Bernstein et al. reported that stumps of congenital and acquired above-the-elbow amputations can also be successfully elongated to improve both nonprosthetic function and prosthetic fitting135. Large amounts of increase in the humeral stump length of up to 120% of the original length were observed135. Humeral bone healing can furthermore be enhanced if flexible intramedullary nails are added67. Popkov et al. (in a Level-II study) observed a decrease in the humeral healing index from 21.3 to 19.4 days/cm (after monofocal osteotomy and use of a flexible intramedullary nail [FIN] for a discrepancy with a congenital etiology), 19.8 to 15.8 days/cm (after monofocal osteotomy and FIN for a discrepancy with an acquired etiology), and 15.2 to 11.9 days/cm (after bifocal osteotomy and FIN for a discrepancy with an acquired etiology)67. The authors speculated that bone formation during the lengthening process was likely stimulated by the sliding motion of the intramedullary nails, thus leading to the decreased healing index and eventual decreased time of external fixation.
Recently, a report on clavicular lengthening in 5 syndromic patients (7 clavicles) with congenital clavicular hypoplasia and abnormal scapular position showed promising results regarding improvement in function (100% of the patients were improved), appearance (80% were improved), shoulder motion (80% were improved), pain (60% were improved), breathing (20% were improved), and shoulder stability (20% were improved) for this indication (Table II)132,133.
Symmetric or asymmetric lengthening of a short or deviated forearm may be indicated to realign the radius and ulna in order to improve function, improve motion, or reduce pain. Recent studies have shown good clinical results after forearm balancing procedures in patients with hereditary multiple exostosis disease71,98,104. Ettl et al. achieved a mean ulnar length gain of 26 mm in 9 patients and 10 extremities98. Postoperative forearm rotation improved in 4 extremities, was unchanged in 4, and deteriorated in 2 extremities. Similar results concerning forearm rotation (5 of 12 children had improvement, 4 were unchanged, and 3 worsened) and wrist range of motion (1 of 12 children had improvement, 10 were unchanged, and 1 worsened) were observed by Vogt et al. after a mean follow-up of 24.6 months71. However, mild recurrence of the deformity appeared at the mid-term period71. Concomitant procedures (osteochondroma excision and osteotomy of the radius) are commonly performed to achieve the desired clinical and radiographic outcomes71,98-100,102-104.
Distraction osteogenesis has also been used in patients with radial longitudinal deficiency to enhance activities of daily life (Figs. 1-A, 1-B, and 1-C). Raimondo et al. subjectively observed that children were able to play on monkey bars, lift weights, handle overhead objects, and perform hobbies and sports without adaptions postoperatively76. Large lengthening amounts of up to 15 cm have therefore been reported95. Although good aesthetic results can be expected, some deterioration of the hand-forearm angle and ulnar bowing at 1.0 to 8.5 years after deformity correction and ulnar lengthening were reported by Farr et al.93. If lengthening procedures are begun at a very young age, repetitive procedures might be necessary to achieve a balanced forearm length because of growth-related recurrence of deformity94. Despite high patient satisfaction after forearm lengthening in patients with radial longitudinal deficiency, the lengthened extremity is still often used only in an assistive manner76. Moreover, potential complications such as finger stiffness or neurapraxia may occur.
External fixation has been used for gradual correction of severe hyperpronation deformity in congenital radioulnar synostosis from a mean value of 100° to a mean of 15° of supination79. This method can also be used to gradually lengthen the forearm (50 to 82 mm) in preparation for a second-stage vascularized bone transfer96,114. Bone lengthening has therefore been successfully applied for indications such as congenital pseudarthrosis of the forearm, radial longitudinal deficiency, and neonatal compartment syndrome.
Postinfectious forearm deformities were addressed by Zhang et al., who reported marked improvement of clinical parameters (radial deviation, wrist flexion-extension, and grip strength) for 13 children after deformity correction with a monolateral fixator136. Despite delayed bone healing in 3 patients, all patients were satisfied with the intervention, with no growth disturbances observed after a mean follow-up of 4.5 years136. Whenever posttraumatic growth arrest of the distal radial physis is evident, gradual distraction osteogenesis can also be considered80,110. Two small case series revealed good clinical outcomes after gradual correction of the radius. Page and Szabo80 reported mean postoperative scores of 11 on the DASH questionnaire, 76 for the Mayo wrist score, 82 on the Short Form-12 questionnaire, and 1 on the visual analog scale for pain. Moreover, Gündeş et al.110 showed a mean postoperative DASH score of 2 and a mean Mayo wrist score of 89. Villa et al. reported that 11 of 12 patients had functional and cosmetic improvement after a length gain of up to 13 cm; 9 of the 12 patients were further noted to be in better psychological condition after achieving the final forearm length77. As reported by Jager et al., the healing index can be reduced by approximately 30% to 22.2 days/cm of regenerate bone if intramedullary wires are added84 (Table III).
