Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 14 , ISSUE 2 ( May-August, 2019 ) > List of Articles

Original Article

Blocking Screw-assisted Intramedullary Nailing Using the Reverse-rule-of-thumbs for Limb Lengthening and Deformity Correction

Sherif Dabash, David T Zhang, S Robert Rozbruch, Austin T. Fragomen

Keywords : Blocking screw, Deformity correction, Internal lengthening nail, Intramedullary nail, Limb lengthening, Poller screw, Precice

Citation Information : Dabash S, Zhang DT, Rozbruch SR, Fragomen AT. Blocking Screw-assisted Intramedullary Nailing Using the Reverse-rule-of-thumbs for Limb Lengthening and Deformity Correction. 2019; 14 (2):77-84.

DOI: 10.5005/jp-journals-10080-1430

License: CC BY-NC-SA 4.0

Published Online: 01-08-2019

Copyright Statement:  Copyright © 2019; Jaypee Brothers Medical Publishers (P) Ltd.


Introduction: Historically, blocking screws have been used to assist in acute reduction of fractures during intramedullary (IM) nailing. The reverse-rule-of-thumbs (RROT) for blocking screws was introduced to facilitate internal lengthening nail use in deformity correction and limb lengthening. Our study investigated the ability of blocking screws, using same principle, to accurately correct long-bone deformity with and without lengthening and to prevent lengthening-induced deformity. Materials and methods: This is an institutional review board (IRB)-approved retrospective study on 86 patients who had IM nail-assisted limb reconstruction of femur or tibia with blocking screws. Surgeries were performed for deformity correction, limb lengthening, or deformity correction and limb lengthening. Data on the following variables were collected: number of blocking screws, distance of each blocking screw to osteotomy, distance of osteotomy from joint line, and amount of lengthening. Mechanical axis deviation (MAD) and joint alignment parameters were measured preoperatively and at the final postoperative follow-up. The primary outcome was the ability to obtain desired MAD and joint orientation angles. Accuracies were reported as postoperative measurements relative to goal. Association for the Study and Applications of the Methods of Ilizarov (ASAMI) scores were collected. Results: The accuracy of deformity correction was within 6 mm from goal, while joint orientation was corrected to within 1.5° of goal. Number of blocking screws did not significantly impact accuracy. Distance of blocking screw to osteotomy and amount of lengthening did not affect accuracy. In femurs, osteotomies greater than 10 cm from the joint line were more accurate in MAD goal (p = 0.017). This result was not replicated in tibias. ASAMI scores were excellent or good. Conclusion: Using RROT configuration, blocking screws were effective in correcting deformities of lower extremity long bones and in preventing deformity during limb lengthening. If positioned correctly, number of screws and their distance to osteotomy did not affect accuracy. Amount of lengthening did not impact accuracy. Distal femoral osteotomy less than 10 cm from knee joint may be challenging even with using blocking screws.

