Limb Lengthening for Congenital Deficiencies Using External Fixation Combined with Flexible Intramedullary Nailing: A Multicenter Study

Background: Hydroxyapatite (HA) coated flexible intramedullary nailing (FIN) stimulates osteogenic activity. The role of HA-coated intramedullary nails remains unclear in normal bone lengthening. The goal of this study was to quantify the influence of FIN on the External Fixation Index (EFI) in patients with congenital lower limb discrepancy. Methods: Patients with femoral deficiency and fibular hemimelia underwent lengthening by the combined technique of external fixation with titanium (Ti) FIN or HA coated FIN and returned for follow-up at least 12 months after frame removal. Results: Seventy patients (mean age of 12.6 y) were included: 19 monofocal femoral lengthenings, 35 tibial monofocal lengthenings, 16 tibial bifocal lengthenings. The mean EFI's for those treated with and without HA-coated nails were not significantly different. The Conover posthoc analysis did not reveal a significant influence of the type of FIN on EFI in any subgroup. However, 2-way analysis of variance revealed simultaneous effects of nail types and age on the EFI in tibial bifocal lengthening. Significant positive correlation between the ratio "nail diameter/medullary shaft diameter" and EFI in tibial bifocal non-HA-coated FIN lengthening, and a significant positive correlation between age and EFI for femoral non-HA-coated FIN lengthening, tibial monofocal and bifocal HA-coated FIN lengthening were revealed. There were 4 cases of fracture at lengthening site required unscheduled surgery. In the non-HA-coated group, there was a statistically significant negative correlation between nail diameter and fracture occurrence at the lengthening site after frame removal. A ratio of <0.15 likely does not ensure required mechanical stability and support. Conclusions: Both Ti-nail and HA-coated nail lengthening provide good and excellent outcomes for femoral and tibial monosegmental lengthening procedures and ensure reduced EFI. In congenital disorders which were not associated with abnormal bone, there are no differences with regard to EFI using HA-coated or non-HA-coated FIN. The ratio of "elastic Ti-nail diameter/medullary canal diameter at narrowest site" <0.15 seems to be associated with higher risk of fracture at the lengthening site after frame removal.