Metacarpal bones and phalanges are lengthened mainly for the purposes of improved appearance or index-to-thumb pinch. Bozan et al. used monolateral and circular frames to elongate 18 metacarpals for a mean length gain of 16.5 mm in children with brachymetacarpia53 (Table IV). All patients younger than 18 years showed significantly accelerated bone healing (decreased healing index; p = 0.002)53. Erdem et al. stated that to avoid metacarpophalangeal joint dislocation, metacarpal lengthening should not exceed 40% of the original bone length123. In another study, all patients were satisfied after adequate digital length was eventually achieved using postdistraction iliac crest bone-grafting126. Miyawaki et al., in contrast, showed increased pinch power (superior to the contralateral side) after digital lengthening using a monofixator and intramedullary Kirschner wire82. Digital lengthening over an intramedullary Kirschner wire also provided a higher percentage of bone lengthening (70% of the original length versus 49%) at the cost of an increased complication rate82. Additional interventions such as web space deepening, bone grafting, or various flaps might be necessary120. Whenever digital lengthening is performed for congenital hand malformations, different growth patterns and different amounts of remaining growth have to be considered94. Although this procedure may often be accompanied with substantial problems such as nonunion, necessitating subsequent bone-grafting in up to 26%69, digital lengthening may lead to improved outcomes such as better key pinch122 and grasp69 and a high rate of patient satisfaction134.
Complications are generally very common in association with bone-lengthening procedures and have been further subdivided by Paley into problems (manageable without further surgery), obstacles (further surgery necessary), and complications (intraoperative injuries)137. The most common complications are superficial pin-track infections, which are caused by a comparatively long time in a frame for many upper-limb conditions. Therefore, the prevalence has been reported to range from 0% to 100%90,91,96,103,104,107,108,117,123,136, with the majority of studies revealing pin-track infection rates of approximately 25% to 50% (Tables I through IV) (see Appendix). In contrast, deep soft-tissue or bone infections are rare events, with a prevalence ranging from 0% to 11%83,114.
Fractures of regenerate bone most commonly occur after device removal, especially if insufficient regenerate bone has been created. In some reports, the prevalence of fractures has been reported to be as high as 50%108. Therefore, despite the potential risk for deep infection, plating of large calluses after long distraction distances has been proposed (Fig. 1-C)93. Delayed bone consolidation and nonunion are further relevant complications, which are regularly reported in the current literature (Figs. 4-A, 4-B, and 4-C). Independent of the lengthened bone, rates have been reported to vary between 0% and 43%69,78,84,93,94,97,98,104,107,117,119,136. Seitz et al., who, to our knowledge, reported the largest clinical series on pediatric upper-limb lengthening, observed an overall nonunion rate of 6% in 141patients134. This type of complication usually requires further surgery with autologous bone-grafting and/or plating for restoration of stability (Fig. 4-C). Premature consolidation is a rather rare event that occurred in only a few series21,71,73,89,96,107,128; Seitz et al. observed this complication in 0.7% of their patients overall134. Device failure, such as pin and wire breakage and loosening, has also frequently been reported and may require subsequent repeat surgery24,68,69,71,83,87,89,94,96,100,116,120,130.
Although reports of vascular complications are uncommon in the literature, neurologic injuries have been observed in many studies12,20,21,74,76-79,89,91,92,95,96,98,101,107,126,129. Injury of the radial nerve specifically is common in association with humeral lengthening procedures12,21,67,74,78,89,91,92. However, most such injuries are temporary and resolve spontaneously. According to the literature, complex regional pain syndrome type II has been reported in 1 patient77.
Further potential problems during lengthening include joint subluxation and dislocation (Fig. 4-B). Ettl et al. and Ip et al. each reported 1 case of progressive radial head dislocation in exostosis-related forearm lengthening98,102. Moreover, dislocation of the thumb metacarpal base during phalangeal lengthening117, subluxation of the proximal interphalangeal joint during severe camptodactyly distraction129, and elbow subluxation in association with a very short below-the-elbow stump135 have been reported. Temporary wrist or finger contractures can occur during forearm lengthening20,76,107,138, whereas elbow contractures occur more often during humeral distraction than during forearm lengthening89,90, with a reported prevalence of up to 27%89. Axial deviation is another potential complication resulting from bone lengthening in the upper extremity68,83,84,89,97,139.
Despite recent developments of fixation devices and web-based software tools, bone lengthening remains a highly complex procedure with a need for dedicated patient compliance and endurance. To avoid potential problems during the lengthy, arduous procedures, the importance of the patient’s social, psychological, and economic background and support must not be underestimated. Future therapeutic approaches with forceful axial loading after completed distraction would likely be beneficial to enhance bone regeneration and consolidation. Moreover, early recognition of regenerate bone at risk for mechanical failure is of paramount importance, as are technical variations such as lengthening over an intramedullary nail, which can accelerate consolidation of regenerate bone67,140,141. Practicable and reliable means for assessment of the regenerate bone are important in deciding when to remove the external fixation142. Favorable outcomes can be achieved if indications are carefully assessed. Patient satisfaction may be high overall, even in the event of complications106,134.
