Boreal guest editor: ee Dror Paley, MD, FRCSC aT Deformity Correction Techniques Operative Techniques in Orthopaedics editor: Freddie H. Fu, MD | »)) www.optechorthopaedics.com Seo a tasOperative Techniques in Orthopaedics Volume 21 Number 2 June 2011 CONTRIBUTORS F. Erkal Bilen, MD, FEBOT Istanbul Medical Faculty, Istanbul University, Capa, Istanbul, Turkey 34390 Istanbul Memorial Hospital, Piyalepasa Bulvari, Okmeydani, Istanbul, Turkey 34385 Noam Bor, MD Orthopaedic Department, Haemek Med Aula, Israel cal Center, Richard S. Davidson, MD Children’s Hospital of Philadelphia, Philadelphia, PA Shriners Hospital, Philadelphia, PA Hospital of University of Pennsylvania, School of Medicine, Philadelphia, PA Christopher lobst, MD Miami Children’s Hospital, Miami, FL Mehmet Kocaoglu, MD Istanbul Medical Faculty, Istanbul University, Capa, Istanbul, Turkey 34390 Istanbul Memorial Hospital, Piyalepasa Bulvari, Okmeydani, Istanbul, Turkey 34385 Monica Paschoal Nogueira, MD Hospital do Servidor Péblico Estadual, Sao Paulo, SP, Brazil Hospital da Beneficéncia Portuguesa, Sao Paulo, SP, Brazil ‘ACD, Associagao de Assisténcia Crianga Deficiente, Sa0 Paulo, SP, Brazil Dror Paley, MD, FRCSC Paley Advanced Limb Lengthening Institute, St. Mary's Medical Center, West Palm Beach, Florida Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada S. Robert Rozbruch, MD Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY Clinical Orthopaedic Surgery, Weill Cornell Medical College, New York, NY Cornell University, New York, NY Nimrod Rozen, MD, PhD Orthopaedic Department, Haemek Medical Center, Atula, Israel Guy Rubin, MD. Orthopaedic Department, Haemek Medical Center, Atula, Israel John K. Sontich, MD MetroHealth Medical Center, Cleveland, OH ‘Alex E. Staubli, MD Privatklinik Sonnmatt, Lucerne, Switzerland Peter M. Stevens, MD Department of Orthopaedics, University of Utah, School of Medicine, Salt Lake City, UTOperative Techniques in Orthopaedics Fixator-Assisted Nailing for Correction of Long Bone Deformities Mehmet Kocaoglu, MD, and F. Erkal Bilen, MD, FEBOT Many surgical options exist for the correction of long bone deformities. The fixator-assisted ling (FAN) technique developed by Paley et al combines the accuracy, lack of invasive ness, and adjustability of external fixation with the stability and comfort of internal fixation. ‘A temporary external fixator is applied for acute deformity correction. Once the desired alignment is achieved, an intramedullary nail is placed and locked statically, interference screws are inserted for additional stability. and the fixator is removed during the surgery. This combinatory technique may further be combined with lengthening or arthrodesis procedures. ‘Oper Tech Orthop 21:163-173 © 2011 Elsevier Inc. All rights reserved. KEYWORDS deformity correction, external fixator, fitator-assisted nailing, intramedullary nail si ere aon ne ears et as psychological consequences to patients, both in child hood and adulthood. It has been shown that deformities around the knee result in arthritic development at the knee joint." Many surgical options exist for the correction of long bone deformities that either acutely or gradually correct the deformity and provide fixation until bone healing is estab: lished at the osteotomy site.™ Howev nailing (FAN) technique described by Paley et al in 1997 has become the gold standard for the correction of long bone delormities.** This technique combines the accuracy, min ‘mal invasiveness, and safety of external fixation with the ps tient convenience of internal fixation, The intramedullary prevents the recurrence of the deformity, which is espe- in patients with metabolic bone diseases torecurrence of the deformity:as the metabolic problem continues. Preoperative Planning Preoperative assessment and preparation are of paramount importance. Patients must be evaluated for malalignment and limb length discrepancy with standing orthoroentgenograms isanbul Medical Faculy, twanbul Universiy, Capa, Inanbul, Turkey 34300, Isanbul Memorial Hospital, Pyalkpasa Balt, Okmeydn, Istanbul, To hey 3385, Address reprint requests to Mehmet Kocaoghs, MD, Istanbul Medial Fac uty, Itnbul Universtiy, Capa, Istanbul, Turkey 34390 t-mal ddmelunethoxanga mal com 1048 66H6/1 1/8. front matter © 2011 Eleever Ine, Al 14i10.105%4 oo 2011.01 010 in both the frontal and the sagittal plane.* ‘The center of rotation of angulation (CORA) site(s) should be marked on the x-rays. By the use of paper tracings, the procedure can be simulated preoperatively, which will help in planning the surgery (Fig, 1, Preoperative pla mation of the diameter and length of the intramedullary nail to be used as well as the location of the interference screws, (poller,” blocking”) for each case. Extra custom-made holes for locking screws may be placed in the nails, f necessary ning also includes an esti- Surgical Technique (Osteotomies in the long bones can be executed throug ited incisions percutaneously either by the Gigli saw tech: nique or by the multiple drill hole technique, The placement of the intramedulkary nail also can be performed theough a 2-cm transverse incision over the patellar ligament (Fig, 2) The reason behind the choice fora transverse incision is that it leads to less scarring, thus making it cosmetically more acceptable. The paratenon and the patellar ligament, how ever, are split longitudinally. Before 