Clinical Orthopaedics and Related Research®

, Volume 470, Issue 4, pp 1221–1231 | Cite as

Femoral Lengthening with Lengthening over a Nail has Fewer Complications than Intramedullary Skeletal Kinetic Distraction

  • Shahab Mahboubian
  • Matthew Seah
  • Austin T. Fragomen
  • S. Robert Rozbruch
Clinical Research

Abstract

Background

Lengthening over a nail and internal lengthening nails have been developed to minimize or eliminate patients’ time wearing a frame during femur lengthening. However it is unclear whether either of these two approaches results in faster times to union or fewer complications over the other.

Questions/purposes

We asked which technique better achieved: (1) the lengthening goals, (2) the distraction rate control, (3) quality of the regenerate bone, (4) fewer complications, and (5) if SF-36 scores and American Academy of Orthopaedic Surgeons Lower Limb Module (AAOS LLM) scores differ in each treatment modality?

Methods

We retrospectively reviewed the records and radiographs of 11 patients who had 12 Intramedullary Skeletal Kinetic Distractor (ISKD) procedures between 2002 and 2005, and 21 patients with 22 femoral lengthenings performed as lengthening over nail procedures between 2005 and 2009. Details such as leg length discrepancies, operative time, time of removal of the external fixator or ISKD, and any complications encountered were recorded. SF-36 and AAOS LLM scores also were compiled. The minimum followups for the ISKD and the lengthening over nail cohorts were 62 months (average, 76 months; range, 62–93 months) and 13 months (average, 27 months; range, 13–38 months), respectively.

Results

We observed no difference in achieving the lengthening goals between the two procedures. Distraction was not well controlled in the ISKD group; the distraction rates were 1.7 mm per day for the fast group (distraction rate greater than 1 mm/day) and 0.84 mm per day for the slow group (less than 1 mm/day). The lengthening over nail group had an average distraction rate of 0.88 mm per day. One of 20 of the patients who had lengthening over a nail had complications requiring additional unanticipated surgeries whereas six of 12 patients who had femoral lengthening in the ISKD group had such complications.

Conclusions

Based on our observations, we believe the lengthening over nail technique for femoral lengthening is associated with fewer complications than the ISKD.

