What's New in Limb Lengthening and Deformity Correction.

Mark T Dahl; Stewart G Morrison; Andrew G Georgiadis; Aaron J Huser

doi:10.2106/jbjs.19.00584

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What's New in Limb Lengthening and Deformity Correction.

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https://doi.org/10.2106/jbjs.19.00584

What's New in Limb Lengthening and Deformity Correction.

Aug 21, 2019
The Journal of bone and joint surgery. American volume
Mark T Dahl +3 more

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Abstract

The Limb Lengthening and Reconstruction Society (LLRS) celebrated its 28th year as an orthopaedic subspecialty, with a combined meeting with the Pediatric Orthopaedic Society of North America (POSNA) at the 2019 American Academy of Orthopaedic Surgeons (AAOS) meeting in Las Vegas. The LLRS 28th Annual Scientific Meeting was held on July 19 and 20, 2019, in Boston, Massachusetts, featuring papers and workshops from around the world. A diverse subspecialty society, we overlap with trauma, pediatric, foot and ankle, sports, arthroplasty, and oncologic orthopaedic surgeons in the diagnosis and treatment of deformities of length, alignment, contracture, nonunion, and bone healing. The purpose of this update was to summarize the important articles with regard to these subjects published since 2018. Guided Growth The technique of temporary, asymmetric growth plate tethering continues to be a successful method of deformity correction in growing children. The concept, known as guided growth, was developed by Dr. Peter Stevens, using a small, 2-hole plate to span the growth plate on 1 side, allowing the opposite side to grow unresisted, and thereby correcting angular deformity without osteotomy. The screws within the plate provide an articulation, with the apex of the correction occurring at the perichondrial ring. A multinational retrospective study described results of guided growth in 537 children with 967 physes treated1. Distal femoral and proximal tibial correction rates were similar, averaging 0.77° per month for the distal part of the femur and 0.79° for the proximal part of the tibia, despite the commonly held opinion that the femur corrects faster than the tibia. Patients with >3 years of growth remaining had a better quality of correction. Infection was uncommon, occurring in 1.78% of patients. Seven of the 8 infections occurred at the upper medial part of the tibia. The study was unable to correlate the effect of body weight on the result, nor did it assess the incidence of rebound deformity. A modified guided growth technique has been previously advocated for only removing the metaphyseal screw and leaving the plate and epiphyseal screw in place once a correction is complete. Thus, in the event that a deformity recurs, a simpler procedure to reinsert a single screw could be performed. A study by Keshet et al. refuted this practice2, as they observed permanent bar formation in 2 of 55 cases using the technique. They also observed that only 12 of their 55 patients required reinsertion of the metaphyseal screw and that 9 of those actually required plate repositioning. Anterior guided growth of the distal part of the femur to treat fixed knee flexion contracture in cerebral palsy has been reported to have favorable results, provided that implants are placed sufficiently anterior and adequate growth remains3. Congenital Pseudarthrosis of the Tibia Congenital pseudarthrosis of the tibia remains a challenge for the orthopaedic surgeon. Richards and Anderson4 reported using bone morphogenetic protein (BMP)-2 without deleterious effects in 21 children with congenital pseudarthrosis. They applied a single sponge around an autologous cancellous bone graft with intramedullary pinning that crossed the ankle joint. This technique seemed to shorten the time to union, but did not eliminate nonunion or refracture, the latter occurring in 5 of the 16 initially healed patients. In a retrospective multicenter study of 119 patients with Crawford type-II congenital pseudarthrosis of the tibia followed to maturity, Shah et al. reported an 86% primary union rate, with 69% still united at maturity5. They did not identify specific factors influencing rates of union or refracture and recommended a larger, prospective, multicenter study. Three-Dimensional Printing Three-dimensional printing, originally known as additive manufacturing, creates models by printing layers of materials on top of one another. These models can be physically held, manipulated, and studied, providing the surgeon preoperative assessment of the specific anatomical geometry. Haleem and Javaid6 described methods to create 3-dimensional models for preparation and practice of orthopaedic procedures. Exact fit models, based on magnetic resonance imaging (MRI) or computed tomography (CT) scanning techniques, can allow for preoperative planning and mock surgical procedures and can create implants specific for complex cases. Corona et al.7 described using 3-dimensional printed titanium truss cages in conjunction with the Masquelet technique to treat massive infected posttraumatic defects. Bone Defects Nauth et al.8 described a 3-stage protocol of (1) radical debridement and resection of infected skeletal elements; (2) defect space management using antibiotic blocks, spacers, or beads, which provide a local depository of culture-specific antibiotic and develop a vascularized membrane; and (3) 8 weeks later, carefully opening the membrane and exchanging the spacer for an autologous graft. Napora et al.9 described excellent functional outcome of patients at 2 to 8 years after tibial defects were treated with bone transport using a stacked hexapod frame. Corticotomy and transport were delayed for 6 to 8 weeks in patients undergoing concurrent flap coverage. The authors noted improved ease and accuracy of the docking with hexapod frames and described a method to augment frame stability near the end of treatment. The Short Musculoskeletal Function Assessment (SMFA) score was not influenced by age, sex, or diabetic status. Seventeen of 38 patients required an additional fixation surgical procedure (plate, nail, or fixator reapplication) at some point during their treatment. Barinaga et al.10 published a case report of successful tibial bone transport combining the use of a motorized magnetic lengthening nail and a limited contact dynamic compression plate, sparing the patient adjunctive external fixation. Limb Lengthening Distraction osteogenesis is the spontaneous formation of new bone in a gradually widening osteotomy site using external fixation. The more recent development of motorized internal limb-lengthening nails has advanced the capabilities of treating patients with limb lengthening and reconstruction needs. Additional authors have reported safe and successful lengthening with motorized intramedullary devices. Iobst et al.11 