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Meta-Analysis
. 2020 Jun 12;4(6):e20.00054.
doi: 10.5435/JAAOSGlobal-D-20-00054. eCollection 2020 Jun.

Integrated Limb Lengthening Is Superior to Classical Limb Lengthening: A Systematic Review and Meta-analysis of the Literature

Gerard A Sheridan  1 , Austin T Fragomen  1 , S Robert Rozbruch  1
Affiliations
Meta-Analysis

Integrated Limb Lengthening Is Superior to Classical Limb Lengthening: A Systematic Review and Meta-analysis of the Literature

Gerard A Sheridan et al. J Am Acad Orthop Surg Glob Res Rev. .

Abstract

Integrated limb lengthening combines both internal and external fixation methods. It has been introduced to improve time to union, patient time in frame, risk of regenerate refracture, and patient function. We systematically review studies to assess whether integrated limb lengthening methods are superior to classic limb lengthening.

Methods: A total of 457 patients had classic limb lengthening, whereas 488 underwent integrated limb lengthening. The primary outcome measures were total length achieved (cm), external fixator index (month/cm) and bone healing index (month/cm). Problems, obstacles, and sequelae were compared using random effects meta-analyses of all available cases. Kaplan-Meier curves were generated to compare the time spent in frame.

Results: Integrated limb lengthening demonstrated a superior external fixator index (P = 0.0001) and bone healing index (P = 0.0146). The mean time spent in frame for integrated lengthening was significantly shorter (P = 0.0015). Significantly fewer problems (P = 0.000) and sequelae (P = 0.001) were observed with integrated lengthening. Deep infections were more common in the integrated cohort. The lengthening over a nail deep infection rate was significantly higher than with the lengthening and then nailing and lengthening and then plating techniques (P = 0.005).

Conclusions: Integrated methods of limb lengthening are superior to classic methods. We suggest the integration of plates and nails with circular frames to improve outcomes in patients undergoing limb lengthening procedures.

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Conflict of interest statement

Dr. Fragomen or an immediate family member serves as board or committee member of Limb Lengthening and Reconstruction Society; serves as a paid consultant and paid presenter or speaker of Nuvasive, Smith & Nephew, and Synthes. Dr. Rozbruch or an immediate family member has received publishing royalties, financial or material support from Informa; serves as board or committee member of Limb Lengthening Reconstruction Society; serves as a paid consultant and paid presenter or speaker of Nuvasive; serves as a paid consultant and has stock or stock options of Orthospin; serves as a paid consultant and paid presenter or speaker of Smith & Nephew; has received publishing royalties, financial, or material support from Springer; has received IP royalties; and serves as a paid consultant and paid presenter or speaker of Stryker. Neither Dr. Sheridan nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Figures

Figure 1
Figure 1
Radiographs demonstrating (A) lengthening and then nailing and (B) lengthening and then plating techniques. C, Fluoroscopic image demonstrating lengthening over nail with external pins avoiding the intramedullary nail.
Figure 2
Figure 2
Flow diagram representing PRISMA. ICTRP = International Clinical Trials Registry Platform, WHO = World Health Organization
Figure 3
Figure 3
Funnel plot diagram illustrating no small study effects.
Figure 4
Figure 4
Time in frame (weeks) (Kaplan-Meier curve). CI = confidence interval
Figure 5
Figure 5
Box plots illustrating classic and integrated external fixation index (EFI) values.
Figure 6
Figure 6
Box plots illustrating classic and integrated bone healing index (BHI) values.
Figure 7
Figure 7
Forest plot (problems). CI = confidence interval, RR = relative risk
Figure 8
Figure 8
Forest plot (obstacles). CI = confidence interval, RR = relative risk
Figure 9
Figure 9
Forest plot (sequelae). CI = confidence interval, RR = relative risk
See this image and copyright information in PMC

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