Limb lengthening by distraction osteogenesis is an accepted orthopaedic surgical technique. The Precice intramedullary lengthening system is the most recent innovation in limb lengthening. Early results have been favourable in femoral lengthening but there is little reported on the outcome in tibial lengthening. The aim of this study is to present our early results of Precice tibial lengthening, and the stepwise evolution of our surgical technique.
Materials and methods: A case series of 17 consecutive tibial lengthenings were prospectively analysed. Healing index, length achieved, range of motion, and complications were recorded. The initial cases followed the recommended surgical technique. Progressive regenerate deformity during lengthening required changes to the surgical method.
Results: No cases were lost to follow-up. All the nails lengthened at the desired rate. There were no complications of infection or poor regenerate formation. Progressive valgus and procurvatum was prevented in later cases by the positioning of Poller blocking screws at the time of nail insertion.
Conclusion: The tibial Precice nail is successful in obtaining length and good regenerate formation. The recommended technique was insufficient to control the deforming forces from the lower limb muscle compartments during lengthening. We therefore recommend the addition of multiple blocking screws in an amended technique.
Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: part I the influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res 1989;238:249. DOI: 10.1097/00003086-198901000-00038.
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. DOI: 10.2106/00004623-199806000-00003.
Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res 1990(250):81. DOI: 10.1097/00003086-199001000-00011.
Burghardt RD, Manzotti A, Bhave A, et al. Tibial lengthening over intramedullary nails. A matched case comparison with Ilizarov tibial lengthening. Bone Joint Res 2016;5(1):1. DOI: 10.1302/2046-3758.51.2000577.
Park H, Ryu KJ, Kim HW, et al. Is there an increase in valgus deviation in tibial distraction using the lengthening over nail technique? Clin Orthop Relat Res 2016;474(5):1283. DOI: 10.1007/s11999-016-4712-8.
Rozbruch SR, Kleinman D, Fragomen AT, et al. Limb lengthening and then insertion of an intramedullary nail. A case-matched comparison. Clin Orthop Relat Res 2008;466(12):2923. DOI: 10.1007/s11999-008-0509-8.
Guichet JM, Deromedis B, Donnan LT, et al. Gradual femoral lengthening with the Albizzia intramedullary nail. J Bone Joint Surg 2003;85-A(5):838. DOI: 10.2106/00004623-200305000-00011.
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;32:129. DOI: 10.1016/S0020-1383(01)00116-4.
Lee DH, Ryu KJ, Song HR, et al. Complications of the intramedullary skeletal kinetic distractor (ISKD) in distraction osteogenesis. Clin Orthop Relat Res 2014;472(12):3852. DOI: 10.1007/s11999-014-3547-4.
Krieg AH, Lenze U, Speth BM, et al. Intramedullary leg lengthening with a motorized nail. Indications, Challenges, and Outcomes in 32 Patients Acta Orthopaedica 2011;82(3):344–350. DOI: 10.3109/17453674.2011.584209.
Dincyurek H, Kocaoglu M, Eralp IL, et al. Functional results of lower extremity lengthening by motorized intramedullary nails. Acta Orthop Traumatol Turc 2012;46(1):42. DOI: 10.3944/AOTT.2012.2671.
Paley D. Precice intramedullary limb lengthening system. Expert Rev Med Devices 2015;12(3):231. DOI: 10.1586/17434440.2015.1005604.
Schiedel FM, Vogt B, Tretow HL, et al. How precise is the PRECICE compared to the ISKD in intra-medullary limb lengthening? Acta Orthop 2014;85(3):293. DOI: 10.3109/17453674.2014.913955.
Kirane YM, Fragomen AT, Rozbruch SR. Precision of the PRECICE internal bone lengthening nail. Clin Orthop Relat Res 2014;472(12):3869. DOI: 10.1007/s11999-014-3575-0.
Paley D, Harris M, Debiparshad K, et al. Limb lengthening by implantable lengthening devices. Tech Orthop 2014;29(2):72. DOI: 10.1097/BTO.0000000000000072.
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. DOI: 10.1007/s11999-014-3572-3.
Rozbruch SR, Birch JG, Dahl MT, et al. Motorized intramedullary nail for management of limb-length discrepancy and deformity. J Am Acad Orthop Surg 2014;22(7):403–409. DOI: 10.5435/JAAOS-22-07-403.
Paley D, Debiparshad K, Balci H, et al. Stature lengthening using the PRECICE intramedullary lengthening nail. Techniq Orthopaed 2015;30(3):167–182. DOI: 10.1097/BTO.0000000000000140.
Laubscher M, Mitchell C, Timms A, et al. Outcomes of femoral lengthening: an initial comparison of the Precice intramedullary lengthening nail and the LRS external fixator lengthening system. Bone Joint J 2016;98-B(10):1382–1388. DOI: 10.1302/0301-620X.98B10.36643.
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. Strat Traum Limb Recon 2016;11(3):199. DOI: 10.1007/s11751-016-0265-3.
Standard SC, Herzenberg JE, Green SA, Antegrade Tibia Operative Technique. https://www.orthovative.com/images/produkte/deformitaeten/precice/16-NuVa-0766-PRECICE-Antegrade-Tibia-Operative-Technique-Guide.pdf.
Paley D. Principles of Deformity Correction. 3rd ed., Berlin: Springer; 2005. pp. 31–61.
Burghardt RD, Herzenberg JE, Specht SC, et al. Mechanical failure of the intramedullary skeletal kinetic distractor in limb lengthening. J Bone Joint Surg Br 2011;93(5):639. DOI: 10.1302/0301-620X.93B5.25986.
Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: part II the influence of the rate and frequency of distraction. Clin Orthop Relat Res 1989(239):263. DOI: 10.1097/00003086-198902000-00029.
Baumgart R, Betz A, Schweiberer L. A fully implantable motorised intramedullary nail for limb lengthening and bone transport. Clin Orthopae Relat Res 1997;343:135.
Furmetz J, Bosl S, Schilling J, et al. Blocking screws for alignment control in intramedullary limb lengthening. Injury 2017;48(7):1597. DOI: 10.1016/j.injury.2017.03.043.