reported on simultaneously performing distal femoral angular correction and insertion of a retrograde intramedullary lengthening nail, while controlling the fragments with a temporary intraoperative external fixator. Length was subsequently achieved with the motorized intramedullary lengthening nail. Acute corrections of up to 15° were possible with the technique. The authors preoperatively planned their cases using the Baumgart method of reverse planning. Magnetic lengthening nails were used with liberal application of blocking screws preventing postoperative deformity. A cost study suggested that patients undergoing intramedullary lengthening have higher initial implant costs than fixator lengthening over a nail, but the former undergo fewer procedures overall12. Reuse of a PRECICE nail (Nuvasive) was reported in a case of a femoral discrepancy after an infection in which a 3-cm lengthening was successfully performed, distal locking screws were removed, the telescopic portion of the nail was retracted, and a second corticotomy and lengthening were performed13. Radiographic evaluation of bone regenerate formation during lengthening is possible by a number of means. A radiographic pilot study by Vulcano et al.14 found that a pixel-density ratio of >0.89 (ratio of pixel density in the regenerate relative to the surrounding cortex) may correlate with osseous healing and may be the threshold for allowing full weight-bearing. In pediatric patients, Archer et al.15 also found that the most reliable radiographic assessments of regenerate were by the pixel value ratio and the Ru Li technique. The mechanical environment of distracted callus affects the quality of new bone formation. An ovine study was performed by Claes et al.16 in which lateral callus distraction was undertaken in tibiae and various cyclic loads were applied at the end of lengthening. Tibiae that underwent compressive loading had more bone formation, higher spicule height, and higher blood vessel density than those experiencing shear or distractive loading. Growth Prediction Makarov et al.17 evaluated 77 patients at their institution, comparing the predictive accuracy of the White-Menelaus, Anderson-Green, Moseley, and multiplier methods for correctly timing epiphysiodesis. Final leg-length prediction errors varied from 0.7 to 1.1 cm, with the multiplier method proving to be the least accurate. Makarov et al.18 also reported a 7% complication rate among 863 epiphysiodeses, the most common of which was incomplete arrest in 31 patients resulting in angular deformity and requiring reoperation in half of such cases. Physeal Violation A sheep model was used by Knapik et al.19 to assess the consequences of distal femoral physeal violation by a retrograde intramedullary implant, noting that violations of ≤7% of the cross-sectional area were associated with continued growth of the physis without bar formation. Congenital Limb Deficiencies A review from the Finnish Register of Congenital Malformations and Care Register for Health Care20 identified all children born with lower-limb deficiencies, comparing their hospital admissions and stays with the general pediatric population of Finland. In the 16-year study period, the authors found that children with lower-limb deficiencies (terminal, long bone, foot, and toe) had 6 times the number of hospital admissions and 10 times the number of days in the hospital per child than all of the children born without limb deficiency. Two-thirds of the patients born with congenital lower-limb deficiencies required an operation, and approximately half of those operations were orthopaedic. The ratio of the short lower extremity to the contralateral, longer lower extremity in patients with congenital deficiencies has historically been considered constant in the orthopaedic literature. Tsai et al.21 attempted to verify this concept of constant inhibition and to further elucidate the pattern of skeletal maturation in patients with fibular hemimelia. They confirmed the concept of constant inhibition, with a mean deviation ranging from 0.1% to 3.3% in the femur and 0.1% to 3% in the tibia. They also noted that the growth patterns of the lower extremities in patients with unilateral fibular hemimelia did not differ when compared with the normal population. Kowalczyk and Kuźnik-Buziewicz22 reported outcomes of rotation-plasty for unilateral proximal femoral focal deficiency, reviewing postoperative function, time to knee fusion, and complications in 8 adolescents followed for 6 to 12 years postoperatively. Intensive preoperative physical therapy was performed to maximize strength and motion, especially ankle dorsiflexion. Patients were all pain-free and were able to walk without assistive devices. The 2 patients who did not exhibit a Trendelenburg gait had undergone preoperative hip stabilization procedures. Spontaneous derotation of the foot occurred in 5 of 8 patients, necessitating a repeat surgical procedure in 2 patients. All patients reported acceptance of the limb appearance and satisfaction with the result. Radhakrishna et al.23 reviewed 6 patients with Jones type-II tibial hemimelia presenting with an absent distal part of the tibia who were treated with limb salvage. All patients were reconstructed with the following elements: gradually moving the fibula distally using an external fixator to normalize the relationship of the proximal parts of the tibia and fibula; centralizing the fibula with creation of a synostosis between the fibula and tibia; and centralizing the foot relative to the fibula distally, creating a fibular-talar fusion, using external fixation and soft-tissue releases. The mean increase in leg length was 4 cm, with a mean time of 43 days in the fixator. Each child required 2 to 4 procedures, with all patients achieving union. Walker et al.24 analyzed a group of patients with ulnar deficiency and noted that a lower-extremity deficiency was present in 55% of patients. The patients with lower-extremity deficiencies and ulnar deficiencies had less severe presentation of ulnar deficiency. The authors observed no patients with tibial hemimelia (pre-axial deficiency) associated with ulnar deficiencies (post-axial deficiency). They pointed out that the upper-limb bud forms earlier than the lower-limb bud, considering the possibility that a developing limb insult would explain the observation that more lower-extremity involvement was related to less upper-extremity involvement. Physeal Arrest and Epiphysiodesis Physeal bar formation was assessed in a rat model by Wattenbarger et al.25. They selectively induced injury by scraping and drilling the metaphyseal and epiphyseal sides of the physis. Basement plate penetration on the epiphyseal side was associated with radiographic and histologic physeal injury, whereas hypertrophic zone violation on the metaphyseal side was associated with continued growth. Arthroscopic and navigation-assisted