Tables showing complications and clinical remarks for pediatric humeral lengthening procedures, pediatric clavicular lengthening procedures, pediatric forearm lengthening procedures, and pediatric hand lengthening procedures are available with the online version of this article as a data supplement at jbjs.org.
Investigation performed at the Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria
1. Codivilla A. The classic: on the means of lengthening, in the lower limbs, the muscles and tissues which are shortened through deformity. 1905. Clin Orthop Relat Res. 2008 ;466(12):2903–9. Epub 2008 Sep 27.
2. Hasler CC, Krieg AH. Current concepts of leg lengthening. J Child Orthop. 2012 ;6(2):89–104. Epub 2012 Mar 21.
3. Ombredanne L. Allongement d’un fémur sur un membre trop court. Bull Mem Soc Chir Paris. 1913;39:1177.
4. Putti V. The operative lengthening of the femur. 1921. Clin Orthop Relat Res. 1990 ;250:4–7.
5. Wittmoser R. [Pressure osteosynthesis]. Langenbecks Arch Klin Chir Ver Dtsch Z Chir. 1953;276:229–31. German.
6. Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res. 1990 ;250:8–26.
7. Schopler SA, Lawrence JF, Johnson MK. Lengthening of the humerus for upper extremity limb length discrepancy. J Pediatr Orthop. 1986 ;6(4):477–80.
8. Kiss S, Pap K, Vízkelety T, Terebessy T, Balla M, Szoke G. The humerus is the best place for bone lengthening. Int Orthop. 2008 ;32(3):385–8. Epub 2007 Feb 24.
9. Dick HM, Tietjen R. Humeral lengthening for septic neonatal growth arrest. Case report. J Bone Joint Surg Am. 1978 ;60(8):1138–9.
10. Katz K, Goldberg I, Bahar A, Yosipovitch Z. Humeral lengthening for septic neonatal growth arrest. J Hand Surg Am. 1989 ;14(5):903–7.
11. Chandler D, King JD, Bernstein SM, Marrero G, Koh J, Hambrecht H. Results of 21 Wagner limb lengthenings in 20 patients. Clin Orthop Relat Res. 1988 ;230:214–22.
12. Janovec M. Short humerus: results of 11 prolongations in 10 children and adolescents. Arch Orthop Trauma Surg. 1991;111(1):13–5.
13. Prevot J, Lascombes P, Gagneux E, Ramborum D. [Arm lengthening in children. Report of 4 cases]. Chirurgie. 1990;116(2):184–9. French.
14. Cheng JC. Distraction lengthening of the forearm. J Hand Surg Br. 1991 ;16(4):441–5.
15. Pritchett JW. Lengthening the ulna in patients with hereditary multiple exostoses. J Bone Joint Surg Br. 1986 ;68(4):561–5.
16. Cattaneo R, Villa A, Catagni M, Tentori L, Cassi M. [Application of the Ilizarov technic in the lengthening of the humerus]. Rev Chir Orthop Reparatrice Appar Mot. 1986;72(3):203–9. French.
17. Cattaneo R, Villa A, Catagni MA, Bell D. Lengthening of the humerus using the Ilizarov technique. Description of the method and report of 43 cases. Clin Orthop Relat Res. 1990 ;250:117–24.
18. Cattaneo R, Villa A, Catagni M, Tentori L. Strategies for limb lengthening in achondroplasia using the Ilizarov method—the experience of the hospital of Lecco, Italy. Basic Life Sci. 1988;48:381–8.
19. Cattaneo R, Catagni MA, Guerreschi F. Applications of the Ilizarov method in the humerus. Lengthenings and nonunions. Hand Clin. 1993 ;9(4):729–39.
20. Catagni MA, Szabo RM, Cattaneo R. Preliminary experience with Ilizarov method in late reconstruction of radial hemimelia. J Hand Surg Am. 1993 ;18(2):316–21.
21. Tetsworth K, Krome J, Paley D. Lengthening and deformity correction of the upper extremity by the Ilizarov technique. Orthop Clin North Am. 1991 ;22(4):689–713.
22. Pickford MA, Scheker LR. Distraction lengthening of the ulna in radial club hand using the Ilizarov technique. J Hand Surg Br. 1998 ;23(2):186–91.
23. Guzanin S. Use of the distraction method in hand surgery. Acta Chir Plast. 1991;33(1):22–33.
24. Arslan H. Metacarpal lengthening by distraction osteogenesis in childhood brachydactyly. Acta Orthop Belg. 2001 ;67(3):242–7.
25. Mansoor IA. Metacarpal lengthening: a case report. J Bone Joint Surg Am. 1969 ;51(8):1638–40.
26. Baruch AD, Hecht OA. Treatment of monodactyly by the distraction-lengthening principle: a case report. J Hand Surg Am. 1983 ;8(5 Pt 1):604–6.
