Rev. bras. ortop. vol.52 número1

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

Femur

lengthening

with

monoplanar

external

fixator

associated

with

locked

intramedullary

nail

夽

Henrique

Paradella

Alvachian

Fernandes

∗

_,

_Danilo

_Gabriel

_do

_Nascimento

_Silva

Barronovo,

Fabio

Lucas

Rodrigues,

Marcos

Hono

HospitalEstadualMarioCovas,FaculdadedeMedicinadoABC,DisciplinadeOrtopediaeTraumatologia,SantoAndré,SP,Brazil

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Articlehistory:

Received28October2015

Accepted29March2016

Availableonline13December2016

Keywords:

Bonelengthening

Externalfixators

Fracturefixation

Intramedullary

a

b

s

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t

Objective:Thisstudyaimedtodemonstratethatthelengtheningtechniqueofanexternal

fixatorassociatedwithlockedintramedullarynailisanefficientmethodthatdecreasesthe

durationoftheexternalfixationandimprovestherehabilitationperiod.

Methods:FromJanuaryof2005toMayof2014,31patientswithmeanlowerlimb

discrep-ancyof5.31cmweretreated.Theetiologiesofthedeformitywerefemurfracturesequelae,

infection,hipdevelopmentdysplasia,polio,andcongenitalshortfemur.

Results:Themeandurationofexternalfixationwas2.47months(externalfixationindex

of16.15dayspercm).Themeantimeforbonehealingwas6.66months(consolidation

index43dayspercm).Initialmeankneerangeofmotionwas−1◦_to₁₀₀◦_,_progressing_to

0◦_–115◦_at_the_end_of_treatment._The_{complications}_observed_were_incomplete_osteotomies,

hipsubluxation,brokenfixator,decreasedkneerangeofmotion,andneedforlockingscrew

removal.

Conclusion:Femurlengtheningwithamonoplanarexternalfixatorassociatedwithlocked

intramedullarynailallowedforashorterperiodofexternalfixationuse,betterprotection

fortheregeneratedbonetissue,andearlyrehabilitationwithpossiblecomplications.

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedattheFaculdadedeMedicinadoABC,HospitalEstadualMarioCovas,SantoAndré,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:henriquepaf@gmail.com(H.P.Fernandes).

http://dx.doi.org/10.1016/j.rboe.2016.03.007

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Alongamento

ósseo

femoral

com

fixador

externo

monoplanar

associado

a

haste

intramedular

bloqueada

Palavras-chave:

Alongamentoósseo

Fixadoresexternos

Fixac¸ãointramedulardefraturas

r

e

s

u

m

o

Objetivo: Demonstrarqueatécnicadealongamentodofixadorexternoassociadoahaste

intramedularbloqueadaéeficazetrazbenefíciosquantoaotempodeusodofixadorea

melhorianareabilitac¸ão.

Método: Entrejaneirode2005emaiode2014foramtratados31pacientescomdiscrepância

demembrosinferiorescommédiadeencurtamentode5,31cm.Asetiologiasda

deformi-dadeforamsequelasdefraturadefêmur,infecc¸ão,displasiadedesenvolvimentodoquadril,

paralisiainfantilefêmurcurtocongênito.

Resultados: Otempomédiodefixac¸ãoexternafoide2,47meses(índicedefixac¸ãoexterna

de16,15diasporcentímetro).Otempomédionecessárioparaconsolidac¸ãoósseafoi6,66

meses(índice deconsolidac¸ão43 diaspor centímetro).A amplitudedemovimento do

joelhomédiainicialerade-1a100grausenotérminodotratamentode0a115graus.As

complicac¸õesobservadasforamosteotomiasincompletas,subluxac¸ãodequadril,quebra

dofixador,limitac¸ãodaamplitudedojoelhoenecessidadederetiradadematerial.

Conclusão: Atécnicadealongamentofemoralcomfixadorexternomonolateralsobrehaste

intramedularpropiciaumtempomenordeusodofixadorexterno,melhorprotec¸ãodo

regeneradoósseoereabilitac¸ãoprecoce,nãoisentadecomplicac¸ões.

EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Lowerlimbshorteningduetofracturesequelaeorcongenital

defectsleads,intheshortterm,topelvictiltandsecondary

scoliosis;inthelongterm,itleadstoearlyosteoarthritisofthe

knee,hip,andspine.1_Another_problem_is_patient_discomfort

duetothetimespentwithaexternalfixator.

