harbacheuski
  • Austin T. Fragomen
  • S. Robert Rozbruch
Clinical Research



Classic bone lengthening requires patients wear external fixation for the distraction and consolidation phases and there is fracture risk after frame removal. Our technique of lengthening with the Taylor Spatial FrameTM and then insertion of a locked plate allows earlier removal of the external fixator during consolidation. Plate insertion is accomplished through a clean pin-free zone avoiding contamination and before frame removal maintaining bone position.


We asked (1) whether lengthening and then plating (LAP) decrease the time for external fixation (2) how alignment and complications compare with those of the classic method.


We performed a retrospective case-matched comparison between LAP and the classic technique with 27 extremities in each group. We compared time wearing the frame, bone healing index, external fixation index, joint ROM, alignment, and complications.


The time wearing the frame and external fixation index were lower in the LAP group (4.5 versus 6.2 months and 1.5 versus 2 months/cm). Deviation from normal alignment was observed in seven and six patients in the LAP and classic group, respectively. Varus malalignment in two patients in the LAP group was associated with plate breakage. The incidence of pin-tract infection was greater in the classic group (12 versus two). No deep infections occurred in the LAP group.


The LAP technique shortened the time patients wore the external fixator but was associated with a high incidence of varus deformity. Stronger plates may help prevent deformity and allow earlier removal of the frame.