27. Kessler I, Hecht O, Baruch A. Distraction-lengthening of digital rays in the management of the injured hand. J Bone Joint Surg Am. 1979 ;61(1):83–7.
28. Al-Sayyad MJ. Taylor Spatial Frame in the treatment of upper extremity conditions. J Pediatr Orthop. 2012 ;32(2):169–78.
29. Paley D. PRECICE intramedullary limb lengthening system. Expert Rev Med Devices. 2015 ;12(3):231–49. Epub 2015 Feb 18.
30. 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 ;238:249–81.
31. 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 ;239:263–85.
32. Frost HM. Why the ISMNI and the Utah paradigm? Their role in skeletal and extraskeletal disorders. J Musculoskelet Neuronal Interact. 2000 ;1(1):5–9.
33. Frost HMAA. A 2003 update of bone physiology and Wolff’s Law for clinicians. Angle Orthod. 2004 ;74(1):3–15.
34. Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury. 2007 ;38(Suppl 4):S3–6.
35. Babatunde OM, Fragomen AT, Rozbruch SR. Noninvasive quantitative assessment of bone healing after distraction osteogenesis. HSS J. 2010 ;6(1):71–8. Epub 2009 Aug 18.
36. Maffulli N, Hughes T, Fixsen JA. Ultrasonographic monitoring of limb lengthening. J Bone Joint Surg Br. 1992 ;74(1):130–2.
37. Hughes TH, Maffulli N, Fixsen JA. Ultrasonographic appearance of regenerate bone in limb lengthening. J R Soc Med. 1993 ;86(1):18–20.
38. Poposka A, Atanasov N, Dzoleva-Tolevska R. Use of ultrasonography in evaluation of new bone formation in patients treated by the method of Ilizarov. Prilozi. 2012;33(1):199–208.
39. Giannikas KA, Bayam L, Naraen A, Buckley J, Maganaris C, Wilkes RA, Hutchinson CE. Cross-sectional anatomy in postdistraction osteogenesis tibia. J Orthop Sci. 2007 ;12(5):430–6. Epub 2007 Sep 28.
40. Aronson J, Good B, Stewart C, Harrison B, Harp J. Preliminary studies of mineralization during distraction osteogenesis. Clin Orthop Relat Res. 1990 ;250:43–9.
41. Theyse LF, Hazewinkel HA, Terlou M, Pollak YW, Voorhout G. Evaluation of delayed-image bone scintigraphy to assess bone formation after distraction osteogenesis in dogs. Am J Vet Res. 2006 ;67(5):790–5.
42. Hussein A, Faflik J, Bik K. The importance of densitometric testing in the evaluation of regenerated bone during long bone lengthening by the Ilizarov method. Ortop Traumatol Rehabil. 2002 ;4(3):282–9.
43. Chotel F, Braillon P, Sailhan F, Gadeyne S, Gellon JO, Panczer G, Pedrini C, Berard J. Bone stiffness in children: part II. Objectives criteria for children to assess healing during leg lengthening. J Pediatr Orthop. 2008 ;28(5):538–43.
44. Eyres KS, Bell MJ, Kanis JA. New bone formation during leg lengthening. Evaluated by dual energy X-ray absorptiometry. J Bone Joint Surg Br. 1993 ;75(1):96–106.
45. Reiter A, Sabo D, Pfeil J, Cotta H. Quantitative assessment of callus distraction using dual energy X-ray absorptiometry. Int Orthop. 1997;21(1):35–40.
46. Zhao L, Fan Q, Venkatesh KP, Park MS, Song HR. Objective guidelines for removing an external fixator after tibial lengthening using pixel value ratio: a pilot study. Clin Orthop Relat Res. 2009 ;467(12):3321–6. Epub 2009 Aug 6.
47. Shim JS, Chung KH, Ahn JM. Value of measuring bone density serial changes on a picture archiving and communication systems (PACS) monitor in distraction osteogenesis. Orthopedics. 2002 ;25(11):1269–72.
48. Li R, Saleh M, Yang L, Coulton L. Radiographic classification of osteogenesis during bone distraction. J Orthop Res. 2006 ;24(3):339–47.
49. Hamanishi C, Yasuwaki Y, Kikuchi H, Tanaka S, Tamura K. Classification of the callus in limb lengthening. Radiographic study of 35 limbs. Acta Orthop Scand. 1992 ;63(4):430–3.
50. Sun XT, Easwar TR, Stephen M, Song SH, Kim SJ, Song HR. Comparative study of callus progression in limb lengthening with or without intramedullary nail with reference to the pixel value ratio and the Ru Li’s classification. Arch Orthop Trauma Surg. 2011 ;131(10):1333–40. Epub 2011 Apr 13.
51. Aronson J. Experimental and clinical experience with distraction osteogenesis. Cleft Palate Craniofac J. 1994 ;31(6):473–81; discussion 481-2.
52. Fischgrund J, Paley D, Suter C. Variables affecting time to bone healing during limb lengthening. Clin Orthop Relat Res. 1994 ;301:31–7.
