Strategies in Trauma and Limb Reconstruction

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VOLUME 18 , ISSUE 1 ( January-April, 2023 ) > List of Articles

Original Article

Trends and Practices in Limb Lengthening: An 11-year US Database Study

Ashish Mittal, Sachin Allahabadi, Rishab Jayaram, Abhinav Nalluri, Matt Callahan, Sanjeev Sabharwal

Keywords : Distraction osteogenesis, External fixator lengthening, Hybrid lengthening, Intramedullary lengthening, Lengthening nail, Limb lengthening, Motorised implantable nail, Short stature

Citation Information : Mittal A, Allahabadi S, Jayaram R, Nalluri A, Callahan M, Sabharwal S. Trends and Practices in Limb Lengthening: An 11-year US Database Study. 2023; 18 (1):21-31.

DOI: 10.5005/jp-journals-10080-1574

License: CC BY-NC-SA 4.0

Published Online: 31-05-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Abstract

Aim: Over the past couple of decades, limb lengthening has evolved to encompass various implants and techniques. The purpose of this study was to (1) determine trends in the utilisation of various limb lengthening techniques for the femur and tibia in the United States, (2) determine trends in 1-year readmission rate following limb lengthening procedures and (3) to study the relationship of limb lengthening implant used and payment method used with the underlying diagnosis associated with limb shortening. Materials and methods: Inpatient data were acquired using the Healthcare Cost and Utilisation Project (HCUP) database from 2005 to 2015 from seven states in the United States. Patients with an International Classification of Diseases (ICD)-9 code for limb lengthening of the femur or tibia were included. A total of 2,563 patients were included. Data were analysed using descriptive statistics, and chi-square test was used for comparison of subcategories. Linear regression analysis was used to examine trends over time. Results: There was a strong linear trend towards increasing proportional use of internal lengthening of the femur from 2011 to 2015 (R2 = 0.99) with an increase of 10.2% per year. A similar trend towards increasing proportional use of internal lengthening of the tibia was seen from 2011 to 2015 (R2 = 0.87) with an increase of 4.9% per year. There was a moderate correlation showing a decrease in readmission rate of 1.07% per year from 2005 to 2015 (R2 = 0.55). Patients with short stature had increased use of internal lengthening and self-payment compared to patients with congenital, post-traumatic or other diagnoses. Conclusion: There was increasing use of internal lengthening techniques from 2011 to 2015. Patients with short stature had higher use of internal lengthening technique and self-pay for payment method. Clinical significance: Intramedullary devices have seen increasing use for limb lengthening procedures. Lengthening technique and payment method may differ by underlying diagnosis.