Traditionally,themostusedsurgicaltechnique forbone

shorteningis thatrecommended byIIizarov. Ituses a

sys-tem of rings anchored by transfixing Kirschner wires in

tensions ranging from 50 to 130N, followed by osteotomy

and subsequent gradual bone distraction.The lengthening

speed is 1mm per day, but the fixator should remain in

place until complete fracture consolidation. Bone

regener-atefracturehasbeendescribedincasesofprematurefixator

removal.2–6

Moreover,patients tolerate the lengtheningperiod well,

which is shorter, but the long wait until consolidation

may present complications, such as pin site infection and

limited joint mobility. The need to use the external

fix-ator until consolidation is not well tolerated by most

patients.7,8

Femorallengtheningwithamonolateralexternalfixator

associatedwithlockedintramedullarynailisanalternative

technique that bringsbenefits suchas shorterduration of

treatmentandimprovedkneerangeofmotionwithout

com-promisingtheboneregenerate.9–12

This study aimed to demonstrate whether the

length-ening technique with an external fixator associated with

locked intramedullary nail is effective and beneficial

regarding duration of external fixator use and improved

rehabilitation.

Material

and

methods

BetweenJanuary2005andMay2014,31patientswithfemoral

shorteningwhounderwentlengtheningtechniquewith

exter-nalfixatorwereretrospectivelystudied.Regardingthecauseof

shortening,23patientshadfracturesequelae,threehad

con-genitalshortfemur,twohadpolio,twohadpreviouslyresolved

infection,and onehaddevelopmental dysplasiaofthe hip.

Agerangedfrom15to62years;26patientsweremaleandfive

female.Initialshorteningrangedfrom2.5cmto8cm,assessed

atascanogramofthelowerlimbs,withameanof5.31cm.The

meaninitialkneerangeofmotionwas1◦_–100◦_._All_patients

weretreatedwithamonolateralexternalfixatorandlocked

intramedullarynails,with23anterogradeandeightretrograde

nails.Thenaildiameterwas9mmforsolidnailsand10mm

formillednails.

Surgicaltechnique

Patientispositionedinlateraldecubitusfortheanterograde

nails andindorsal decubitus forthe retrogradenails,ona

radiolucentoperatingtable.Femoralosteotomyismadebya

smalllongitudinallateralincisioninthemiddlethirdofthe

thigh. Subsequently,asemi-circumferentialbonedrillingis

madewitha3.5-mmdrillinthelateral,medial,andanterior

cortices,andacompletelinearosteotomyisfinalizedwiththe

osteotomeintheposteriorcortex.Afterthenailisintroduced,

thelockingscrewsarepositionedclosesttotheentranceofthe

guide.ASchanzscrewisthenplacedinthefragment

proxi-maltotheosteotomy,perpendicularlytothe lateralcortex,

fromlateraltomedial,inordertoavoidanimpactonthe

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Fig.1–Radiographicimageofafemurinthelengthening phaseafterosteotomy,undergoinglengthening.

positionedonthescrewandthelengtheningdeviceisinstalled

inthesamedirectionofthemechanicalaxisofthefemur.The

distalheadiscoupledontothedeviceand,guidedbyits

ori-fices,aSchanzscrewofsamedimensionisinsertedinthe

same orientation.After bonealignment,positioning ofthe

screws,andstructureoftheexternaldeviceareassessedand

confirmed,deviceassemblyiscompletedwithtwoor three

screwsintheproximalanddistalfragments(Fig.1).

Inthepresentstudy,antibiotictherapywasperformedwith

1gintravenouscephalothinevery6hduringhospitalizations,

followedby500mgoralcephalexinevery 6hforsevendays

afterdischarge.

Patientswereinstructedtoinitiatedistractiononthe

sev-enth day, with afrequency ofone-quarter of a turn every

6h,or1mmperday.Allpatientswerefollowed-upeverytwo

weeksuntiltheendofthelengtheningphase.Oneweekafter

theprogrammedbonelengtheningwasreached,distal

lock-ingscrewsofthenailsweremade;theexternalfixatorwas

removedandthekneewasmanipulated.Then,activeand

pas-sivemovementsofthehip, knee,and anklewere initiated.

Partially-loadedgaitwiththeaidofcrutcheswasstimulated

astolerated; patients were followed-up monthly thereafter

(Fig.2).

A bone regenerate was considered consolidated when

frontalandprofileradiographspresentedvisiblebonecallus

inthreecortices.

Fig.2–Radiographicimageofthefemurafterthefinal lengthening,inwhichbonehealingcanbeobserved.

The external fixation duration, time interval until

con-solidation, knee range of motion, and complications were

assessed.

Results

Bone consolidationwas observedinall patients.Themean

lengtheningwas4.65cmperpatient.Themeandurationof

externalfixationusewas2.47months(externalfixationindex

of16.15dayspercentimeter).Themeantimetobonehealing

was 6.665months(consolidation indexof43 daysratio per

centimeter).Themeankneerangeofmotionwas0◦_–115◦_.

No fractures or residual deformities were observed in

theboneregenerate.Regardingcomplications,fourpatients

werere-approachedduetoosteotomiesthatwereconsidered

incomplete;thepatientwithdysplasiasequelahadhip

sub-luxation.Thefixatorofonepatientbroke,andwasreplaced

onanoutpatientbasis;alockingscrewwasremovedinone

patient.Twopatientsevolvedwithkneelimitation,andwere

treatedwitharthroscopic release,whichimprovedrangeof

motion.