53. Bozan ME, Altinel L, Kuru I, Maralcan G, Acar M, Durmaz H. Factors that affect the healing index of metacarpal lengthening: a retrospective study. J Orthop Surg (Hong Kong). 2006 ;14(2):167–71.
54. Herbert AJ, Herzenberg JE, Paley D. A review for pediatricians on limb lengthening and the Ilizarov method. Curr Opin Pediatr. 1995 ;7(1):98–105.
55. Kim SJ, Agashe MV, Song SH, Choi HJ, Lee H, Song HR. Comparison between upper and lower limb lengthening in patients with achondroplasia: a retrospective study. J Bone Joint Surg Br. 2012 ;94(1):128–33.
56. Tanaka K, Nakamura K, Matsushita T, Horinaka S, Kusaba I, Kurokawa T. Callus formation in the humerus compared with the femur and tibia during limb lengthening. Arch Orthop Trauma Surg. 1998;117(4-5):262–4.
57. Latalski M, Elbatrawy YA, Thabet AM, Gregosiewicz A, Raganowicz T, Fatyga M. Enhancing bone healing during distraction osteogenesis with platelet-rich plasma. Injury. 2011 ;42(8):821–4. Epub 2011 Apr 21.
58. Kiely P, Ward K, Bellemore C M, Briody J, Cowell CT, Little DG. Bisphosphonate rescue in distraction osteogenesis: a case series. J Pediatr Orthop. 2007 ;27(4):467–71.
59. Lindley TE, Dahdaleh NS, Menezes AH, Abode-Iyamah KO. Complications associated with recombinant human bone morphogenetic protein use in pediatric craniocervical arthrodesis. J Neurosurg Pediatr. 2011 ;7(5):468–74.
60. Jain A, Kebaish KM, Sponseller PD. Factors associated with use of bone morphogenetic protein during pediatric spinal fusion surgery: an analysis of 4817 patients. J Bone Joint Surg Am. 2013 ;95(14):1265–70.
61. Dudda M, Hauser J, Muhr G, Esenwein SA. Low-intensity pulsed ultrasound as a useful adjuvant during distraction osteogenesis: a prospective, randomized controlled trial. J Trauma. 2011 ;71(5):1376–80.
62. Salem KH, Schmelz A. Low-intensity pulsed ultrasound shortens the treatment time in tibial distraction osteogenesis. Int Orthop. 2014 ;38(7):1477–82. Epub 2014 Jan 7.
63. Das SP, Ganesh S, Pradhan S, Singh D, Mohanty RN. Effectiveness of recombinant human bone morphogenetic protein-7 in the management of congenital pseudoarthrosis of the tibia: a randomised controlled trial. Int Orthop. 2014 ;38(9):1987–92. Epub 2014 May 15.
64. Oetgen ME, Richards BS. Complications associated with the use of bone morphogenetic protein in pediatric patients. J Pediatr Orthop. 2010 ;30(2):192–8.
65. Ritting AW, Weber EW, Lee MC. Exaggerated inflammatory response and bony resorption from BMP-2 use in a pediatric forearm nonunion. J Hand Surg Am. 2012 ;37(2):316–21. Epub 2011 Nov 25.
66. Zhang P, Yokota H. Elbow loading promotes longitudinal bone growth of the ulna and the humerus. J Bone Miner Metab. 2012 ;30(1):31–9. Epub 2011 Jul 6.
67. Popkov D, Popkov A, Haumont T, Journeau P, Lascombes P. Flexible intramedullary nail use in limb lengthening. J Pediatr Orthop. 2010 ;30(8):910–8.
68. Matsuno T, Ishida O, Sunagawa T, Ichikawa M, Ikuta Y, Ochi M. Bone lengthening for congenital differences of the hands and digits in children. J Hand Surg Am. 2004 ;29(4):712–9.
69. Salom M, Aroca JE, Chover V, Alonso R, Vilar R. Distraction-lengthening of digital rays using a small external fixator. J Hand Surg Br. 1998 ;23(6):781–4.
70. Manktelow RT, Wainwright DJ. A technique of distraction osteosynthesis in the hand. J Hand Surg Am. 1984 ;9(6):858–62.
71. Vogt B, Tretow HL, Daniilidis K, Wacker S, Buller TC, Henrichs MP, Roedl RW, Schiedel F. Reconstruction of forearm deformity by distraction osteogenesis in children with relative shortening of the ulna due to multiple cartilaginous exostosis. J Pediatr Orthop. 2011 ;31(4):393–401.
72. Minguella J, Cabrera M, Escolá J. Techniques for small-bone lengthening in congenital anomalies of the hand and foot. J Pediatr Orthop B. 2001 ;10(4):355–9.
73. McLawhorn AS, Sherman SL, Blyakher A, Widmann RF. Humeral lengthening and deformity correction with the multiaxial correction system. J Pediatr Orthop B. 2011 ;20(2):111–6.