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  1. Fragomen AT, Rozbruch SR. The mechanics of external fixation. HSS J. 2007;3(1):13–29. DOI: 10.1007/s11420-006-9025-0.
  2. Kawoosa AA, Wani IH, Dar FA, et al. Deformity correction about knee with Ilizarov technique: Accuracy of correction and effectiveness of gradual distraction after conventional straight cut osteotomy. Ortop Traumatol Rehabil 2015;17(6):587–592. DOI: 10.5604/15093492.1193011.
  3. McCarthy JJ, Ranade A, Davidson RS. Pediatric deformity correction using a multiaxial correction fixator. Clin Orthop Relat Res 2008;466(12):3011–3017. DOI: 10.1007/s11999-008-0491-1.
  4. Danziger MB, Kumar A, Deweese J. Fractures after femoral lengthening using the ilizarov method. J Pediatr Orthop 1995;15(2):220–223. PMID: 7745098
  5. Paley D. Current techniques of limb lengthening. J Pediatr Orthopaed 1988;8(1):73–92. DOI: https://doi.org/10.1097/01241398-198801000-00018.
  6. Paley D. Problems, obstacles, and complications of limb lengthening by the Illizarov technique. Clin Orthop Relat Res 1990;250:81–104. PMID: 2403498.
  7. Faber FWM, Keessen W, van Roermund PM. Complications of leg lengthening: 46 procedures in 28 patients. Acta Orthop 1991;62(4):327–332. PMID: 1882670.
  8. Dahl MT, Gulli B, Berg T. Complications of limb lengthening: A learning curve. Clin Orthop Relat Res 1994;(301):10–18. PMID: 8156659.
  9. Noonan KJ, Leyes M, Forriol F, et al. Distraction osteogenesis of the lower extremity with use of monolateral external fixation: A study of two hundred and sixty-one femora and tibiae. J Bone Joint Surg Am 1998;80(6):793–806. PMID: 9655097.
  10. Laubscher M, Mitchell C, Timms A, et al. Outcomes following femoral lengthening: An initial comparison of the precice intramedullary lengthening nail and the lrs external fixator monorail system. Bone Joint J 2016;98-B(10):1382–1388. DOI: https://doi.org/10.1302/0301-620X.98B10.36643.
  11. Tjernström B, Olerud S, Rehnberg L. Limb lengthening by callus distraction: Complications in 53 cases operated 1980–1991. Acta Orthop 1994;65(4):447–455. DOI: https://doi.org/10.3109/17453679408995491.
  12. Aaron AD, Eilert RE. Results of the Wagner and Ilizarov methods of limb-lengthening. J Bone Joint Surg Am 1996;78(1):20–29. DOI: https://doi.org/10.2106/00004623-199601000-00004.
  13. Dammerer D, Kirschbichler K, Donnan L, et al. Clinical value of the Taylor Spatial Frame: A comparison with the Ilizarov and Orthofix fixators. J Child Orthop 2011;5(5):343–349. DOI: https://doi.org/10.1007/s11832-011-0361-3.
  14. Tiefenboeck TM, Zak L, Bukaty A, et al. Pitfalls in automatic limb lengthening – First results with an intramedullary lengthening device. Orthop Traumatol Surg Res 2016;102(7):851–855. DOI: http://dx.doi.org/10.1016/j.otsr.2016.07.004.
  15. Hankemeier S, Pape HC, Gosling T, et al. Improved comfort in lower limb lengthening with the intramedullary skeletal kinetic distractor. Principles and preliminary clinical experiences. Arch Orthop Trauma Surg 2004;124(2):129–133. DOI: https://doi.org/10.1007/s00402-003-0625-6.
  16. Fragomen AT, Miller AO, Brause BD, et al. Prophylactic postoperative antibiotics may not reduce pin site infections after external fixation. HSS J 2017;13(2):165–170. DOI: https://doi.org/10.1007/s11420-016-9539-z.
  17. Kazmers NH, Fragomen AT, Rozbruch SR. Prevention of pin site infection in external fixation: A review of the literature. Strateg Trauma Limb Reconstr 2016;11(2):75–85. DOI: https://doi.org/10.1007/s11751-016-0256-4.
  18. Bhave A, Shabtai L, Woelber E, et al. Muscle strength and knee range of motion after femoral lengthening: 2- to 5-year follow-up. Acta Orthop 2017;88(2):179–184. DOI: https://doi.org/10.1080/17453674.2016.1262678.
  19. Hosalkar HS, Jones S, Chowdhury M, et al. Quadricepsplasty for knee stiffness after femoral lengthening in congenital short femur. J Bone Joint Surg - Ser B. 2003;85(2):261–264. DOI: https://doi.org/10.1302/0301-620X.85B2.13144.
  20. Khakharia S, Fragomen AT, Rozbruch SR. Limited quadricepsplasty for contracture during femoral lengthening. Clin Orthop Relat Res 2009;467(11):2911–2917. DOI: https://doi.org/10.1007/s11999-009-0951-2.
  21. Black SR, Kwon MS, Cherkashin AM, et al. Lengthening in congenital femoral deficiency a comparison of circular external fixation and a motorized intramedullary nail. J Bone Joint Surg – Am 2014;97(17):1432–1440. DOI: https://doi.org/10.2106/JBJS.N.00932.
