Limb length discrepancy (LLD) and limb shortening are frequent conditions and can be successfully treated since Ilizarov described the method of callus distraction1.
The indications for humeral lengthening are less frequent than in the lower extremities, because humeral shortening is caused by osteomyelitis, postseptic shortening, aneurysmal bone cysts, achondroplasia, and growth plate closure after tumor or trauma or for cosmetic reasons2-6. It is beneficial to provide increased performance in daily activities, to improve sports performance and to significantly enhance self-image2,3.
Humeral lengthening with an external device has been used for years and is described as a safe procedure with good results3,7. Various fixators such as Ilizarov frames8, monolateral fixators9, and the hexapod-designed Taylor spatial frame10 have been described in publications. Therefore, complications such as pin track infections, radial nerve palsy, fracture of the regenerate, inferior subluxation of the shoulder joint, or premature consolidation of the regenerate can occur11. The patient's acceptance of an external fixator is lower on the upper extremities than on the lower ones. As newer devices became available, external frames were pushed into the background12.
The PRECICE nail (NuVasive), a magnetically actuated mechanical system, was introduced in 201113. Depending on the nail length, the distraction distance is limited: a 160-mm nail extends 30 mm, and with a 230-mm nail, lengthening up to 50 mm is possible. An 80-mm distraction can only be performed with a 240-mm nail. However, this is not practical in most cases of a shortened humerus. The first reported case of intramedullary humeral lengthening was published by Tiefenboeck et al. in 201614. Since that time, several publications regarding this method have been published in the literature15-17.
The following case presents our strategy for extended humeral lengthening with an internal lengthening device.
The patient was informed that data concerning the case would be submitted for publication, and he provided consent.
Patient characteristics are presented in Table I. The 48-year-old patient suffered from an epiphyseal injury of the proximal humerus after a fall during childhood and presented to our outpatient clinic with a 6.5-cm (2.6-inch) shortening of the right humerus compared to the left one (Fig. 1).
TABLE I -
||Humeral epiphyseal fracture in the childhood
||Functional impairment, especially when carrying objects, participating in sports, wearing shirts.
||6.5 cm, 2.6 inch
|Type of nail
||PRECICE, NuVasive, 8.5 mm telescopic tibial lengthening nail, 10° bend, 215 mm length
||Below deltoid muscle insertion
|Distraction index (mm/day)
|Healing index (month/cm)
|Consolidation index (days/cm)
||Movement restriction in the shoulder joint during distraction
His major clinical problems were increasing pain at his cervical and thoracic spine resulting from a poor working posture caused by asymmetric limb length, functional impairment especially when carrying objects, and limitations in performing sports such as swimming with breaststroke or poor cycling posture while holding bicycle handlebars. Another limitation was a rotator cuff tear, caused by his posttraumatic humeral head deformity, which was fixed with three anchors 25 years ago (Fig. 2). His active mobility was 100° abduction, 120° forward flexion, 40° extension, and good external and internal rotation of 40° and 45° was seen at his last follow-up.
Despite the patient's age of 48, the history of previous shoulder surgery and the deformity-induced impaired shoulder-joint motion, we decided to lengthen the humerus with an internal tibial lengthening device. Nail length and diameter were determined by preoperative planning using radiographs with a reference ball and a ruler implemented in the TraumaCad planning software (Brainlab). The first surgery took place in February 2017. Under general anesthesia and beach-chair position, the insertion point of the nail was defined after delta-split approach and a sharp cut through the rotator cuff in the center of the humeral head. After reaming and collecting the cancellous intramedullary bone, the humerus was osteotomized fan-shaped below the deltoid insertion. The osteotomy was completed with a chisel. Then, an 8.5 mm diameter antegrade tibial nail 215 mm in length was implanted and interlocked. Acquired bone was added to the osteotomy gap after intraoperative lengthening of 1 mm. The postoperative course was uneventful. After a latency period of 5 days, distraction of 1 mm per day was started in 2 steps. X-rays were taken regularly every 2 weeks. Physiotherapy was performed immediately to prevent impaired motion of the shoulder. After 5 cm of lengthening, the maximum distraction of the nail was reached, leaving a 2 cm humeral length discrepancy. The patient persisted on further lengthening to reach limb length equality.
The second procedure was performed 65 days after the first surgery and distraction was continued the next day.
The patient was placed in a slight beach chair position. A simple monolateral fixator was mounted with one pin in the distal and one pin in the proximal humeral metaphysis avoiding damage to the nail and allowing safe lengthening and rotation (Fig. 3). The upper extremity was placed on a small surgical table in a horizontal position. Both distal interlocking bolts were removed in a minimally invasive procedure. The nail was backwound just 1.5 cm, and the senior author only had to drill one new drill hole for the second interlocking bolt, which was proximal to the first bolt (Fig. 4). However, backwinding of the telescopic nail took approximately 3 hours of the entire 4 hours of surgery. Technical pearls and pitfalls are shown in Table II.