physeal bar resection is being increasingly reported. Miyamura et al.26 reported a case with a 2-year follow-up of a distal radial bar excision and concomitant osteotomy, planned using 3-dimensional CT, patient-specific guides, and intraoperative endoscopic visualization. Foot and Ankle Ankle arthrodesis for neuropathic foot deformity is historically associated with poor union rates. A fusion technique combining an external fixator and an intramedullary nail was reported to achieve fusion in 22 of 24 patients by El-Mowafi et al.27. Neuropathic foot deformity with concurrent osteomyelitis is the subject of an article by Kliushin et al.28. Seventy-seven patients were treated for a mean time of 180 days in an external fixator, with infection eradicated in 90.9% of patients at a 1-year follow-up. The American Orthopaedic Foot & Ankle Score (AOFAS) increased marginally, which the authors attributed to the pain component of the outcome score. Brandão et al.29 discussed the management of diabetic neuropathy of the foot with both internal and external fixation techniques, with particular attention to the concept of beaming of the midfoot with axial internal fixation. This concept was described as stiff, thick, intramedullary longitudinal support from hindfoot to forefoot. Staged distraction osteogenesis and ankle arthrodesis were performed by Lou et al.30 in 12 patients with posttraumatic or infectious bone loss of the distal part of the tibia who were treated with simultaneous proximal lengthening and distal compression osteosynthesis using circular fixation to provide ankle fusion. The AOFAS improved from a mean of 37.3 to 75.3 points, and successful regenerate was formed in all, although 2 patients underwent bone-grafting. Ahmad et al.31 reported the results of the treatment of rigid equinus foot deformity with circular external fixation in an adolescent and pediatric population. They reported a mean correction angle of 47.4°. Pin-track infections occurred in 4 of the 30 patients. Equinus deformity secondary to burn contractures treated with circular external fixation was the subject of a report by Zhang et al.32. The authors described a wire technique in the foot, predominantly using hindfoot wires, recognizing the need to avoid injury to the posterior tibial neurovascular bundle. A cadaver study by Kelly et al.33 identified safe hindfoot wire insertion using an entry point one-third of the distance along a line from the posterior aspect of the calcaneus to the lateral malleolus to predictably avoid the posteromedial neurovascular bundle. Nepalese children who were 1 to 5 years of age and had neglected clubfoot deformity were treated by the Ponseti method34. Ninety-five percent of feet remained plantigrade at a minimum of 10 years. Despite some residual deformity, patient-reported outcomes were satisfactory, with a relapse rate of 3%. Trauma The role of external fixation in the management of tibial fractures was described in a number of publications. In a retrospective study, Berven et al.35 compared Ilizarov frame fixation with locking plate fixation of proximal tibial fractures between 62 patients treated at 1 center using the Ilizarov technique and 68 patients treated at a different institution using internal fixation. Time to union was considered faster in the internal fixation group. Deep infection, alignment, reoperation, and range of motion were similar in the 2 groups. Lovisetti et al.36 reported the results of circular external fixation in bicondylar tibial plateau fractures, with a mean follow-up period of 37.3 months. All 20 cases were initially managed with knee-spanning fixation. The results were measured by radiographs and Hospital for Special Surgery (HSS) score and were described as favorable when compared with other series presented in the literature. Napora et al.9 examined functional outcomes in 38 patients with infected tibial nonunion managed with stacked hexapod external fixators for the purpose of bone transport. Corticotomy and transport were delayed for 6 to 8 weeks in patients undergoing concurrent flap coverage. The study noted that, with an intact fibula, the proximal and distal portions of the frame programs must be a mirror image of each other and that if angular, translational, rotation, or additional length deformity correction is built into the frame, a fibular osteotomy is required. Patients completed an SMFA survey at the time of final follow-up. The SMFA score was not influenced by age, sex, or diabetic status. Of 38 patients, 17 required an additional fixation surgical procedure (plate, nail, or fixator reapplication) at some point during their treatment. Arsoy et al.37 reported that patients presumed to have aseptic nonunion but later determined to have positive cultures had an 84% union rate with systemic antibiotic therapy. Tumor Elalfy et al.38 determined that chemotherapy had a negative effect on bone healing and diminished bone hypertrophy when using modulated compliant compressive forces to induce osteointegration in a tumor prosthesis. The 49 patients receiving chemotherapy postoperatively had less bone formation than the 44 patients who did not receive chemotherapy. Implant survival was not affected by chemotherapy, with 10-year survival rates of 85%. Limb-salvage techniques in the management of pediatric sarcoma continue to evolve. Segmental metadiaphyseal distal femoral defects after resection can be reconstructed with a novel vascularized fibular A-frame technique, augmented with an intramedullary nail. This provides a biological reconstruction with greater cross-sectional area than a single vascularized fibula, with a segment amenable to later limb lengthening39. For patients with limb growth potential remaining who require endoprosthetic reconstruction, growing prostheses are described. These include both minimally invasive devices (requiring lengthening under fluoroscopic guidance) and noninvasive devices (driven by an external magnet), and these were compared in a survival analysis by Medellin et al.40. Prosthesis survival was demonstrated as 79% (minimally invasive) and 70% (noninvasive) at 10 years. Patients receiving noninvasive prostheses had a higher mean Musculoskeletal Tumor Society Score (27 points) compared with patients who received minimally invasive devices (24.7 points), which, although not attaining significance (p = 0.295), was attributed by the authors to higher patient satisfaction, better gait, and greater independence. A novel approach to limb salvage in sarcoma of the distal part of the tibia was also described by Lou et al.30, with 5 patients undergoing resection of tumor (including the distal part of the tibia and the talar chondral surface) and subsequent tibial bone transport to achieve tibiotalar fusion. The segment was plated 1 month following the transport phase to expedite frame removal, with mean final Musculoskeletal Tumor Society Score of 88 points.