1 valgus deformities of the knee of >20°, prophylactic per- ‘oneal nerve release must be performed. ° The patient is placed. supine on a radiolucent table and checked with fluoroscopy from the hip to the ankle in both planes before sterile prep- FAN for Femoral Deformity Fither an antegrade ora retrograde technique can be used for femoral deformities. The authors prefer retrograde naling for164 ‘M, Kocaogia and FE Bilen Figure 1 Paper tracing to simulate the surgery distal femoral deformity correction and antegrade nailing for proximal femoral deformity correction. Valgus deformity of the distal emur (14°) with the CORA at the level ofthe knee joint (Fig. 3A) is performed as follows: Insert 2 paits of extemal fixation pins (1 distal and proxi mal) from the lateral side Fig. 3B). The pins rmust be placed away from the path of the intramedullary nai, especially at the site of nal insertion on the sagittal plane (Fig, 3C). When erts the distal Schanz screws, both femoral condyles ‘must superimpose on lateral views with the image intensifier (rue lateral view). The same applies forthe proximal par of the femur. Thisalso enables correction rotational deformities, if present The osteotomy is performed through a mini incision, pref= bly by the multiple drill hole technique or with use of the focal dome dnl guide as described hy Paley (Fig. 4A). The medial and lateral edges of the osteotomy are completed by an osteotome (Fig, 4B, C). The osteotome is inserted into the cemeer of the bone, going through both cortices, and then twisted so the desired translation at the osteotomy site is, established (Fig. 5). Altematively, Schanz pins may be used. asa joystick to produce the translation manually (Fig, 6). The translation precedes the angular correction, and its amount is calculated preoperatively using a goniometer (Fig. 7) ‘The angular correction is then performed either man lly oF more accurately with use of the external fixator (the au thors prefer the EBI monorail system with swivel clamp; Bi ‘omet, Warsaw, IN). At this point, the accuracy of the correc tion must be confirmed with an image intensifier as well as with intraoperative long radiographs (Fig. 8). Ifthe desired correction isachieved, then the surgeon can proceed with the nailing, If not, the correction must be repeated until the de. sired amount of correction is confirmed. The authors prefer inserting the interference screws before reaming, to guide the intramedullary dil as well as to pre: vent loss of the correction (Fig. 9). Retrograde reaming over a guidewire is performed through a mini incision as described previously. The reamings produce an internal grafting effect The nail is inserted and locked statically (proximally and distally; Fig. 10). The authors prefer using regular tibial nails for retrograde femoral nailing because their curve helps cor= rect any sagittal deformity present. (Figure 11, B). Addi- tional interference screws may be inserted it needed. TI ‘external fixator is removed at the end of the surgery, and the nail maintains the correction (Fig, 12) FAN for Tibial Deformity Varus deformity of the proximal tibia (10°) with the CORA at the metaphyseal level (Fig. 13) is performed as follows: 2 pairs of Schal (parallel to joint line) and distally (perpendicular to the anatomic axis) in the tibia, The pins should be at the posterior aspect of the tibia on the sagital plane to leave enough space for the nai (Fig. 14). Fust, the fibula is osteotomized percutaneously Then, percutaneous osteotomy is performed through a small Incision either by the multiple drill hole technique or with the use ofa focal dome dill guide as described by Paley etal (Fig the simplicity and quickness, The osteotome is inserted into the center and then twisted to complete the osteotomy and produce the desired amount of translation (Fig, 16). Alterna: tively, the translation may be created by manipulating the Schanz pins as a joystick (Fig. 17). Angular correction is, performed after achieving the desired amount of translation ‘either manually or with use of the monolateral fixator (the authors prefer the EBI monorail system with swivel camp) 15). The authors prefer Gigli saw osteotomy because of Figre2 Transverse insicion aver patellar ligament. (Color version of figure is available onlineFAN for correction of long bone deformities Figure 3 right femur witha distal valgus deformity of 14°. The CORA isat the cent 15 1 fof the joint (A). The Schane pins and the momolateral fixator ate placed (B). Anterior placement ofthe Schan serews to leave space forthe inane ullay nail (), (Color version offiguee is available online.) AL this point, intraoperative roentgenograms are taken, and a malalignment test is performed. Ifthe desired amount of correction is achieved accurately, then the surgeon pro- ceeds with the nailing. Otherwise, the correction is repeated ‘until cis confirmed by intraoperative roentgenograms. Inter ference serews are inserted before reaming to guide the in. tramedullary drill as well as to prevent loss ofthe correction, Antegrade reaming over a guidewire is performed! through a mini incision, The reamings produce an internal grafting ef fect, The nal isimserted and locked statically (proximally and distally) (Fig, 18). Additional interference screws may be in serted if needed. The external fixator is removed at the end of the surgery, and the nail maintains