Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 12 , ISSUE 3 ( November, 2017 ) > List of Articles

Original Article

Distal femoral flexion deformity from growth disturbance treated with a two-level osteotomy and internal lengthening nail

Austin T. Fragomen, Fiona R. Fragomen

Keywords : Magnetic internal lengthening nail, Precice, TomoFix, Osteotomy, Deformity, Limb lengthening

Citation Information : Fragomen AT, Fragomen FR. Distal femoral flexion deformity from growth disturbance treated with a two-level osteotomy and internal lengthening nail. 2017; 12 (3):159-167.

DOI: 10.1007/s11751-017-0298-2

License: CC BY-NC-SA 4.0

Published Online: 30-11-2017

Copyright Statement:  Copyright © 2017; Jaypee Brothers Medical Publishers (P) Ltd.


Salter Harris fractures of the distal femur can lead to growth disturbance with resulting leg length inequality and knee deformity. We have looked at a case series (3) of patients who presented with a distal femur flexion malunion and shortening treated with a distal femoral osteotomy and plating and a proximal femoral osteotomy with a magnetic internal lengthening nail. Does a two-level osteotomy and internal fixation approach provide a reliable result both radiographically and functionally? The average knee extension loss was 12°, LLD 47 mm, PDFA 65°, MAD 2 mm. The patients were treated with an acute, posterior, opening wedge osteotomy of the distal femur stabilized with a lateral plate and screws and grafted with cancellous chips and putty. A second osteotomy was made proximally in the femur percutaneously, and the internal lengthening nail was inserted. Lengthening was done at approximately 1 mm/day. The average extension gain was 12°; amount of lengthening at the proximal site was 40 mm, LLD was 3 mm. The average PDFA was 81°, and MAD 3 mm. There were no complications. Functional results were excellent. Bone healing index was 24 days/cm. The average distance from the distal osteotomy to the joint line was 57 mm. The technique of two-level femur osteotomy stabilized with a plate and lengthening nail yielded excellent results with acceptable correction of deformity, full knee extension, and improved function. There were no complications including implant failure, infection, need for blood transfusion, knee stiffness, nonunion, compartment syndrome, or malunion.

PDF Share
  1. Basener CJ, Mehlman CT, DiPasquale TG (2009) Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma 23(9):663-667
  2. Spiro AS, Stenger P, Hoffmann M, Vettorazzi E, Babin K, Lipovac S, Kolb JP, Novo de Oliveira A, Rueger JM, Stuecker R (2012) Treatment of fixed knee flexion deformity by anterior distal femoral stapling. Knee Surg Sports Traumatol Arthrosc 20(12):2413-2418. doi:10.1007/s00167-012-1915-8
  3. Klatt J, Stevens PM (2008) Guided growth for fixed knee flexion deformity. J Pediatr Orthop 28(6):626-631
  4. de Morais Filho MC, Neves DL, Abreu FP, Juliano Y, Guimarães L (2008) Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy. J Child Orthop 2(1):37-43
  5. de Moraes Barros Fucs PM, Svartman C, de Assumpção RM (2005) Knee flexion deformity from poliomyelitis treated by supracondylar femoral extension osteotomy. Int Orthop 29(6):380-384
  6. Grant AD, Small RD, Lehman WB (1982) Correction of flexion deformity of the knee by supracondylar osteotomy. Bull Hosp Joint Dis Orthop Inst 42(1):28-38
  7. Kocaoglu M, Eralp L, Bilen FE, Balci HI (2009) Fixator-assisted acute femoral deformity correction and consecutive lengthening over an intramedullary nail. J Bone Joint Surg Am 91(1):152-159
  8. McCarthy JJ, Ranade A, Davidson RS (2008) Pediatric deformity correction using a multiaxial correction fixator. Clin Orthop Relat Res 466(12):3011-3017
  9. Zarek S, Macias J (2002) The Ilizarov method in the treatment of postinflammatory deformites of the distal epiphysis of the femur. Ortop Traumatol Rehabil 4(3):341-347
  10. Kawoosa AA, Wani IH, Dar FA, Sultan A, Qazi M, Halwai MA (2015) Deformity correction about knee with Ilizarov technique: accuracy of correction and effectiveness of gradual distraction after conventional straight cut osteotomy. Ortop Traumatol Rehabil 17(6):587-592
  11. Pallaro J, Angelliaume A, Dunet B, Lavoinne N, Tournier C, Fabre T (2015) Reconstruction of femoral bone loss with a monoplane external fixator and bone transport. Orthop Traumatol Surg Res 101(5):583-587. doi:10.1016/j.otsr.2015.04.001
  12. Khakharia S, Fragomen AT, Rozbruch SR (2009) Limited quadricepsplasty for contracture during femoral lengthening. Clin Orthop Rel Res 467(11):2911-2917
  13. Hosalkar HS, Jones S, Chowdhury M, Hartley J, Hill RA (2003) Quadricepsplasty for knee stiffness after femoral lengthening in congenital short femur. J Bone Joint Surg Br 85(2):261-264
  14. Koczewski P, Shadi M (2005) Repair of the knee extension apparatus in the treatment of knee extension contracture after femoral lengthening. Chir Narz Ruchu Ortop Pol 70(2):91-96
  15. Georgiadis AG, Rossow JK, Laine JC, Iobst CA, Dahl MT (2017) Plate-assisted lengthening of the femur and tibia in pediatric patients. J Pediatr Orthop 37(7):473-478
  16. Iobst CA, Dahl MT (2007) Limb lengthening with submuscular plate stabilization: a case series and description of the technique. Pediatr Orthop 27(5):504-509
  17. Black SR, Kwon MS, Cherkashin AM, Samchukov ML, Birch JG, Jo CH (2015) Lengthening in congenital femoral deficiency: a comparison of circular external fixation and a motorized intramedullary nail. J Bone Joint Surg Am 97(17):1432-1440
  18. Landge V, Shabtai L, Gesheff M, Specht SC, Herzenberg JE (2015) Patient satisfaction after limb lengthening with internal and external devices. J Surg Orthop Adv 24(3):174-179
  19. Harbacheuski R, Fragomen AT, Rozbruch SR (2012) Does lengthening and plating shorten duration of external fixation? Clin Orthop Relat Res 470(6):1771-1781
  20. Baumgart R, Betz A, Schweiberer L (1997) A fully implantable motorized intramedullary nail for limb lengthening and bone transport. Clin Orthop 343:135-143
  21. Kirane Y, Fragomen A, Rozbruch SR (2014) Precision of the PRECICE internal bone lengthening nail. Clin Orthop Rel Res 472(12):3869-3878
  22. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD (1998) Knee Injury and Osteoarthritis Outcome Score (KOOS)— development of a self-administered outcome measure. J Orthop Sports Phys Ther 28(2):88-96
  23. Burghardt RD, Paley D, Specht SC, Herzenberg JE (2012) The effect on mechanical axis deviation of femoral lengthening with an intramedullary telescopic nail. J Bone Joint Surg Br 94(9):1241-1245
  24. Kucukkaya M, Karakoyun O, Erol MF (2016) The importance of reaming the posterior femoral cortex before inserting lengthening nails calculation of the amount of reaming. J Orthop Surg Res 11:11
  25. Krieg AH, Lenze U, Speth BM, Hasler CC (2011) Intramedullary leg lengthening with a motorized nail. Acta Orthop 82(3):344-350
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.