Exploring bone fixation methods in limb lengthening surgery

Limb lengthening surgery, a procedure designed to correct deformities or enhance stature, has evolved significantly over the years. Central to the success of this procedure is the method of bone fixation, which plays a crucial role in stabilising bones during the lengthening process.  In his latest online article, Mr Dimitrios Giotikas delves into the various methods of bone fixation employed in limb lengthening surgeries, highlighting their mechanisms, advantages, and limitations.

External fixators:

External fixation is one of the oldest and most established methods for bone stabilisation in limb lengthening surgery. It involves the use of metal frames, pins, and wires placed outside the body to hold the bone segments in place. Two common types of external fixators are the Ilizarov and Hexapod Circular Frames.

• Ilizarov fixator: Named after the Russian orthopaedic surgeon Dr Gavriil Abramovich Ilizarov, this fixator consists of rings connected by threaded rods and wires. It allows for multiplanar adjustments, enabling gradual bone distraction and correction of deformities.

• Hexapod frame: This computer-assisted hexapod fixator provides precise control over bone alignment through software-guided adjustments. Its versatility makes it suitable for complex deformities and allows for simultaneous lengthening and correction.

Advantages: External fixators facilitate controlled distraction, are adjustable, and offer versatility in treating various deformities.

Limitations: Despite their efficacy, external fixators can be inconvenient, require meticulous pin care to prevent infections, and may cause patient discomfort.

Intramedullary nailing:

Intramedullary nailing involves the insertion of a metal rod into the medullary canal of the bone. This method is commonly used in limb lengthening of the femur and tibia. During the lengthening process, the nail serves as an internal scaffold, providing stability and support.

• Precice-2 intramedullary nail: This motorised, remote-controlled nail allows for gradual bone distraction utilizing an external magnetic field which is produced by the ERC (External Remote Control) device. The ERC is a portable, hand-held unit that precisely lengthens or shortens the PRECISE_” nail through the touch of a button. The ERC prescription is customized by the physician to meet the needs of each patient. The ERC is designed to be used in a clinic setting or from the comfort of the patient’s home, reducing the need for frequent clinic visits.

• G-nail (Guichet): G-Nail is based on the successful design of Albizzia nail which was introduced to clinical practice in the USA in 1991. The current version of G-nail has been in clinical use continuously since 2010.

• G-nail is made of hardened stainless steel, Chromium and Cobalt alloy. This alloy is one of the most well studied and most commonly used in orthopaedic implants of all sorts. It has uninterrupted CE Mark approval in the EU since 2010. No signs of osteolysis related to metal debris and corrosion has ever been recorded, as it was the case with other intramedullary nails.

• G-nail allows full weight bearing with crutches from the day of the surgery.

• G-nail doesn’t require external electrically powered appliances for the lengthening which makes early repatriation of patients at 6 weeks after surgery logistically easier (no need for technical support of the appliance, no problems with customs clearance of the appliance during traveling, no problems with incompatibility with electrical networks in different countries)

• An additional advantage of g-nail instrumentation is that the femoral osteotomy is performed with the intramedullary low energy saw, allowing the surgeon to do the surgery with less skin incisions.

• G-nail facilitates controlled distraction through an internal gearing mechanism. It offers the advantage of simplicity.

Advantages: Intramedullary nailing provides internal stabilisation, reducing the risk of pin site infections and offering better patient comfort.

Limitations: It may not be suitable for all types of deformities, and precise control over distraction may be challenging compared to external fixators.

Hybrid fixation: Hybrid fixation combines elements of both external and internal fixation techniques to optimise outcomes. This approach allows surgeons to capitalise on the benefits of each method while mitigating their respective limitations.

Circular external fixator with intramedullary nail:

This hybrid approach combines the stability of intramedullary nailing with the versatility of external fixation. The intramedullary nail in this case is just a simple fracture nail ( not lengthening nail) which provides internal support, while the external frame allows for controlled distraction and deformity correction during the lengthening period.

Advantages: Hybrid fixation my is less expensive than internal lengthening nails and combines the advantages of internal and external fixation methods, offering greater stability, versatility, and precision.

Limitations: This approach may increase surgical complexity and the risk of complications associated with multiple fixation devices.

Mr Dimitrios Giotikas is an esteemed consultant surgeon in trauma & orthopaedics. You can schedule an appointment with Mr Giotikas on his Top Doctors profile.