S Robert Rozbruch1, Austin T Fragomen1. 1. Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY.
Abstract
INTRODUCTION: Femoral lengthening with an intramedullary nail avoids the need for external fixation with its inherent challenges. STEP 1 PREOPERATIVE PLANNING: Determine the location of the osteotomy, which should be at the apex of the deformity or at the natural anterior bow of the femur, as well as the length and type of nail, which must be ordered a few weeks in advance. STEP 2 OPERATING ROOM SETUP: Position the patient supine on a flat radiolucent table; the goal is access for antegrade canal reaming and nail insertion. STEP 3 PART 1 OF THE OSTEOTOMY MULTIPLE PERCUTANEOUS DRILL-HOLES: Begin the osteotomy by making multiple percutaneous drill-holes, thereby avoiding the soft-tissue stripping and heat necrosis associated with the use of a power saw. STEP 4 ENTRY INTO THE PROXIMAL PART OF THE MEDULLARY CANAL: Use a minimal incision approach to the proximal part of the medullary canal. STEP 5 PREPARATION OF THE MEDULLARY CANAL AND INSERTION OF ROTATIONAL MARKERS: Ream the medullary canal of the intact bone over a guidewire; mark the rotation before the osteotomy is complete. STEP 6 INSERTION OF THE NAIL AND PART 2 OF THE OSTEOTOMY: Insert the internal lengthening nail in an antegrade direction up to the osteotomy location, complete the osteotomy, and pass the nail across the osteotomy site. STEP 7 INSERTION OF LOCKING SCREWS: Insert proximal and distal interlocking screws. STEP 8 RELEASE OF THE ILIOTIBIAL BAND: To prevent knee stiffness, release the iliotibial band through a 3-cm lateral incision, which is usually made by connecting the two stab wounds created for the distal interlocking screws. STEP 9 MARKING THE MAGNET LOCATION: Mark the magnet location in the implant on the skin to enable use of the remote control. STEP 10 POSTOPERATIVE CARE: Postoperative management entails limited weight-bearing, distraction, and range-of-motion exercises. RESULTS: Femoral lengthening with the remote-controlled magnetic intramedullary nail has had excellent clinical efficacy.
INTRODUCTION: Femoral lengthening with an intramedullary nail avoids the need for external fixation with its inherent challenges. STEP 1 PREOPERATIVE PLANNING: Determine the location of the osteotomy, which should be at the apex of the deformity or at the natural anterior bow of the femur, as well as the length and type of nail, which must be ordered a few weeks in advance. STEP 2 OPERATING ROOM SETUP: Position the patient supine on a flat radiolucent table; the goal is access for antegrade canal reaming and nail insertion. STEP 3 PART 1 OF THE OSTEOTOMY MULTIPLE PERCUTANEOUS DRILL-HOLES: Begin the osteotomy by making multiple percutaneous drill-holes, thereby avoiding the soft-tissue stripping and heat necrosis associated with the use of a power saw. STEP 4 ENTRY INTO THE PROXIMAL PART OF THE MEDULLARY CANAL: Use a minimal incision approach to the proximal part of the medullary canal. STEP 5 PREPARATION OF THE MEDULLARY CANAL AND INSERTION OF ROTATIONAL MARKERS: Ream the medullary canal of the intact bone over a guidewire; mark the rotation before the osteotomy is complete. STEP 6 INSERTION OF THE NAIL AND PART 2 OF THE OSTEOTOMY: Insert the internal lengthening nail in an antegrade direction up to the osteotomy location, complete the osteotomy, and pass the nail across the osteotomy site. STEP 7 INSERTION OF LOCKING SCREWS: Insert proximal and distal interlocking screws. STEP 8 RELEASE OF THE ILIOTIBIAL BAND: To prevent knee stiffness, release the iliotibial band through a 3-cm lateral incision, which is usually made by connecting the two stab wounds created for the distal interlocking screws. STEP 9 MARKING THE MAGNET LOCATION: Mark the magnet location in the implant on the skin to enable use of the remote control. STEP 10 POSTOPERATIVE CARE: Postoperative management entails limited weight-bearing, distraction, and range-of-motion exercises. RESULTS: Femoral lengthening with the remote-controlled magnetic intramedullary nail has had excellent clinical efficacy.