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Sebastian J Ko + 5 more +5

To determine the trajectory of recovery after tibial shaft fracture treated with intramedullary nail over the first 5 years and to evaluate the magnitude of the changes in functional outcome at various time intervals. Prospective cohort study. A Level 1 trauma center. One hundred thirty-two patients with tibial shaft fracture (OTA 42-A, B, C) were enrolled into the Center's prospective orthopaedic trauma database between January 2005 and February 2010. Functional outcome data were collected at baseline, 6 months, 1 year, and 5 years. Enrolled patients were treated acutely with intramedullary nailing of their tibia. Evaluation was performed using the Short Form-36 and Short Musculoskeletal Function Assessment (SMFA). Mean SF-36 physical component scores improved between 6 and 12 months (P = 0.0008) and between 1 and 5 years (P = 0.0029). Similarly, mean SMFA dysfunction index scores improved between 6 and 12 months (P = 0.0254) and between 1 and 5 years (P = 0.0106). In both scores, the rate or slope of this improvement is flatter between 1 and 5 years than it is between 6 and 12 months. Furthermore, SF-36 and SMFA scores did not reach baseline at 5 years (SF-36 P < 0.0001, SMFA P = 0.0026). A significant proportion of patients were still achieving a minimal clinically important difference in function between 1 and 5 years (SF-36 = 54%, SMFA = 44%). The trajectory of functional recovery after tibial shaft fracture is characterized by an initial decline in function, followed by improvement between 6 and 12 months. There is still further improvement beyond 1 year, but this is of flatter trajectory. The 5-year results indicate that function does not improve to baseline by 5 years after injury. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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Orthopedic implant removal following open reduction internal fixation of a fracture is a common procedure, especially in the foot and ankle. The purpose of this study was to evaluate functional change after the removal of symptomatic implants following ankle fracture open reduction internal fixation (ORIF) using the Short Musculoskeletal Function Assessment (SMFA) outcome score. We hypothesized that implant removal after ankle fracture would result in improved functional outcomes. Retrospective review of prospectively collected data on patients with a closed ankle fracture between 2013 and 2016 was performed. Inclusion criteria were skeletal maturity, symptomatic ankle implants and completion of the SMFA questionnaire prior to and 6 months after removal. Exclusion criteria were development of a nonunion, prior or current infection, peripheral neuropathy or ongoing litigation surrounding the surgery. The primary outcome was change in SMFA score from baseline to follow-up using Wilcoxon signed-rank test. Additional logistic regression models evaluated the effects of age, sex, body mass index, smoking status, and patient American Society of Anesthesiologists scores. The study population consisted of 43 patients. There was a statistically significant improvement in function, represented by a decrease in SMFA scores from baseline to the 6-month follow-up period (∆ = -4.1 [95% confidence interval, -7.0, -1.3]; P = .003). Secondary outcome measures of the bother index and daily activities domain also demonstrated significant improvements ( P = .005 and P = .002, respectively). Additional logistical regression models identified no significant effects by assessed covariates for change in SMFA scores. Patients with symptomatic implants following ankle fracture ORIF had a statistically significant improvement in function following implant removal. There appears to be value in removing implants from the ankle in patients who report discomfort during daily activities. Further investigation into the specific indications for implant removal and the impact of injury and fracture pattern on outcomes is warranted. Level IV, case series.

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Motorized Internal Limb Lengthening: International Perspectives

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S Robert Rozbruch + 1 more +1