Level of Evidence

Level III, therapeutic study (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    Apivatthakakul T, Arpornchayanon O. Minimally invasive plate osteosynthesis (MIPO) combined with distraction osteogenesis in the treatment of bone defects: a new technique of bone transport. A report of two cases. Injury. 2002;33:460–465.PubMedCrossRefGoogle Scholar
  2. 2.
    Aston WJ, Calder PR, Baker D, Hartley J, Hill RA. Lengthening of the congenital short femur using the Ilizarov technique: a single-surgeon series. J Bone Joint Surg Br. 2009;91:962–967.PubMedCrossRefGoogle Scholar
  3. 3.
    Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P 3rd, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma. 2002;16:562–566.PubMedCrossRefGoogle Scholar
  4. 4.
    Blondel B, Launay F, Glard Y, Jacopin S, Jouve JL, Bollini G. Limb lengthening and deformity correction in children using hexapodal external fixation: preliminary results for 36 cases. Orthop Traumatol Surg Res. 2009;95:425–430.PubMedCrossRefGoogle Scholar
  5. 5.
    Catagni MA, Lovisetti L, Guerreschi F, Combi A, Ottaviani G. Cosmetic bilateral leg lengthening: experience of 54 cases. J Bone Joint Surg Br. 2005;87:1402–1405.PubMedCrossRefGoogle Scholar
  6. 6.
    Corrales LA, Morshed S, Bhandari M, Miclau T 3rd. Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Joint Surg Am. 2008;90:1862–1868.PubMedCrossRefGoogle Scholar
  7. 7.
    Danziger MB, Kumar A, DeWeese J. Fractures after femoral lengthening using the Ilizarov method. J Pediatr Orthop. 1995;15:220–223.PubMedGoogle Scholar
  8. 8.
    Endo H, Asaumi K, Mitani S, Noda T, Minagawa H, Tetsunaga T, Ozaki T. The minimally invasive plate osteosynthesis (MIPO) technique with a locking compression plate for femoral lengthening. Acta Med Okayama. 2008;62:333–339.PubMedGoogle Scholar
  9. 9.
    Gantsoudes GD, Fragomen AT, Rozbruch SR. Intraoperative measurement of mounting parameters for the Taylor Spatial Frame. J Orthop Trauma. 2010;24:258–262.PubMedCrossRefGoogle Scholar
  10. 10.
    Gereli A, Nalbantoglu U, Kocaoglu B, Turkmen M. Comparison of palmar locking plate and K-wire augmented external fixation for intra-articular and comminuted distal radius fractures. Acta Orthop Traumatol Turc. 2010;44:212–219.PubMedCrossRefGoogle Scholar
  11. 11.
    Green SA. Pin and wire technique for external fixation. Instr Course Lect. 1995;44:487–493.PubMedGoogle Scholar
  12. 12.
    Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;239:263–285.PubMedGoogle Scholar
  13. 13.
    Ilizarov GA. Transosseous Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue. New York, NY: Springer-Verlag; 1992.Google Scholar
  14. 14.
    Iobst CA, Dahl MT. Limb lengthening with submuscular plate stabilization: a case series and description of the technique. J Pediatr Orthop. 2007;27:504–509.PubMedCrossRefGoogle Scholar
  15. 15.
    Kristiansen LP, Steen H, Reikeras O. No difference in tibial lengthening index by use of Taylor spatial frame or Ilizarov external fixator. Acta Orthop. 2006;77:772–777.PubMedCrossRefGoogle Scholar
  16. 16.
    Lerner A, Chezar A, Haddad M, Kaufman H, Rozen N, Stein H. Complications encountered while using thin-wire-hybrid-external fixation modular frames for fracture fixation: a retrospective clinical analysis and possible support for “Damage Control Orthopaedic Surgery”. Injury. 2005;36:590–598.PubMedCrossRefGoogle Scholar
  17. 17.
    Lie CW, Chow W. Limb lengthening in short-stature patients using monolateral and circular external fixators. Hong Kong Med J. 2009;15:280–284.PubMedGoogle Scholar
  18. 18.
    Matsubara H, Tsuchiya H, Sakurakichi K, Watanabe K, Tomita K. Deformity correction and lengthening of lower legs with an external fixator. Int Orthop. 2006;30:550–554.PubMedCrossRefGoogle Scholar
  19. 19.
    McClelland D, Thomas PB, Bancroft G, Moorcraft CI. Fracture healing assessment comparing stiffness measurements using radiographs. Clin Orthop Relat Res. 2007;457:214–219.PubMedGoogle Scholar
  20. 20.
    Nakase T, Kitano M, Kawai H, Ueda T, Higuchi C, Hamada M, Yoshikawa H. Distraction osteogenesis for correction of three-dimensional deformities with shortening of lower limbs by Taylor Spatial Frame. Arch Orthop Trauma Surg. 2009;129:1197–1201.PubMedCrossRefGoogle Scholar
  21. 21.
    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
  22. 22.
    Oh CW, Shetty GM, Song HR, Kyung HS, Oh JK, Min WK, Lee BW, Park BC. Submuscular plating after distraction osteogenesis in children. J Pediatr Orthop B. 2008;17:265–269.PubMedCrossRefGoogle Scholar
  23. 23.
    Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990;250:81–104.PubMedGoogle Scholar
  24. 24.
    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
  25. 25.
    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(suppl 4):156–174.PubMedCrossRefGoogle Scholar
  26. 26.
    Rozbruch SR, Kleinman D, Fragomen AT, Ilizarov S. Limb lengthening and then insertion of an intramedullary nail: a case-matched comparison. Clin Orthop Relat Res. 2008;466:2923–2932.PubMedCrossRefGoogle Scholar
  27. 27.
    Rozbruch SR, Segal K, Ilizarov S, Fragomen AT, Ilizarov G. Does the Taylor Spatial Frame accurately correct tibial deformities? Clin Orthop Relat Res. 2010;468:1352–1361.PubMedCrossRefGoogle Scholar
  28. 28.
    Smith & Nephew Inc. Taylor Spatial FrameTM Software. Available at: Accessed October 19, 2011.
  29. 29.
    Song HR, Myrboh V, Oh CW, Lee ST, Lee SH. Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis. Acta Orthop. 2005;76:261–269.PubMedCrossRefGoogle Scholar
  30. 30.
    Temple J, Santy J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev. 2004;1:CD004551.Google Scholar
  31. 31.
    Uysal M, Akpinar S, Cesur N, Hersekli MA, Tandogan RN. Plating after lengthening (PAL): technical notes and preliminary clinical experiences. Arch Orthop Trauma Surg. 2007;127:889–893.PubMedCrossRefGoogle Scholar
  32. 32.
    Wagner H. Operative lengthening of the femur. Clin Orthop Relat Res. 1978;136:125–142.PubMedGoogle Scholar
  33. 33.
    Wu CC, Lee ZL, Wu CC, Lee ZL. Speeded gradual lengthening and secondary angled blade plate stabilisation for proximal tibial shaft non-union with shortening. Int Orthop. 2008;32:693–696.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Ryhor Harbacheuski
    • 1
  • Austin T. Fragomen
    • 1
  • S. Robert Rozbruch
    • 1
  1. 1.Limb Lengthening and Complex Reconstruction Service, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA

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