PDF Share
  1. Dodd L, Jackson M, Varma R. Poller blocking screws and Intramedullary nailing in tibial malunion. Ann R Coll Surg Engl 2007;89(8):816–818. DOI: 10.1308/rcsann.2007.89.8.816b.
  2. Fragomen AT, Rozbruch SR. Retrograde magnetic internal lengthening nail for acute femoral deformity correction and limb lengthening. Expert Rev Med Devices 2017;14(10):811–820. DOI: 10.1080/17434440.2017.1378092.
  3. Rozbruch SR. Adult posttraumatic reconstruction using a magnetic internal lengthening nail. J Orthop Trauma 2017;31(Suppl 2):S14–S19. DOI: 10.1097/BOT.0000000000000843.
  4. Fragomen AT, Rozbruch SR. Lengthening and deformity correction about the knee using a magnetic internal lengthening nail. SICOT J 2017;3:25. DOI: 10.1051/sicotj/2017014.
  5. Fragomen AT, Rozbruch SR. Lengthening of the femur with a remotecontrolled magnetic intramedullary nail: retrograde technique. JBJS Essent Surg Techniq 2016;6(1):e2. DOI: 10.2106/JBJS.ST.15. 00069.
  6. Chan DS, Nayak AN, Blaisdell G, et al. Effect of distal interlocking screw number and position after intramedullary nailing of distal tibial fractures: a biomechanical study simulating immediate weight-bearing. J Orthop Trauma 2015;29(2):98–104. DOI: 10.1097/BOT.0000000000000195.
  7. Stedtfeld H-W, Mittlmeier T, Landgraf P, et al. The logic and clinical applications of blocking screws. JBJS 2004;86(Suppl 2):17–25. DOI: 10.2106/00004623-200412002-00004.
  8. Furmetz J, Bosl S, Schilling J, et al. Blocking screws for alignment control in intramedullary limb lengthening. Injury 2017;48(7): 1597–1602. DOI: 10.1016/j.injury.2017.03.043.
  9. Muthusamy S, Rozbruch SR, Fragomen AT. The use of blocking screws with internal lengthening nail and reverse rule of thumb for blocking screws in limb lengthening and deformity correction surgery. Strateg Trauma Limb Reconstr 2016;11(3):199–205. DOI: 10.1007/s11751-016-0265-3.
  10. Fabricant PD, Camara JM, Rozbruch SR. Femoral deformity planning: intentional placement of the apex of deformity. Orthopedics 2013;36(5):e533–537. DOI: 10.3928/01477447-20130426-11.
  11. Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthopaed Relat Res 1989;241(241):146–165. DOI: 10.1097/00003086-198904000-00017.
  12. Paley D. Normal lower limb alignment and joint orientation. Principles of deformity correction. Springer; 2002. pp. 1–18.
  13. Krieg AH, Lenze U, Speth BM, et al. Intramedullary leg lengthening with a motorized nail: indications, challenges, and outcome in 32 patients. Acta Orthop 2011;82(3):344–350. DOI: 10.3109/17453674.2011.584209.
  14. Lenze U, Hasler C, Krieg A. Ausgleich posttraumatischer Beinverkürzungen mit einem motorisierten intramedullären Nagel. Unfallchirurg 2011;114(7):604–610. DOI: 10.1007/s00113-010-1820-x.
  15. Kirane YM, Fragomen AT, Rozbruch SR. Precision of the PRECICE internal bone lengthening nail. Clin Orthop Relat Res 2014;472(12):3869–3878. DOI: 10.1007/s11999-014-3575-0.
  16. Accadbled F, Pailhé R, Cavaignac E, et al. Bone lengthening using the Fitbone® motorized intramedullary nail: the first experience in France. Orthopaed Traumatol Surg Res 2016;102(2):217–222. DOI: 10.1016/j.otsr.2015.10.011.
  17. Iobst CA, Rozbruch SR, Nelson S, et al. Simultaneous acute femoral deformity correction and gradual limb lengthening using a retrograde femoral nail: technique and clinical results. J Am Acad Orthop Surg 2018;26(7):241–250. DOI: 10.5435/JAAOS-D-16-00573.
  18. Ricci WM, O’boyle M, Borrelli J, et al. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma 2001;15(4):264–270. DOI: 10.1097/00005131-200105000-00005.
  19. Gao KD, Huang JH, Li F, et al. Treatment of aseptic diaphyseal nonunion of the lower extremities with exchange intramedullary nailing and blocking screws without open bone graft. Orthopaed Surg 2009;1(4):264–268. DOI: 10.1111/j.1757-7861.2009.00041.x.
  20. Bong MR, Koval KJ, Egol KA. The history of intramedullary nailing. Bull NYU Hosp Jt Dis 2006;64(3–4):94–97.
  21. Ostrum RF, Maurer JP. Distal third femur fractures treated with retrograde femoral nailing and blocking screws. J Orthop Trauma 2009;23(9):681–684. DOI: 10.1097/BOT.0b013e3181ad61f2.
  22. Gavaskar AS, Chowdary N. Blocking screws: an adjunct to retrograde nailing for distal femoral shaft fractures. J Orthopaed Surg 2013;21(2):158–162. DOI: 10.1177/230949901302100208.
  23. Kulkarni SG, Varshneya A, Kulkarni S, et al. Intramedullary nailing supplemented with poller screws for proximal tibial fractures. J Orthop Surg (Hong Kong) 2012;20(3):307–311. DOI: 10.1177/230949901202000308.
  24. Burghardt R, Paley D, Specht S, et al. The effect on mechanical axis deviation of femoral lengthening with an intramedullary telescopic nail. J Bone Joint Surg Br 2012;94(9):1241–1245. DOI: 10.1302/0301-620X.94B9.28672.
  25. Rozbruch SR, Fragomen AT. Lengthening of the femur with a remotecontrolled magnetic intramedullary nail: antegrade technique. JBJS Essent Surg Tech 2016;6(1):e2. DOI: 10.2106/JBJS.ST.O.00063.
  26. 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: 10.1080/17453674.2018.1534321.
  27. Hessmann MH, Rommens PM. Intramedullary Nailing: A Comprehensive Guide. Springer; 2015.
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.