The remote-controlled, motorized, intramedullary lengthening nail is a disruptive technology that has fundamentally changed the approach to limb lengthening and reconstruction surgery globally. This new paradigm for limb reconstruction, marked by a decreased need for external fixation, has ignited a fervor among limb deformity surgeons. Although the origins of the Ilizarov method of distraction osteogenesis are deeply entwined with circular external fixation, the disadvantages of external fixators are well known and include pin track infections, skin pain, soft-tissue tethering, and joint stiffness. Integrated fixation techniques were developed combining internal and external fixation such as lengthening over a nail, lengthening and then nailing, lengthening and then plating, and bone transport over a nail to minimize the treatment time in external fixation. 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The second design, now most widely used in the United States, is a telescopic rod with a magnetic drive mechanism, activated by a hand-held external electromagnetic actuator. Furthermore, in addition to the functional mechanism differences, there are nails made from titanium or from stainless steel, and these have different biomechanical properties. The indications range by bone and nail orientation. The femur can be approached antegrade through a piriformis or greater trochanteric entry or can be entered retrograde. A short residual femur after amputation can be lengthened with a specially designed nail. The tibia is approached antegrade. Although the ILNs are primarily used for distraction osteogenesis bone lengthening, the magnetic ILN can also be used for compression of nonunions. In the last several years, there has been some experience with bone transport nails but recently, a motorized magnetic bone transport nail for treatment of segmental bone defects up to 10 cm has been launched, and the early experience is currently being accumulated. Creative, off-label uses of the commercially available nails have included humerus lengthening, retrograde tibia through an ankle/subtalar arthrodesis, extramedullary lengthening with a nail, and bone transport over a plate. Additional internal lengthening designs are in development including humerus nails, ankle fusion/retrograde tibia nails, and internal lengthening plates. In the absence of angular deformity, lengthening of a long bone with the ILN is an ideal surgical indication. Rotation may be corrected over the nail. Blocking screws may be needed to prevent predictable deformities that occur during lengthening. 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Preoperative Plan with 3D Printing in Internal and External Fixation for Complex Tibial Plateau Fractures

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Wei‐Yong Wu + 3 more +3

ObjectiveTo compare short‐term treatment effects of internal and external fixation in the treatment of complicated tibial plateau fractures by preoperative planning with 3D printing.MethodsSixty‐nine patients with tibial plateau fractures were examined. 3D printing was used to establish the model in all patients before the operation. Thirty‐four patients were treated with an external fixator (9‐Schatzker Type V, 25‐Schatzker Type VI) and 35 patients were treated with internal fixation (12‐Schatzker Type V, 23‐Schatzker Type VI). The time span of the study was 2 years after the operation. All patients were followed up in the clinic of the attending physician who recorded patient follow‐up information at the same time. Finally, the Rasmussen functional score, radiographic parameters, complication rates, hospital days and operative parameters of the two groups were analyzed.ResultsThe short‐term (within 2 years) Rasmussen score in the external fixation group was close to that of the internal fixation group; the differences were not significant (P > 0.05). The fractures were reduced adequately using both forms of surgical treatment. There is no significant difference between internal and external fixation in terms of radiographic parameters after 2 years (Mann–Whitney U‐tests, P > 0.05). Thrombosis was detected in 7 cases (2 external fixation, 5 internal fixation). Superficial infection was detected in 3 cases (1 external fixation, 2 internal fixation). Deep infection was detected in 3 cases (0 external fixation, 3 internal fixation). Knee stiffness was detected in 4 cases (2 external fixation, 2 internal fixation); 1 (2.7%) case of screw pullout occurred in the internal fixation group. The external fixation group had shorter operation times (172.94 ± 50.00 min vs 253.86 ± 64.59 min), less bleeding volume (395.88 ± 121.10 mL vs 864.29 ± 238.12 mL), and fewer days (17.03 ± 5.03 days vs 30.17 ± 8.64 days) of hospitalization compared to the internal fixation (t‐test, P = 0.00); subgroup analysis of all patients with complex tibial plateau fractures revealed that for patients with tibial plateau fracture type VI, the functional score of external fixation (26.79 ± 2.04) is better than that (25.54 ± 1.69) of internal fixation (t‐ test, P = 0.026) and the overall infection rate of external fixation is lower than that of internal fixation (χ2‐ test, P = 0.047).ConclusionUsing 3D printed models in combination with external fixation has more advantages for short‐term treatment of complex tibial plateau fractures. In particular, relatively better functional recovery and lower rates of infection can be achieved for Schatzker type VI fractures. The external fixation treatment was preferred in cases of Schatzker VI tibial plateau fractures.

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Compression Forces of Internal and External Ankle Fixation Devices with Simulated Bone Resorption

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Christopher M Yakacki + 4 more +4

Internal and external fixation techniques have been developed to provide rigidity and stability to a fusion site such as in tibiotalocalcaneal (TTC) arthrodesis. Compression of the fusion site plays an integral role in primary bone healing, though little work has been done to quantify the compressive force values of ankle fixation devices. Using synthetic and cadaveric bone models, a Newdeal/Integra PantaNail and DePuy VersaNail were tested as compressive intramedullary (IM) nails while an Encore True/Lok and an Ace-Fischer frame were tested as external fixators. The PantaNail experienced maximum compressive loads of 1898 and 1255 N in synthetic and cadaveric constructs, respectively. The VersaNail experienced max compressive loads 388 N during installation. All IM nails tested experienced decreased compressive loads after removal of the external guide and instrumentation. The external fixators were loaded to approximately 1200 N in both synthetic and cadaveric constructs. The decrease in compressive load was recorded as a function of simulated fusion site bone resorption for all devices. The IM nails experienced a 90% reduction in load with less than 1 mm of resorption, while the external fixators held 50% load for over 4 mm of resorption. These data were verified using a simple constitutive model of IM nails and external fixators. Intramedullary nails are capable of generating compression, however, are unable to provide sustained compression for any considerable amount of resorption. External fixators are inherently capable of applying and sustaining greater amounts of compression. Surgeons who perform TTC arthrodesis procedures should be aware of a device's ability to generate and sustain compression with respect to bone resorption.

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10.1177/2473011417s000409

Does Hardware Removal Improve Function Following Ankle Open Reduction and Internal Fixation?