Discussion

Thelengtheningmethodoverintramedullarynailswas

devel-opedbyPaleyetal.9 _to_accelerate_the_healing_and_onset_of

rehabilitation.Thepresentstudywasnotcomparative.

How-ever,theexternalfixationtechniquewithintramedullarynails

showedsatisfactoryresultsinrelationtoconsolidationtime,

durationofexternalfixatoruse,andmobilityofthekneejoint.

ThebonelengtheningmethodintroducedbyIIizarovis

cur-rentlythe treatment ofchoiceforlimblengthdiscrepancy,

regardlessoftheetiology.Themajordisadvantagedescribed

istheprolongeduseofexternalfixation,especiallyduringthe

regenerated bonehealingtime.Thisimposespsychological

complicationstoboththepatientsandtheirfamilies.7,8

The use oflocked intramedullary nails associated with

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thelengtheningphase.Theconsolidationperiod,whichisat

leasttwiceaslongasthelengthening,canbecompletedusing

onlyalockedintramedullarynail.Thistechniqueallowsfor

earlyjointmobilityandprotectstheboneregenerate.9–12

In 1992, García-Cimbrelo et al.7 _reported _that, _of ₁₀₀

patientstreatedwiththetraditionaltechniqueusingthe

cir-cularexternalfixator,inwhich47patientsweresubjectedto

lengthening,complicationssuchasintolerancetothedevice

occurredin6%,musclecontracturein22%,andtwopatients

presentedfracturesintheboneregenerate.Theyconcluded

that the prolonged duration of external fixation use

con-tributedtocomplications.Inthepresentstudy,asthefixator

wasremovedafterthelengtheningperiod,these

complica-tionsdidnotoccur.

Several authors have described the advantages of bone

lengtheningthroughthe associationofexternalfixatorand

lockedintramedullarynails.9,13

In2011,Sunetal.14 _conducted_a_{retrospective}

compara-tivestudyintibialbonelengtheninginwhichtheycompared

176patients(289tibias)thatwereelongatedwith(143)and

without (146) theassociation ofintramedullary nails.They

concludedthatthegroupofexternalfixationassociatedwith

intramedullarynailspresentedbetterresultsregardingbone

healingtime.

In2012,inasystematicreviewcomparingthetraditional

Ilizarovmethodwiththetechniqueofexternalfixator

associ-atedwithintramedullarynailsintibiallengthening,Jainand

Harwood15_assessed_whether_the_healing_time_and_the

dura-tionofexternalfixator usedecreased.They concludedthat

therewasnochangeinthetimeofconsolidation,andthat

thedurationofexternalfixationinthecombinedtechnique

waslower.Complicationsweresimilarinbothmethods.These

resultsareinagreementwiththoseobtainedinthepresent

study.

Mahboubianetal.,16_in_2011,_compared_the_use_of

exter-nalfixator overnails withtelescopic intramedullarynail in

femorallengthening.Theyreportedthatpatientswhoused

externalfixatorovernailshadfewercomplicationsandbetter

controlofthelengtheningspeed.

El-Husseiniet al.,17 _in_a_randomized_prospective_clinical

study, compared lower limb lengthening (femur and tibia)

throughtheIlizarovtechniquewiththetechniqueofexternal

fixatorassociatedwithintramedullarynailsTheyconcluded

thatthehealingtimewasshorterinthegroupthatusedthe

fixatorovernails.Inaddition,morecomplicationsobserved

inthegroupinwhichonlyanexternalfixatorwasused.The

presentstudywasnotcomparative;therefore,itwasnot

pos-sibletoconcludewhethertheconsolidationtimewasshorter.

The technique of lengthening over nails is not free of

complications.Somestudiesonfemurlengtheningreported

that, when lengthening reached 20% of total limb length,

patientsevolved withposterior subluxationofthe knee or

patellarsubluxation.Althoughlengtheningovernailsreduces

thedurationofexternalfixationuse, cautionisrequiredto

preventthemaincomplicationsreported.18

Inthepresentstudy,somecomplications(28.7%)related

totheosteotomytechniquewereobserved.Infourpatients,a

newosteotomywasnecessary.Intraoperativemaneuverswith

fragmenttranslation,confirmedbyfluoroscopy,facilitatedthe

confirmationthattheosteotomywascomplete.

Surgical manipulationofthe kneewas performedin all

patients;intwocases,arthroscopywasused.These

maneu-versallowtheimprovementofthekneerangeofmotion.

Conclusion

Femorallengtheningtechniquewithmonolateralexternal

fix-atoroverintramedullarynailisaneffectivemethod,allowsa

shorterduration ofexternalfixatoruse,betterprotectionof

theboneregenerate,andearlyjointrehabilitation;however,it

isnotfreeofcomplications.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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