74. Pawar AY, McCoy TH Jr, Fragomen AT, Rozbruch SR. Does humeral lengthening with a monolateral frame improve function? Clin Orthop Relat Res. 2013 ;471(1):277–83. Epub 2012 Aug 28.
75. Gordon A, Page R, Saleh M. Index finger lengthening by gradual distraction and bone grafting. J Hand Surg Br. 1998 ;23(6):785–7.
76. Raimondo RA, Skaggs DL, Rosenwasser MP, Dick HM. Lengthening of pediatric forearm deformities using the Ilizarov technique: functional and cosmetic results. J Hand Surg Am. 1999 ;24(2):331–8.
77. Villa A, Paley D, Catagni MA, Bell D, Cattaneo R. Lengthening of the forearm by the Ilizarov technique. Clin Orthop Relat Res. 1990 ;250:125–37.
78. Kołodziej L, Kołban M, Zacha S, Chmielnicki M. The use of the Ilizarov technique in the treatment of upper limb deformity in patients with Ollier’s disease. J Pediatr Orthop. 2005 ;25(2):202–5.
79. Rubin G, Rozen N, Bor N. Gradual correction of congenital radioulnar synostosis by an osteotomy and Ilizarov external fixation. J Hand Surg Am. 2013 ;38(3):447–52. Epub 2013 Jan 4.
80. Page WT, Szabo RM. Distraction osteogenesis for correction of distal radius deformity after physeal arrest. J Hand Surg Am. 2009 ;34(4):617–26.
81. Manner HM, Huebl M, Radler C, Ganger R, Petje G, Grill F. Accuracy of complex lower-limb deformity correction with external fixation: a comparison of the Taylor Spatial Frame with the Ilizarov ring fixator. J Child Orthop. 2007 ;1(1):55–61. Epub 2006 Dec 30.
82. Miyawaki T, Masuzawa G, Hirakawa M, Kurihara K. Bone-lengthening for symbrachydactyly of the hand with the technique of callus distraction. J Bone Joint Surg Am. 2002 ;84(6):986–91.
83. Dhalla R, Strecker W, Manske PR. A comparison of two techniques for digital distraction lengthening in skeletally immature patients. J Hand Surg Am. 2001 ;26(4):603–10.
84. Jager T, Popkov D, Lascombes P, Popkov A, Journeau P. Elastic intramedullary nailing as a complement to Ilizarov’s method for forearm lengthening: a comparative pediatric prospective study. Orthop Traumatol Surg Res. 2012 ;98(4):376–82. Epub 2012 May 2.
85. Krieg AH, Lenze U, Speth BM, Hasler CC. Intramedullary leg lengthening with a motorized nail. Acta Orthop. 2011 ;82(3):344–50. Epub 2011 May 11.
86. Schiedel FM, Vogt B, Tretow HL, Schuhknecht B, Gosheger G, Horter MJ, Rödl R. How precise is the PRECICE compared to the ISKD in intramedullary limb lengthening? Reliability and safety in 26 procedures. Acta Orthop. 2014 ;85(3):293–8. Epub 2014 Apr 23.
87. Dal Monte A, Andrisano A, Manfrini M, Zucchi M. Humeral lengthening in hypoplasia of the upper limb. J Pediatr Orthop. 1985 ;5(2):202–7.
88. Lamoureux J, Verstreken L. Progressive upper limb lengthening in children: a report of two cases. J Pediatr Orthop. 1986 ;6(4):481–5.
89. Ruette P, Lammens J. Humeral lengthening by distraction osteogenesis: a safe procedure? Acta Orthop Belg. 2013 ;79(6):636–42.
90. Malot R, Park KW, Song SH, Kwon HN, Song HR. Role of hybrid monolateral fixators in managing humeral length and deformity correction. Acta Orthop. 2013 ;84(3):280–5. Epub 2013 Mar 19.
91. Hosny GA. Unilateral humeral lengthening in children and adolescents. J Pediatr Orthop B. 2005 ;14(6):439–43.
92. Kashiwagi N, Suzuki S, Seto Y, Futami T. Bilateral humeral lengthening in achondroplasia. Clin Orthop Relat Res. 2001 ;391:251–7.
93. Farr S, Petje G, Sadoghi P, Ganger R, Grill F, Girsch W. Radiographic early to midterm results of distraction osteogenesis in radial longitudinal deficiency. J Hand Surg Am. 2012 ;37(11):2313–9.
94. Matsuno T, Ishida O, Sunagawa T, Suzuki O, Ikuta Y, Ochi M. Radius lengthening for the treatment of Bayne and Klug type II and type III radial longitudinal deficiency. J Hand Surg Am. 2006 ;31(5):822–9.
95. Cattaneo R, Catagni MA, Guerreschi F. [Treatment of radial agenesis with the Ilizarov method]. Rev Chir Orthop Reparatrice Appar Mot. 2001 ;87(5):443–50. French.
96. Taghinia AH, Al-Sheikh AA, Panossian AE, Upton J. Two-stage distraction lengthening of the forearm. J Craniofac Surg. 2013 ;24(1):79–84.