Sep 01, 2017
Foot & Ankle Orthopaedics
Benjamin Williams + 5 more +5

Category: Ankle, Trauma Introduction/Purpose: Orthopaedic hardware removal (HWR) is one of the most common orthopaedic procedures performed, with rates reported between 5% and 16%. Despite the high rates of HWR, there is still no consensus or guideline for removal after osseous healing without infection. Outcome studies for HWR are scarce, particularly in the lower extremity. The purpose of this study is to evaluate the effect of removal of symptomatic ankle hardware using the Short Musculoskeletal Function Assessment (SMFA) dysfunction index as the primary outcome. We hypothesize that HWR after ankle fracture will result in improved functional outcomes. Methods: Utilizing a prospectively collected ankle fracture registry, all patients that underwent HWR between 2013 and 2016 were retrospectively reviewed. Inclusion criteria were skeletal maturity, closed intra-articular ankle fracture, symptomatic ankle hardware and completion of the SMFA questionnaire prior to and 5-months after hardware removal. Exclusion criteria were development of a nonunion, infection or complex regional pain syndrome from initial surgery. The primary outcome was change in SMFA score from baseline. Paired t-test was used to compare baseline and follow-up SMFA scores. A multiple linear regression model evaluated the effects of age, sex, body mass index (BMI), smoking status, number of comorbidities, and Lauge-Hansen fracture classification on outcomes. Results: The study included 43 patients (31 females, 12 males), mean age 49.9 (range, 19 to 83). Mean time from initial surgery to HWR was 37±46 months (range, 2.2 to 209). Follow-up SMFA questionnaires were completed 5.7±0.5 months (range, 5.1 to 7.4) after HWR. The fractures were classified as 23 (53%) supination-external rotation, 6 (14%) pronation-external rotation, 2 (4.7%) pronation-abduction and 1 (2.3%) supination-adduction. Eleven fractures (26%) were classified as pilons. The SMFA dysfunction index improved significantly from baseline to follow-up (3.71±7.4, p=0.002). Significant improvement was seen in the secondary outcomes of SMFA bother index (4.40±8.9, p=0.003) and SMFA daily activities domain (4.12±9.1, p=0.006). Regression analysis revealed a significant improvement in the bother index correlating with female gender (p=0.01) and decreasing number of comorbidities (p=0.03). Conclusion: Our study demonstrates that patients with ankle fractures have a significant improvement in function following the removal of symptomatic ankle hardware. Patients also showed a significant improvement in the bother index and daily activities domain of the SMFA. Further investigation into the specific indications for HWR and the impact of injury and fracture pattern on outcomes is warranted.

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Cureus
Amandeep S Bakshi + 4 more +4

Introduction: Infected non-union of bones shows problems in providing stability and controlling the infection. The treatment comprises debridement with or without the use of antibiotic cement and achieving stability by either external or internal fixation with or without bone grafting. The use of antibiotic-impregnated cement-coated intramedullary nailing gives stability and treats the infection, thereby permitting early mobilization. External fixation is a definitive mode of fracture stabilization indicated in cases of infected non-unions of the humerus, tibia, and juxta-articular bone. The present study was conducted to compare the results of management of infected non-union long bones treated with an external fixator (Ilizarov and Limb Reconstruction System (LRS)) and vancomycin-coated intramedullary nail.Materials and method: The present prospective study was conducted on 40 study subjects aged >18 years, and were randomly divided using the alternative method into two groups. Group A: 20 Patients were treated with antibiotic-coated intramedullary interlocking nail (ACIIN). Group B: 20 patients were treated with the external fixator (LRS/Ilizarov). All patients were then evaluated post-operatively using laboratory investigations, and for any sign of inflammation or infection. Results were evaluated using association for the study and application of methods of Ilizarov (ASAMI) scoring system. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA).Results: It was observed that 80.0% of patients in Group A, and 70% of subjects in Group B showed bony union, revealing a statistically significant (p-value<0.05) difference. Infection control, limb length discrepancy, and deformity were also assessed in both groups. Bone and functional outcomes were assessed using the ASAMI score in both groups. In LRS/Ilizarov, it was observed that 55% of subjects had no infection, 15% showed loosening, and 30% had an infection.Conclusion: The ACIIN should not be used for bone defects more than 4 cm as it does not achieve stability and for these cases, procedures like external fixators (Ilizarov and LRS) should be used. Antibiotic-coated nail eliminated the complications of the external fixators like pin loosening, and pin infections and was technically less demanding. In our study, stiffness of adjacent joints was more in external fixators (LRS/Ilizarov) than ACIIN.

Research Article
1
10.1097/corr.0000000000001669

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Mar 11, 2021
Clinical Orthopaedics & Related Research
Joshua K Napora + 2 more +2

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Research Article
25
10.3109/17453670903035567

External fixation compared to intramedullary nailing of tibial fractures in the rat

Jan 01, 2009
Acta Orthopaedica
Ulf E W Sigurdsen + 2 more +2

Background and purpose It is not known whether there is a difference in bone healing after external fixation and after intramedullary nailing. We therefore compared fracture healing in rats after these two procedures.Methods 40 male rats were subjected to a standardized tibial shaft osteotomy and were randomly assigned to 2 treatment groups: external fixation or intramedullary nailing. Evaluation of half of each treatment group at 30 days and the remaining half at 60 days included radiography, dual energy radiographic absorbtiometry, and mechanical testing.Results Radiographically, both treatment groups showed sign of fracture healing with gradual bridging of the fracture line, while with intramedullary nailing the visible collar of callus was increased peripherally, indicative of periosteal healing. At 30 days, densitometric and mechanical properties were similar in the 2 groups. At 60 days, however, the intramedullary nailed bones had more strength, greater callus area, and higher bone mineral content in the callus segment compared to externally fixated fractures.Interpretation Tibial shaft fractures in the rat treated with external fixation and intramedullary nailing show a similar healing pattern in the early phase of fracture healing, while at the time of healing intramedullary nailing provides improved densitometric properties and superior mechanical properties compared to external fixation. Clinical findings indicate that intramedullary nailing in human tibial fractures may be more advantageous for bone healing than external fixation, in a similar way.