Level of Evidence

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

References

  1. 1.
    Anand A, Feldman DS, Patel RJ, Lehman WB, van Bosse HJ, Badra MI, Sala DA. Interobserver and intraobserver reliability of radiographic evidence of bone healing at osteotomy sites. J Pediatr Orthop B. 2006;15:271–272.PubMedCrossRefGoogle Scholar
  2. 2.
    Burghardt RD, Herzenberg JE, Specht SC, Paley D. Mechanical failure of the Intramedullary Skeletal Kinetic Distractor in limb lengthening. J Bone Joint Surg Br. 2011;93:639–643.PubMedCrossRefGoogle Scholar
  3. 3.
    Chaudhary M. Limb lengthening over a nail can safely reduce the duration of external fixation. Indian J Orthop. 2008;42:323–329.PubMedCrossRefGoogle Scholar
  4. 4.
    Cole J, 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(suppl 4):SD129–139.PubMedGoogle Scholar
  5. 5.
    Garcia-Cimbrelo E, Olsen B, Ruiz-Yague M, Fernandez-Baillo N, Munuera-Martinez L. Ilizarov technique: results and difficulties. Clin Orthop Relat Res. 1992;283:116–123.PubMedGoogle Scholar
  6. 6.
    Hankemeier S, Pape H-C, Gosling T, Hufner T, Richter M, Krettek C. Improved comfort in lower limb lengthening with the intramedullary skeletal kinetic distractor: principles and preliminary clinical experiences. Arch Orthop Trauma Surg. 2004;124:129–133.PubMedCrossRefGoogle Scholar
  7. 7.
    Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989;238:249–281.PubMedGoogle Scholar
  8. 8.
    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.Google Scholar
  9. 9.
    Johanson NA, Liang MH, Daltroy L, Rudicel S, Richmond J. American Academy of Orthopaedic Surgeons lower limb outcomes assessment instruments: reliability, validity, and sensitivity to change. J Bone Joint Surg Am. 2004;86:902–909.PubMedGoogle Scholar
  10. 10.
    Kenawey M, Krettek C, Liodakis E, Meller R, Hankemeier S. Insufficient bone regenerate after intramedullary femoral lengthening: risk factors and classification system. Clin Orthop Relat Res. 2011;469:264–273.PubMedCrossRefGoogle Scholar
  11. 11.
    Kenawey M, Krettek C, Liodakis E, Wiebking U, Hankemeier S. Leg lengthening using intramedullary skeletal kinetic distractor: results of 57 consecutive applications. Injury. 2011;42:150–155.PubMedCrossRefGoogle Scholar
  12. 12.
    Khakharia S, Bigman D, Fragomen AT, Pavlov H, Rozbruch SR. Comparison of PACS and hard-copy 51-inch radiographs for measuring leg length and deformity. Clin Orthop Relat Res. 2011;469:244–250.PubMedCrossRefGoogle Scholar
  13. 13.
    Kocaoglu M, Eralp L, Kilicoglu O, Burc H, Cakmak M. Complication encountered during lengthening over an intramedullary nail. J Bone Joint Surg Am. 2004;86:2406–2411.PubMedGoogle Scholar
  14. 14.
    Kubiak EN, Strauss E, Grant A, Feldman D, Egol KA. [Early complications encountered using a self-lengthening intramedullary nail for the correction of limb length inequality][in Turkish]. Joint Dis Relat Surg (Eklem Hastalik Cerrahisi). 2007;18:52–57.Google Scholar
  15. 15.
    Li R, Saleh M, Yang L, Coulton L. Radiographic classification of osteogenesis during bone distraction. J Orthop Res. 2006;24:339–347.PubMedCrossRefGoogle Scholar
  16. 16.
    Min WK, Min BG, Oh CW, Song HR, Oh JK, Ahn HS, Park BC, Kim PT. Biomechanical advantage of lengthening of the femur with an external fixator over an intramedullary nail. J Pediatr Orthop B. 2007;16:39–43.PubMedCrossRefGoogle Scholar
  17. 17.
    Palatnik Y, Rozbruch SR. Femoral reconstruction using external fixation. Advances in Orthopedics. 2011;2011:Article ID 967186. doi:10.4061/2011/967186.
  18. 18.
    Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990;250:81–104.PubMedGoogle Scholar
  19. 19.
    Paley D, Herzenberg J, 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
  20. 20.
    Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am. 1994;25:425–465.PubMedGoogle Scholar
  21. 21.
    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
  22. 22.
    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
  23. 23.
    Sabharwal S, Kumar A. Methods for assessing leg length discrepancy. Clin Orthop Relat Res. 2008;466:2910–2922.PubMedCrossRefGoogle Scholar
  24. 24.
    Schiedel FM, Pip S, Wacker S, Pöpping J, Tretow H, Leidinger B, Rödl R. Intramedullary limb lengthening with the Intramedullary Skeletal Kinetic Distractor in the lower limb. J Bone Joint Surg Br. 2011;93:788–792.PubMedCrossRefGoogle Scholar
  25. 25.
    Simpson AH, Cole AS, Kenwright J. Leg lengthening over an intramedullary nail. J Bone Joint Surg Br. 1999;81:1041–1045.PubMedCrossRefGoogle Scholar
  26. 26.
    Simpson AH, Shalaby H, Keenan G. Femoral lengthening with the Intramedullary Skeletal Kinetic Distractor. J Bone Joint Surg Br. 2009;91:955–961.PubMedGoogle Scholar
  27. 27.
    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
  28. 28.
    Thonse R, Herzenberg JE, Standard SC, Paley D. Limb lengthening with a fully implantable, telescopic, intramedullary nail. Oper Tech Orthop. 2005;15:355–362.CrossRefGoogle Scholar
  29. 29.
    Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;30:473–483.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Shahab Mahboubian
    • 1
  • Matthew Seah
    • 1
  • Austin T. Fragomen
    • 1
  • S. Robert Rozbruch
    • 1
  1. 1.Limb Lengthening and Complex Reconstruction ServiceHospital for Special SurgeryNew YorkUSA

Personalised recommendations