TABLE II -
Technical Pearls and Pitfalls
| Correct positioning of the nail-insertion—straight insertion necessary
| Prevent damaging the rotator cuff in the area of insertion
| Osteotomy below the insertion of the deltoid muscle to prevent lowering of the muscle insertion and therefore restriction of the shoulder joint function
| External fixator to prevent loss of lengthening, shortening, or rotational deformity
| Backwinding of the nail takes a few hours-an anesthesia and surgical team has to stay at the patient—the remote control has to be fixed at the right position and the button on the remote control has to be pressed
| Vascular and nerval injuries—increased risk—external fixator and distal locking
| Failure of the lengthening mechanism during backwinding and forewinding-a faster backwinding is not possible—even in “in vitro situations”
| Impaired joint motion during lengthening
| New drill holes are necessary for reblocking the nail—weakening of the bone
Postoperatively, physiotherapy was immediately initiated during the in-patient stay to retain shoulder and elbow joint motion and to prevent joint contractures. The patient himself performed the lengthening with the external remote control system.
Lengthening was pursued until a total of 6.5 cm of distraction and equal humeral length was finally reached (Fig. 5).
Despite the massive lengthening, excellent bone healing was observed. There were no soft tissue or nerve problems noticed during follow-up. Movement restriction of the shoulder joint, which initially appeared during distraction, disappeared after intensive physiotherapy and movement exercises.
Radiographic bone healing was achieved approximately 7.6 months (distraction consolidation time = 227 days) after distraction with continuous and uninterrupted callus formation at 3 out of 4 cortices in both the anteroposterior and lateral projections (Fig. 6)16. The healing index was 1.1 month/cm.
Further parameters included the distraction index (DI), which was measured by the length achieved in mm divided by the duration of lengthening in days with a value of 0.82 mm/day, and the consolidation index (CI), where the number of days from surgery until consolidation are divided by the length of the regenerate in cm with a value of 32.4 days/cm16.
Figure 7 shows complete bone healing with 4 visible cortices more than 15 month after surgery. The patient has free function of the shoulder and elbow joint and is satisfied with the result.
Figs. 7-A and 7-B Radiological results 15.5 months after surgery with complete bone healing presented in two planes.
Summarizing our case, we presented a new method for extensive limb lengthening at the upper extremity with an internal lengthening device. Finally, the patient was satisfied with the end result and was without any limitations in his daily activities.
Intramedullary humeral lengthening is reported as a feasible method with good results, good control over the lengthening process, less complications than external devices, and good patient satisfaction with limitations regarding the nail design14,16. At the time of treatment, only tibial nails with a 10° bending angle were available for humeral lengthening. The nail length limits the distraction in a short humerus, and therefore, a maximum of only 5 cm of distraction is possible in most cases.
Therefore, the question remains, which options are available in extensive LLD in the upper extremity? Options such as external fixators, acute lengthening, and other devices are described in the literature. These techniques often present with limitations. Hammouda et al. reported acute distraction of the osteotomy of 8 mm to achieve the final lengthening goal of 5.8 cm. Therefore, a longer latency period was used, and bone consolidation was achieved16. However, this procedure is limited in distance and presents with disadvantages such as nerve lesions18,19.
Another very expensive approach is to use a second nail for further intramedullary lengthening with the risk of damaging the new callus tissue during wire or nail insertion. Additionally, the approach through the rotator cuff for a second time needs to be questioned. The risk of bone weakening with new drill holes remains the same.
One of the major limitations of our presented novel method is the long time for anesthesia as it took hours for backwinding the nail. However, to reduce the time in the operation room (OR), a new device is available for faster nail shortening and lengthening. The “fast distractor” (NuVasive) can be used intraoperatively on the limb and is driven by a simple drill. The distraction or compression time for 10 mm is then reduced to approximately 10 minutes. It also important to note that this is an “off-label use,” and the patient is required to give special informed consent before surgery.
Kiss et al. found that the humerus had almost the same healing index as the bones of the lower extremity, but patients who had humeral lengthening had a faster functional recovery2. It has also been described that the humerus shows significantly faster bony reconstruction than the tibia with no significant differences between the humerus and the femur20.
The healing index in our case was 1.1 cm/month or 32 days/month lower than the expected values described in the literature, as measured on the lower extremities18, but comparable to the presented results of intramedullary humeral lengthening with an healing index of 27.1 ± 4.121 or 32 day/cm with a range of 25 to 40 day/cm2, a DI of 0.5 to 0.8, and a CI 24.5 to 4516. These parameters depend on the complexity of correction, the bone, the level of osteotomy, number and form of osteotomy, etiology, and patient age18.
We conclude that extended nail lengthening with distal unlocking, intraoperative backwinding of the nail, and relocking is a cost-effective, minimally invasive procedure in cases of limited maximum distraction. However, it is important to note again that this technique is an “off-label use” and should only be considered in selected cases.
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