Research Article
192
10.2106/00004623-200502000-00030

Damage Control Orthopaedics

Feb 01, 2005
The Journal of Bone & Joint Surgery
Craig S Roberts + 5 more +5

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

Research Article
74
10.1097/00005373-200210000-00018

Current practice in the intramedullary nailing of tibial shaft fractures: an international survey.

Oct 01, 2002
The Journal of Trauma: Injury, Infection, and Critical Care
Mohit Bhandari + 7 more +7

Tibial fractures are the most common of all long bone fractures. Although many tibial fractures may be managed conservatively, a certain subset, including unstable fractures and open fractures, require operative stabilization. Intramedullary nails have become the popular choice of implant in the treatment of tibial shaft fractures. The variability in outcomes with tibial shaft fractures may reflect technical aspects of the surgical procedure and perioperative care regimens among surgeons. Identifying the distribution of surgeons' preferences in nailing technique, and the rationale for their choices, will aid in focusing educational activities for the orthopedic community and planning future clinical trials. Our objectives were to clarify surgeons' opinions regarding technical aspects of surgery and perioperative care after intramedullary nailing of closed and open tibial shaft fractures, and to identify predictors of surgeons' preferences in technique and perioperative care. This study was a cross-sectional survey using focus groups, key informants, and sampling to redundancy strategies to develop a survey to examine surgeons' preferences in the treatment of tibial shaft fractures. The survey was pilot tested for clarity and content validity. We mailed this survey in July 2000 to 577 orthopedic surgeons who have an interest in trauma care. These were members of the Orthopaedic Trauma Association, American Academy of Orthopaedic Surgeons, or European AO International affiliated trauma centers. We used several strategies to improve response rates including personalized cover letters, stamped return envelopes, follow-up telephone calls, and repeat mailing of questionnaires. Main outcome measures included technical issues such as reduction, exposure, intramedullary reaming, and interlocking screws; and factors associated with surgeons' preferences such as age, fellowship, academic practice, and geographic location. Four hundred forty-four surgeons (77%) responded. Sixty percent of respondents had an academic practice, 84% supervised residents, and 65.1% had fellowship training in trauma. Approximately half (51.5%) of surgeons used a tourniquet. The odds that a surgeon in Asia or Africa used tourniquets was 10 times that of a North American surgeon (p = 0.004 and p = 0.002, respectively). Patellar tendon retraction and an inferior-based entry portal was the popular choice among surgeons (70.1% and 70.8%, respectively). Surgeons from Australia (odds ratio [OR] = 50, p < 0.001), South America (OR = 9.0, p < 0.001), Europe (OR = 3.7, p = 0.001), and Asia (OR = 3.8, p = 0.006) were significantly more likely to use a patellar splitting approach compared with North American surgeons. In the perioperative care of open tibial shaft fractures, there was consensus in the use of intravenous antibiotics and wound irrigation (96.5% and 95.6%, respectively). However, we found considerable variability in surgeons' preference in wound irrigation pressures (high, 38.7%; low, 45.4%). Surgeons in South America were 10 times more likely to use low-pressure irrigation than North American surgeons (p = 0.0005). In grade IIIB open tibial shaft fractures, 94% of surgeons believed wound closure should be obtained within the first 7 days after the injury. A surgeon's geographic location was a significant predictor of the timing of soft tissue coverage (p = 0.001). Consensus in the use of irrigation and intravenous antibiotics in open fractures was achieved among surgeons. However, there remains considerable variability in the surgical technique of intramedullary nailing, the duration of antibiotic use, and the timing of wound closure in open tibial fracture care. Continued education and large multicenter trials are needed to establish best practice in the operative treatment of tibial shaft fracture.

Research Article
7
10.1177/20503121231181648

Prevalence and associated factors of infection after intramedullary nailing of long bone fractures among patients attending St. Paul’s Hospital Millennium Medical College, AaBET Hospital, Addis Ababa, Ethiopia