  22. Horn J, Grimsrud Ø, Dagsgard AH, Huhnstock S, Steen H. Femoral lengthening with a motorized intramedullary nail: A matched-pair comparison with external ring fixator lengthening in 30 cases. Acta Orthop 2015;86(2):248–256. DOI: https://doi.org/10.3109/17453674.2014.960647.
  23. Baumgart R, Betz A, Schweiberer L. A fully implantable motorized intramedullary nail for limb lengthening and bone transport. Clin Orthopaed Related Res 1997;343:135–143. DOI: https://doi.org/10.1097/00003086-199710000-00023.
  24. Cole JD, Justin D, Kasparis T, et al. The intramedullary skeletal kinetic distractor (ISKD): First clinical results of a new intramedullary nail for lengthening of the femur and tibia. Injury 2001;32:SD-129-139. DOI: https://doi.org/10.1016/S0020-1383(01)00116-4.
  25. Guichet JM, Casar RS. Mechanical characterization of a totally intramedullary gradual elongation nail. Clin Orthop Relat Res 1997;(337):281–290. DOI: https://doi.org/10.1097/00003086-199704000-00032.
  26. Guichet J-M, Deromedis B, Donnan LT, et al. Gradual femoral lengthening with the Albizzia intramedullary nail. J Bone Joint Surg Am 2003;85(5):838–848. DOI: https://doi.org/10.2106/00004623-200305000-00011.
  27. Hankemeier S, Gösling T, Pape HC, et al. Verlängerung der unteren Extremität mit dem Intramedullary Skeletal Kinetic Distractor (ISKD). Oper Orthop Traumatol 2005;17(1):79–101. DOI: https://doi.org/10.1007/s00064-005-1123-5.
  28. Paley D, Herzenberg JE, Paremain G, et al. Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening. J Bone Joint Surg Am 1997;79(10):1464–1480. DOI: https://doi.org/10.2106/00004623-199710000-00003.
  29. Bernstein M, Fragomen AT, Sabharwal S, et al. Does integrated fixation provide benefit in the reconstruction of posttraumatic tibial bone defects? Clin Orthop Relat Res 2015;473(10):3143–3153. DOI: https://doi.org/10.1007/s11999-015-4326-6.
  30. Harbacheuski R, Fragomen AT, Rozbruch SR. Does lengthening and then plating (LAP) shorten duration of external fixation? Clin Orthop Relat Res 2012;470(6):1771–1781. DOI: https://doi.org/10.1007/s11999-011-2178-2.
  31. 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. Strateg Trauma Limb Reconstr 2020;15(1):54–61. DOI: https://doi.org/10.5005/jp-journals-10080-1451.
  32. Hasler CC, Krieg AH. Current concepts of leg lengthening. J Child Orthop 2012;6(2):89–104. DOI: https://doi.org/10.1007/s11832-012-0391-5.
  33. Sabharwal S. Pediatric Lower Limb Deformities. Springer International Publishing Switzerland 2016. DOI: https://doi.org/10.1007/978-3-319-17097-8.
  34. Paley D. PRECICE intramedullary limb lengthening system. Expert Rev Med Devices 2015;12(3):231–249. DOI: https://doi.org/10.1586/17434440.2015.1005604.
  35. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality. Available from https://www.ahrq.gov/data/hcup/index.html (April 25, 2021).
  36. Paley D, Harris M, Debiparshad K, et al. Limb lengthening by implantable limb lengthening devices. Tech Orthop. 2014;29(2):72–85. DOI: https://doi.org/10.1097/BTO.0000000000000072.
  37. Harris M, Paley D, Prince D. New implantable lengthening nail. In: EPOS Annual Meeting, 2013.
  38. Herzenberg JE, Specht SC, Standard SC. Limb lengthening in children with a new, controllable, internal device. In: EPOS Annual Meeting, 2013.
  39. Kirane YM, Fragomen AT, Rozbruch SR. Precision of the new remote controlled internal lengthening nail. In: HSS Research Symposium, 2013.
  40. Landge V, Shabtai L, Gesheff M, et al. Patient satisfaction after limb lengthening with internal and external devices. J Surg Orthop Adv 2015;24(3):174–179. DOI: https://doi.org/10.3113/JSOA.2015.0174.
  41. Rölfing JD, Kold S, Nygaard T, et al. Pain, osteolysis, and periosteal reaction are associated with the STRYDE limb lengthening nail: A nationwide cross-sectional study. Acta Orthop 2021;92(4):479–484. DOI: https://doi.org/10.1080/17453674.2021.1903278.
  42. Sax OC, Molavi DW, Herzenberg JE, et al. Biopsy proven focal osteolysis in a stainless-steel limb-lengthening device: A report of three cases. J Am Acad Orthop Surg Glob Res Rev. 2021;5(10):1–6. DOI: https://doi.org/10.5435/JAAOSGlobal-D-21-00101.
  43. Sabharwal S. Evolution of tibial lengthening techniques: Two steps forward, one step back? J Limb Lengthening Reconstr 2020;6(1):5. DOI: https://doi.org/10.4103/jllr.jllr_14_20.
  44. Wagner P, Burghardt RD, Green SA, et al. PRECICE magnetically-driven, telescopic, intramedullary lengthening nail: Pre-clinical testing and first 30 patients. Sicot-J 2017;3:19. DOI: https://doi.org/10.1051/sicotj/2016048.
