File Name: limb lengthening and reconstruction surgery case atlas .zip
A new generation of internal lengthening nail is now available that has reliable remote-controlled mechanisms. This allows accurate and well-controlled distraction rate and rhythm, and early clinical results have been very positive.
A new generation of internal lengthening nail is now available that has reliable remote-controlled mechanisms. This allows accurate and well-controlled distraction rate and rhythm, and early clinical results have been very positive. In this article, 2 posttraumatic cases are presented that illustrate deformity correction and lengthening using the internal lengthening nail. Surgical planning and adjuvant techniques of fixator-assisted nailing and the use of blocking screws are discussed.
The primary indications for bone lengthening and deformity correction are congenital and posttraumatic conditions including malunion and growth arrest. Distraction osteogenesis DO has been successfully used over the past half century to lengthen bone.
Bone lengthening with a fully implantable device is desirable to avoid external fixation entirely; however, the mechanical integrity and accurate control of distraction are mandatory. Internal lengthening nails ILNs are telescopic nails that are inserted into the intramedullary IM canal of long bones after performing osteotomy at the desired location. The distal and proximal nail segments are fixed to the respective bone segments using interlocking screws, and thus, distraction of the nail results in lengthening of the bone.
Previous generations of ILNs did not have accurate control of distraction, resulting in a high complication rate. New remote controlled internal lengthening IM nails have recently become available and can be used in both the femur and tibia. The inventory available includes antegrade femur piriformis and trochanteric entries , retrograde femur, and tibial ILNs. Distraction of the nail is brought about by the application of a remote-controller unit containing 2 revolving external magnets.
The controller unit is applied externally at the exact location of the nail's internal magnet which is marked on the skin intraoperatively under fluoroscopic guidance. The magnet revolutions within the external controller unit cause reciprocal movement of the internal magnet and consequently the gearbox and screw shaft assembly within the nail.
As a result, the nail elongates causing the desired change in bone length. The ILN may be used for bone lengthening and deformity correction if needed. Adjuvant techniques used include fixator-assisted nailing 12 and the use of blocking screws. A year-old man presented with a tibial malunion. Two years prior, he sustained a grade 3 open tibial fracture with segmental bone loss. He was treated with a rotational flap and bone transport using a circular external fixator.
His preoperative deformity included 9 degrees of valgus deformity and 25 mm of leg length discrepancy LLD Fig. Tibial malunion case, preoperative. A, Erect leg x-ray showing LLD of 25 mm and valgus alignment. B, Apex of deformity is mm from joint line.
C, Lateral x-ray shows step off at previous distal docking site. The apex of the deformity is mm distal to the knee joint line. The thick part of the nail will pull out of the distal moving fragment, and the ideal goal is for there to be 50 mm of thick nail in the distal fragment at the end of distraction.
The starting length of the nail has 30 mm of thin protruding nail at the end. Based on nail inventory and analysis of the x-ray, a mm nail was chosen. A longer nail would be difficult to pass across the previous docking site that has mild translation on the lateral x-ray Fig. When the width of the IM canal is greater than the diameter of the nail, the nail will not automatically correct the angular deformity. In this case, the lateral blocking screw is needed to achieve correction of the valgus deformity and is placed before the IM canal is reamed Fig.
A, At the end of distraction showing utility of blocking screw to correct valgus deformity. B, Anteroposterior x-ray showing consolidation and the proximal and distal fibula tibia screws. C, Lateral x-ray showing consolidation. D, Erect leg x-ray showing correction of LLD and deformity. The 2-pin fixator is placed, so the pins are outside of the tract of the IM nail. Each pin is placed in the respective segment orthogonal to the axis of that segment.
The pins also mark the rotational alignment of each segment so that rotational deformity can be prevented or corrected as needed.
The proximal and distal tibia—fibula relationship are stabilized before lengthening of the tibia Fig. This ensures that the fibula osteotomy will separate and lengthen with the tibia. Omission of this step would result in proximal migration of the distal fibula and distal migration of the proximal fibula despite a fibula osteotomy. Complications of deformity and contracture of the ankle and knee would ensue if this step were omitted. Acute correction of tibial deformity carries a risk of compartment syndrome and nerve injury.
Adjuvant procedures of prophylactic fasciotomy and peroneal nerve decompression may be appropriate. In this case, anterior and lateral compartment fasciotomies were done through small incisions at the initial surgery. Gastrocsoleus recession GSR may be needed to prevent or treat equinus contracture 14 during tibial lengthening. In this case, GSR was done 6 weeks after the initial surgery to treat a degree equinus contracture that developed during the lengthening.