Jan 01, 2023
SAGE Open Medicine
Tilahun Desta + 4 more +4

Objectives:The intramedullary nailing of long bone fractures is a major challenge for orthopedic surgeons, with increased risk of infection in third-world countries. Research gaps remain in Ethiopia, determining the magnitude of the problem. This study aimed to determine the prevalence and associated factors of infection after intramedullary nailing of long bone fractures in Ethiopia.Methods:This was a descriptive, cross-sectional, retrospective design study with a total census of 227 cases of long bone fractures treated with intramedullary Surgical Implant Generation Network nails at Addis Ababa Burn Emergency and Trauma Hospital from August 2015 to April 2017. Data were collected from 227 patients and descriptive analyses were done to summarize the study variables. Binary and multivariable logistic regression analyses were performed at a p value of 0.05 with a 95% confidence interval and adjusted odds ratio.Results:The mean age of patients was 32.9 years, with a male-to-female ratio of 3.5:1. Only 22 (9.3%) of the 227 patients with long bone fractures treated with intramedullary nails developed a surgical site infection, and 8 (3.4%) were developed deep (implant) infections requiring debridement. Road traffic injuries were the leading cause of trauma (60.9%), followed by falls from a height (22.7%). Debridement was done within 24 h for 52 (61.9%) and within 72 h for 69 (82.1%) patients with open fractures. Only 19 (22.4%) and 55 (64.7%) patients with open fractures and tibial long bone fractures received antibiotics within 3 h. Open fractures and tibial fractures had higher percentages of infection, 18.6% and 12.1%, respectively. Previous use of an external fixator (44.4%) and prolonged surgery (12.5%) were associated with higher proportions of infection.Conclusion:This study found that the prevalence of infections after intramedullary nailing of long bone fractures in Ethiopia was 44.4% after external fixation, compared to 6.4% after intramedullary nail was inserted directly. Proper control measures are needed to reduce morbidity and complications related to long fracture treatment, such as open fractures, tibial fractures, the use of an external fixator, delayed debridement and skin closure, and prolonged surgery developed surgical site infection rate.

Research Article
10.3760/cma.j.issn.1671-7600.2014.11.003

Comparison of locking compression plate and intramedullary nail in staged treatment of open tibial fractures

Nov 15, 2014
Chinese Journal of Orthopaedic Trauma
Yang Han + 2 more +2

Objective To compare the clinical efficacy of locking compression plate (LCP) versus intramedullary nail in staged treatment of complex compound tibial fractures.Methods From February 2008 to January 2013,55 cases of complex tibial open fracture were treated at our department.They were 39 men and 16 women,with an average age of 32.5 years (from 17 to 72 years).The fractures were on the left side in 24 patients,on the right side in 28 and both sides in 3.By Gustilo classification,18 fractures were type Ⅰ,24 type Ⅱ and 16 type ⅢA; by AO classification,6 fractures were type 42-A,32 type 42-B,and 20 type 42-C.They were treated by external fixation and vacuun sealing drainage (VSD) at the primary stage followed by fixation with LCP or intramedullary nail at the secondary stage.Locking intramedullary nail was used in 32 patients (34 fractures) and LCP in 23 patients (24 ffractures).The 2 groups were compared in terms of fracture healing time,functional recovery of the affected limbs,and postoperative complications.Results The 55 patients were followed up for 12 to 34 months (average,18 months).All the fractures were healed from 16 to 48 weeks after the staged treatment,with an average of 24.2±5.3 weeks in the intramedullary nail group and 26.1 ± 7.2 weeks in the LCP group.There was no significant difference in the healing time between the 2 groups (P ＞ 0.05).According to the functional assessment by the Johner-Wruhs system,the intramedullary nail group had 13 excellent cases,18 good ones and 3 fair ones (the excellent to good rate,91.2％) while the LCP group had 9 excellent,12 good and 3 fair ones (the excellent to good rate,87.5％),showing no significant between-group difference (P ＞ 0.05).There was no significant difference either between the 2 groups regarding the postoperative complication rate [20.6％ (7/34) for the intramedullary nail group versus 12.5％ (3/24) for the LCP group] (P ＞ 0.05).Conclusion In the staged treatment of complex open tibia fractures,both intramedullary nail and LCP can result in reliable fixation of the fracture ends,a low complication rate and thus satisfactory clinical efficacy. Key words: Tibial fractures; Fractures, open; External fixator; Bone nails; Bone plates

Research Article
3
10.1007/s00590-025-04282-9

External fixation to intramedullary nailing for femoral and tibial fractures: an eleven-year cohort study at a level I trauma center

Jan 01, 2025
European Journal of Orthopaedic Surgery & Traumatology
Diego González-Morgado + 7 more +7

PurposeTo identify factors that contribute to the incidence of postoperative complications following staged treatment of femoral and tibial fractures with external fixation (EF) and intramedullary nailing (IMN).MethodsThis retrospective cohort study involved patients with tibial and/or femoral fractures temporarily immobilized using EF, followed by IMN. Patient characteristics, types of injury, treatments, and outcomes were recorded. Primary outcomes were pin tract infection (PTI) and fracture-related infection (FRI).ResultsThe study had 103 patients involving 119 fractures: 73 tibial (61.3%) and 46 femoral (38.7%). Of these, 44.5% were open. 31.1% of the EFs were implanted by an orthopedic trauma (OT) specialist. In femoral fractures, OT specialists placed the pins a mean 78.2 mm from the fracture site, versus just 37.3 mm by non-OT surgeons (p < 0.01). This difference was not observed in the tibia. The average time of EF was 12.6 ± 7.8 days. PTI occurred in seven cases (5.9%), on average 14.9 ± 10.9 days after EF placement. FRI occurred in nine patients (7.6%): two in the femur (4.5%) and seven in the tibia (10.6%). All FRIs occurred in cases where the EF had been implanted by a surgeon without specialization in OT (p = 0.03). FRI was more frequent in patients with prior PTI than in those without (57.1% vs. 4.5%, respectively; p < 0.01).ConclusionPTI was a risk factor for FRI after IMN of tibial and femoral fractures. Surgeon specialization in OT was a protective factor against FRI, probably related to pin placement further from the fracture site.