Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications

Abstract

Purpose: Circular frames have been the gold standard of treatment for complex deformity corrections and bone loss. However, despite the success of frames, patient satisfaction has been low, and complications are frequent. Most recently, lengthening nails have been used to correct leg length discrepancies. In this article, we review the current trends in deformity correction with emphasis on bone lengthening and present our case examples on the use of lengthening nails for management of complex malunions, non-unions, and a novel use in bone transport.

Materials and methods: A nonsystematic literature review on the topic was performed. Four case examples from our institute, Brighton and Sussex University Hospitals, East Sussex, England, UK, were included.

Results: New techniques based on intramedullary bone lengthening and deformity correction are replacing the conventional external frames. Introduction of lengthening and then nailing and lengthening over a nail techniques paved the way for popularization of the more recent lengthening nails. Lengthening nails have gone through evolution from the first mechanical nails to motorized nails and more recently the magnetic lengthening nails. Two case examples demonstrate successful use of lengthening nails for management of malunion, and two case examples describe novel use in management of non-unions, including the first report in the literature of plate-assisted bone segment transport for the longest defect successfully treated using this novel technique.

Conclusion: With the significant advancement of intramedullary lengthening devices with lower complications rates and higher patient satisfaction, the era of the circular frame may be over.

How to cite this article: Barakat AH, Sayani J, O'Dowd-Booth C, et al. Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications. Strategies Trauma Limb Reconstr 2020;15(1):54-61.

Keywords: Deformity correction; Distraction osteogenesis; Lengthening nails; Malunion; Non-union.

Figs 1A to D

(A) Radiograph showing the complex deformity in the left distal femur; (B) Intraoperative radiographs showing the use of temporary Taylor spatial frame to correct the deformity followed by lengthening nail as part of computer hexapod-assisted orthopaedic surgery; (C) Distraction and restoration of length using a lengthening nail; (D) Final anteroposterior and lateral radiographs showing solid consolidation and exchange of lengthening nail with a fixed nail

Figs 2A to D

(A) Radiograph showing the deformed right tibia; (B and C) Subsequent application and lengthening using lengthening nail; (D) Final radiograph showing solid union of the regenerate and exchange of the lengthening nail with a conventional nail

Figs 3A to D

(A) Radiographs showing the initial injury of the right tibia and management by bone transport over a tibial nail; (B) Radiographs showing successful regenerate formation and bone transport over an intramedullary nail however with non-union of the docking site; (C) Radiographs showing different trials to induced union at the docking site first by using Taylor spatial frame then a conventional nail then exchange nailing; (D) Final radiographs showing the distraction of the docking site using a lengthening nail then compression to induce union (accordion manoeuvre)

Figs 4A to E

(A and B) Radiographs showing non-union of the femur using both an intramedullary nail then a plate; (C and D) Removal of the plate and application of a lengthening nail then lengthening as shown; (E) Final radiographs showing restoration of length and full consolidation at the non-union site

Figs 5A to C

(A) Radiographs showing the use of the bone transport nail augmented by a side plate; (B and C) Final radiographs showing final application of conventional intramedullary nail after removal of the bone transport nail and the plate. Good regenerate formation is present and the docking site was refreshed, fixed wih a hook plate and filled with bone graft substitute