97. Launay F, Jouve JL, Guillaume JM, Viehweger E, Jacquemier M, Bollini G. [Progressive forearm lengthening in children: 14 cases]. Rev Chir Orthop Reparatrice Appar Mot. 2001 ;87(8):786–95. French.
98. Ettl V, Wild A, Thorey F, Kirschner S, Krauspe R, Raab P. [Correction of forearm deformities in children with multiple cartilaginous osteochondromas]. Z Orthop Ihre Grenzgeb. 2005 ;143(1):106–11. German.
99. Matsubara H, Tsuchiya H, Sakurakichi K, Yamashiro T, Watanabe K, Tomita K. Correction and lengthening for deformities of the forearm in multiple cartilaginous exostoses. J Orthop Sci. 2006 ;11(5):459–66.
100. Bader B, Grill F. [Ulnar lengthening in osteochondroma (multiple cartilagenous exostoses) of the forearm]. Handchir Mikrochir Plast Chir. 2000 ;32(5):321–7. German.
101. Masada K, Tsuyuguchi Y, Kawai H, Kawabata H, Noguchi K, Ono K. Operations for forearm deformity caused by multiple osteochondromas. J Bone Joint Surg Br. 1989 ;71(1):24–9.
102. Ip D, Li YH, Chow W, Leong JC. Reconstruction of forearm deformities in multiple cartilaginous exostoses. J Pediatr Orthop B. 2003 ;12(1):17–21.
103. Demir B, Gursu S, Ozturk K, Yildirim T, Konya MN, Er T. Single-stage treatment of complete dislocation of radial head and forearm deformity using distraction osteogenesis in paediatric patients having multiple cartilaginous exostosis. Arch Orthop Trauma Surg. 2011 ;131(9):1195–201. Epub 2011 Feb 6.
104. Tang ZW, Cao YL, Liu T, Chen T, Zhang XS. Management of forearm deformities with ulnar shortening more than 15 mm caused by hereditary multiple osteochondromas. Eur J Orthop Surg Traumatol. 2013 ;23(5):611–8. Epub 2012 Jul 1.
105. Bilen FE, Eralp L, Balci HI, Kocaoglu M, Ozger H. Correction of forearm deformities in children with multiple osteochondroma, by corrective radial osteotomy and ulnar lengthening by distraction osteogenesis. Acta Orthop Belg. 2009 ;75(6):743–7.
106. Litzelmann E, Mazda K, Jehanno P, Brasher C, Penneçot GF, Ilharreborde B. Forearm deformities in hereditary multiple exostosis: clinical and functional results at maturity. J Pediatr Orthop. 2012 ;32(8):835–41.
107. Hill RA, Ibrahim T, Mann HA, Siapkara A. Forearm lengthening by distraction osteogenesis in children: a report of 22 cases. J Bone Joint Surg Br. 2011 ;93(11):1550–5.
108. Abe M, Shirai H, Okamoto M, Onomura T. Lengthening of the forearm by callus distraction. J Hand Surg Br. 1996 ;21(2):151–63.
109. Mader K, Gausepohl T, Pennig D. Shortening and deformity of radius and ulna in children: correction of axis and length by callus distraction. J Pediatr Orthop B. 2003 ;12(3):183–91.
110. Gündeş H, Buluç L, Sahin M, Alici T. Deformity correction by Ilizarov distraction osteogenesis after distal radius physeal arrest. Acta Orthop Traumatol Turc. 2011;45(6):406–11.
111. Pajardi G. [Upper limb lengthening. 47 clinical cases]. Ann Chir Main Memb Super. 1995;14(4-5):218–23. French.
112. Bagatur AE, Doğan A, Zorer G. [Correction of deformities and length discrepancies of the forearm in children by distraction osteogenesis]. Acta Orthop Traumatol Turc. 2002;36(2):111–6. Turkish.
113. Kakarala G, Kavarthapu V, Lahoti O. Distraction osteogenesis to improve limb function in congenital bilateral humeroradioulnar synostosis. Acta Orthop Belg. 2006 ;72(6):765–8.
114. Mateev M, Imanaliev A. Two-stage reconstruction in congenital pseudarthrosis of the forearm using the Ilizarov technique and vascularized osteoseptocutaneous fibula. J Reconstr Microsurg. 2006 ;22(3):143–8.
115. Orhun H, Saka G, Bilgic E, Kavakh B. Lengthening of short stumps for functional use of prostheses. Prosthet Orthot Int. 2003 ;27(2):153–7.
116. Jasiewicz B, Tesiorowski M, Kacki W, Kasprzyk M, Zarzycki D. Lengthening of congenital forearm stumps. J Pediatr Orthop B. 2006 ;15(3):198–201.