  45. Lee RC, Aulisio M, Liu RW. Exploring the ethics of stature lengthening as treatment for height dysphoria. Strateg Trauma Limb Reconstr 2020;15(3):163–168. DOI: https://doi.org/10.5005/jp-journals-10080-1502.
  46. Park KB, Kwak YH, Lee JW, et al. Functional recovery of daily living and sports activities after cosmetic bilateral tibia lengthening. Int Orthop 2019;43(9):2017–2023. DOI: https://doi.org/10.1007/s00264-018-4159-5.
  47. Laubscher M, Mitchell C, Timms A, et al. Outcomes following femoral lengthening: An initial comparison of the precice intramedullary lengthening nail and the lrs external fixator monorail system. Bone Jt J. 2016;98-B(10):1382–1388. DOI: https://doi.org/10.1302/0301-620X.98B10.36643.
  48. Cosic F, Edwards E. PRECICE intramedullary nail in the treatment of adult leg length discrepancy. Injury 2020;51(4):1091–1096. DOI: https://doi.org/10.1016/j.injury.2020.03.004
  49. Nasto LA, Coppa V, Riganti S, et al. Clinical results and complication rates of lower limb lengthening in paediatric patients using the PRECICE 2 intramedullary magnetic nail. J Pediatr Orthop B. 2020;Publish Ah:1–7. DOI: https://doi.org/10.1097/BPB.0000000000000651.
  50. Horn J, Hvid I, Huhnstock S, et al. Limb lengthening and deformity correction with externally controlled motorized intramedullary nails: evaluation of 50 consecutive lengthenings. Acta Orthop 2019;90(1):81–87. DOI: https://doi.org/10.1080/17453674.2018.1534321.
  51. Hammouda AI, Jauregui JJ, Gesheff MG, et al. Trochanteric entry for femoral lengthening nails in children: Is it safe? J Pediatr Orthop 2017;37(4):258–264. DOI: https://doi.org/10.1097/BPO.0000000000000636.
  52. Hammouda AI, Jauregui JJ, Gesheff MG, et al. Treatment of post-traumatic femoral discrepancy with PRECICE magnetic-powered intramedullary lengthening nails. J Orthop Trauma 2017;31(7):369–374. DOI: https://doi.org/10.1097/BOT.0000000000000828.
  53. Szymczuk VL, Hammouda AI, Gesheff MG, et al. Lengthening with monolateral external fixation versus magnetically motorized intramedullary nail in congenital femoral deficiency. J Pediatr Orthop 2019;39(9):458–465. DOI: https://doi.org/10.1097/BPO.0000000000001047.
  54. Fragomen AT, Kurtz AM, Barclay JR, et al. A comparison of femoral lengthening methods favors the magnetic internal lengthening nail when compared with lengthening over a nail. HSS J 2018;14(2):166–176. DOI: https://doi.org/10.1007/s11420-017-9596-y.
  55. Wang K, Edwards E. Intramedullary skeletal kinetic distractor in the treatment of leg length discrepancy—A review of 16 cases and analysis of complications. J Orthop Trauma 2012;26(9):e138–44. DOI: https://doi.org/10.1097/BOT.0b013e318238b5b1.
  56. Liu Y, Yushan M, Liu Z, et al. Complications of bone transport technique using the Ilizarov method in the lower extremity: A retrospective analysis of 282 consecutive cases over 10 years. BMC Musculoskelet Disord 2020;21(1):1–9. DOI: https://doi.org/10.1186/s12891-020-03335-w.
  57. Song HR, Oh CW, Mattoo R, et al. Femoral lengthening over an intramedullary nail using the external fixator: Risk of infection and knee problems in 22 patients with a follow-up of 2 years or more. Acta Orthop 2005;76(2):245–252. DOI: https://doi.org/10.1080/00016470510030652.
  58. Kenawey M, Krettek C, Liodakis E, et al. Leg lengthening using intramedullay skeletal kinetic distractor: Results of 57 consecutive applications. Injury 2011;42(2):150–155. DOI: http://dx.doi.org/10.1016/j.injury.2010.06.016.
  59. Shabtai L, Specht SC, Standard SC, et al. Internal lengthening device for congenital femoral deficiency and fibular hemimelia. Clin Orthop Relat Res 2014;472(12):3860–3868. DOI: https://doi.org/10.1007/s11999-014-3572-3.
  60. Sabharwal S, Nelson SC, Sontich JK. What's new in limb lengthening and deformity correction. J Bone Joint Surg-Am 2015;97(16):1375–1384. DOI: https://doi.org/10.2106/JBJS.O.00298.
  61. Oostenbroek HJ, Brand R, Van Roermund PM, et al. Paediatric lower limb deformity correction using the Ilizarov technique: A statistical analysis of factors affecting the complication rate. J Pediatr Orthop Part B 2014;23(1):26–31. DOI: https://doi.org/10.1097/BPB.0b013e32836422ba.
  62. Mittal A, Allahabadi S, Jayaram R, et al. What factors correlate with length of stay and readmission after limb lengthening procedures? A large-database study. Clin Orthop Relat Res 2022;480(9):1754–1763. DOI: https://doi.org/10.1097/CORR.0000000000002201.
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