A multiple drill hole osteotomy technique is used. This is a low-energy osteotomy that minimizes thermal necrosis. First, multiple drill holes are made in a transverse fashion at the osteotomy level. A new sharp 4. The final step is completion of the transverse osteotomy with a sharp osteotome. A tourniquet is not used. The canal is sequentially reamed 2 mm larger than the nail to be inserted.
Distraction of the tibia 15 was started on postoperative day POD 7 and was 0. X-rays were obtained every 2 weeks during the distraction and monthly thereafter. Knee and ankle range of motion ROM exercises were prescribed. Distraction was completed on POD A GSR was performed 6 weeks after the surgery to treat a degree equinus contracture.
Acute correction of equinus was not done, and the patient was not casted. Consolidation progressed and full weight bearing was allowed at 4 months. The fibula tibia screws were removed after 4 months when the fibula was noted to be well healed. The tibial nail was removed 12 months after the initial surgery. The patient is fully functional and has normal ROM of the knee and the ankle Fig. A year-old man presented with right lower extremity LLD and valgus deformity. At age 14, he sustained a traumatic distal femur growth plate fracture that was treated with cast.
Over time, this developed into a LLD of 21 mm and 8 degrees of valgus deformity Figs. Distal femur traumatic growth arrest case, preoperative. A, Clinical photograph. B, Erect leg showing LLD of 21 mm and valgus alignment. C, Mechanical axis surgical planning. D, Anatomic axis surgical planning. The apex of the deformity was noted to be in the distal femur. Mechanical axis planning Fig.
The SNL analysis was done as was explained earlier. A mm nail was chosen based on inventory and the SNL analysis. A longer nail was not desirable since it would not be able to pass the proximal sagittal bow of the femur.
To achieve correction of the valgus deformity, blocking screws were needed in the concavity of the valgus deformity. Since the IM canal was wider than the nail diameter on both sides of the osteotomy, blocking screws were placed both proximal and distal to the osteotomy site.
The entry point in the distal femur and the direction of the nail in the distal segment was derived from the surgical planning and was critical to achieve correction of the deformity Fig. Intraoperative images. A, Placement of blocking screws in concavity of deformity; direction of nail path in distal segment; just about to complete osteotomy. B, With fixator in place in preparation for IM canal reaming.
C, Insertion of ILN. D, ILN locked distally. A 2-pin fixator was applied out of the path of the ILN 18 orthogonal to each segment axis.
After the osteotomy and deformity correction, the external fixator was used to stabilize the femur in the optimal orientation for IM reaming Fig. The fixator pins were placed to mark the axial rotation. Iliotibial band tenotomy was performed and is routinely done for femur lengthenings. A multiple drill hole osteotomy technique was used. The canal was sequentially reamed 2 mm larger than the nail to be inserted. Entry point in distal femur IM canal and establish direction of nail in distal segment.
Insert ILN Fig. Distal interlocking screw insertion with jig Fig. Distraction was started on POD 4 at a rate of 0. Then the rate was slowed to 0.
X-rays are obtained every 2 weeks during the distraction and monthly thereafter.
Thaller, P. Trauma und Berufskrankheit 19, — Thaller et. Osteosynthese International Abstracs. The Knee [Internet]. Melcher, C.
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Correspondence Address : Dr. Context: Ilizarov method of bone transport is a well-recognized method in treating bone loss; however, soft tissue complications and potential flap compromise associated with the transport process are a major drawback. Aim: We propose the use of a central transport system of cables and pulleys, as introduced by Weber in to help preserve soft tissue cover, retain flap integrity, and decrease patient discomfort. Design: This was a retrospective study. Patients and Methods: Consecutive series of patients treated for severe bone loss and fragile soft tissue cover, between and , according to the Weber method of bone transport, were included in the study. In total, six cases were identified. Inclusion criteria were any patient who underwent bone transport using the Weber method due to bone loss caused by trauma or infection.
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Many authors consider osteotomy of the bowed non-broken tibia a contraindication. However, leaving the patient with a deformed, bowed leg is intolerable and is associated with deformity progression and increased risk of fracture. X-ray tibia showed partially healed congenital pseudoarthrosis of the tibia and 30 degrees of flexion deformity.
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Ее мысли прервал шипящий звук открываемой пневматической двери. В Третий узел заглянул Стратмор.
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