117. Houshian S, Ipsen T. Metacarpal and phalangeal lengthening by callus distraction. J Hand Surg Br. 2001 ;26(1):13–6.
118. Matev IB. Thumb reconstruction in children through metacarpal lengthening. Plast Reconstr Surg. 1979 ;64(5):665–9.
119. Seitz WH Jr, Froimson AI. Digital lengthening using the callotasis technique. Orthopedics. 1995 ;18(2):129–38.
120. Rudolf KD, Preisser P, Partecke BD. Callus distraction in the hand skeleton. Injury. 2000;31(Suppl 1):113–20.
121. Rösslein R. First experience with a distraction apparatus prototype (SM-fix-phalanx distractor) for phalanges lengthening. Eur J Pediatr Surg. 1993 ;3(4):231–5.
122. Seitz WH Jr, Froimson AI. Callotasis lengthening in the upper extremity: indications, techniques, and pitfalls. J Hand Surg Am. 1991 ;16(5):932–9.
123. Erdem M, Sen C, Eralp L, Kocaoğlu M, Ozden V. Lengthening of short bones by distraction osteogenesis—results and complications. Int Orthop. 2009 ;33(3):807–13. Epub 2007 Dec 19.
124. Kato H, Minami A, Suenaga N, Iwasaki M, Kimura T. Callotasis lengthening in patients with brachymetacarpia. J Pediatr Orthop. 2002 ;22(4):497–500.
125. Sen C, Kocaoğlu M, Eralp L, Cinar M. [Bone lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique]. Acta Orthop Traumatol Turc. 2003;37(2):154–61. Turkish.
126. Ogino T, Kato H, Ishii S, Usui M. Digital lengthening in congenital hand deformities. J Hand Surg Br. 1994 ;19(1):120–9.
127. Volpi AD, Fragomen AT. Percutaneous distraction lengthening in brachymetacarpia. Orthopedics. 2011 ;34(8):e424–7. Epub 2011 Aug 8.
128. Hierner R, Wilhelm K, Brehl B. [Callus distraction for lengthening of mid-hand and finger stumps in congenital hand abnormalities—personal results and review of the literature]. Handchir Mikrochir Plast Chir. 1998 ;30(3):196–202; discussion 203-5. German.
129. Hülsbergen-Krüger S, Preisser P, Partecke BD. Ilizarov distraction-lengthening in congenital anomalies of the upper limb. J Hand Surg Br. 1998 ;23(2):192–5.
130. Vargel I, Calis M, Cavusoglu T, Ekin O, Oznur A. Application of C-shaped osteotomy and distraction osteogenesis for correction of radial angulation deformities of the hand in children with Apert syndrome: review of 10 years of experience. Ann Plast Surg. 2015 ;75(5):513–7.
131. Moser N, Rösslein R. [A new method for treating the Kirner deformity with the SM-Fix phalangeal distractor]. Handchir Mikrochir Plast Chir. 1996 ;28(1):34–8. German.
132. Sewell MD, Higgs DS, Lambert SM. Clavicle lengthening by distraction osteogenesis for congenital clavicular hypoplasia: case series and description of technique. J Pediatr Orthop. 2013 ;33(3):314–20.
133. Karslioglu B, Eyi YE, Erdem Y. Clavicle lengthening by distraction osteogenesis for congenital clavicular hypoplasia: is it a real indication? J Pediatr Orthop. 2015 ;35(4):e36.
134. Seitz WH Jr, Shimko P, Patterson RW. Long-term results of callus distraction-lengthening in the hand and upper extremity for traumatic and congenital skeletal deficiencies. J Bone Joint Surg Am. 2010 ;92(Suppl 2):47–58.
135. Bernstein RM, Watts HG, Setoguchi Y. The lengthening of short upper extremity amputation stumps. J Pediatr Orthop. 2008 ;28(1):86–90.
136. Zhang X, Duan L, Li Z, Chen X. Callus distraction for the treatment of acquired radial club-hand deformity after osteomyelitis. J Bone Joint Surg Br. 2007 ;89(11):1515–8.
137. Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990 ;250:81–104.
138. Horii E, Nakamura R, Nakao E, Kato H, Yajima H. Distraction lengthening of the forearm for congenital and developmental problems. J Hand Surg Br. 2000 ;25(1):15–21.
139. Pensler JM, Carroll NC, Cheng LF. Distraction osteogenesis in the hand. Plast Reconstr Surg. 1998 ;102(1):92–5.
140. Monsell F, Hughes AW, Turner J, Bellemore MC, Bilston L. Can the material properties of regenerate bone be predicted with non-invasive methods of assessment? Exploring the correlation between dual X-ray absorptiometry and compression testing to failure in an animal model of distraction osteogenesis. Strategies Trauma Limb Reconstr. 2014 ;9(1):45–51. Epub 2014 Mar 5.
141. Laumen A, Lammens J, Vanlauwe J. Reduction of treatment time in external ring fixation using the monofix device. Acta Orthop Belg. 2012 ;78(4):543–7.
142. Starr KA, Fillman R, Raney EM. Reliability of radiographic assessment of distraction osteogenesis site. J Pediatr Orthop. 2004 ;24(1):26–9.