the correction (Fig, 19), A Case Examples Case examples are shown in Figure 20A-C, Figure 214, B, and Figure 224, B, Figure 234, B, and Figure 244-D. Discussion Lower-linb deformities either angular or rotational, can be corrected by many diferent methods. Two main options ex ist external fixation and intemmal fixation. Each has its own advantages and disadvantages. Exteral fixation techniques provide accuracy, less invasiveness and adjustability.” By conteast, the patient's comfort decreases significantly, and tL Figare4 ‘The planning of the foal dome osteotomy atourid the CORA (A), Cutting of te medial (B) and lateral (C) edges ofthe osteotomy using an osteotome. (Color version of igure is available online.)Figure § “Translation atthe osteotomy site obtained by roration ofthe many external fxator-related complications, such as track infections and joint contractures as well as others, may ‘occur. Internal fixation methods provide strong stability and convenience but lack accuracy and adjustabil The FAN technique was developed to combine the advan. tages of both external fixation and internal fixation tech- niques while preventing their disadvantages. The temporary external fixator adds the accuracy and adjustability, and the nail adds the stability and convenience. ** The immediate correction of angular deformities raises concems regarding neurovascular compromise, There is a particularly high risk of peroneal nerve injury when an acute correction of a valgus knee is performed. To prevent this complication, prophylactic peroneal nerve release can be performed.® FAN can also be applied for ankle deformities associated with ankle arthrosis, ie, fixator-assisted acute deformity cor- rection followed by retrograde nailing for calcanco-tibial ta Dilization and fusion. Another combination can be pet- formed for shortening deformities of long bones, as with fixator-assisted acute deformity correction and consecutive Figure 7 Translation and angulation obiained by the monolateral fixator with swivel clamp (EBI monorail system). (Color version of figute is available online.) lengthening over an intramedullary nail (LON), or the FAN- LON technique 2 During lengthening hy the LON technique, particulary in valgus knees, the valgus deformity may increase, which re- «quires correction. This can be performed by the FAN tech: rnigte at the end of the lengthening period through an- ther osteotomy, if necessary (the LON-FAN technique) (Fig, 254-D), Epidural anesthesia can be performed for postoperative analgesia, However, the surgeon must be aware ofthe risk for compartment syndrome during tibial applications (uncom: ‘mon but consequential), which might be masked by the epi dural analgesia FAN, although technically demanding, is an accurate and safe method for the correction of long bone deformities, The accuracy of correction rivals that achieved! by nal fixation, This is achieved by meticulous preoperative planning, preoperative malalignment testing and adjustment of the correction with the monolatera fixator. Perc circular exter- gure § Masual production of the translation and angulation effects atthe osteotomy site, (Color version of figure is available online.)AN for correction of long bone deformities 187 ‘mLDFA = 87° Figre 8 The confirmation ofthe correction intraoperatively by ol jraphs and malalignment test, (Color version of taining long Figare 10 The intramedullary nals inserted iret and locked both proximally and distally. (Color version of available online ) osteotomy, internal grafting by reaming the medullary canal and the stability provided by the intramedullary nail lead to In conclusion, FAN provides accurate deformity correc rapid healing of the osteotomy site The FAN technique raises concern about the tisk of recur rence of infection in patients with a history of infection. How can be per if Figure § Incerlerence serows are ansered prior reaming so that they guide the drill bicand then the intramedullary nail. (Color version of gure 1 The uibial nai can be inserted o the femur ina retrograde dizection to produce extension effect (A) or flexion ellect (B) on, reduces patient discomfort (as the external fixator is removed at the end of the procedure), enables more rapid rehabilitation compared with external fixation techniques, ever, it was shown that intramedullary nailing, and prevents the recurrence of the deformity because of the formed suecessfully in patients with infect well.! retained intramedullary naiMLDFA = 87° Figure 12 The external fisator is removed once the correction 1s he interference secured by the intramedullary locking nail and screws. (Color version of figure is availabe online) ‘CORA ‘er Normal ‘MPTA=87" 1 Figure 13.4 ubia with a prosimal varus deformity of 10°. The CORA level. (Color version of figute is available is at the metaphysea online.) ‘M Kocaogia and FE Bilen Fgura 14 The Schanz pins ae inserted proximally and distally and ‘connected to the monolateral fixator, On the sgitl plane the pins he anterior in the sia to leave space for the intramedullary nail (Color version of figute is available online.) Figure 18 The focal dome osteotomy is planned and performed (Color version of figure is asilable online )FAN for correction of long bone deformities 169 Figure 16. The transla ver of the osteoxome, ay be produced by the rotational mane- ‘olor version of figure is available online ) Figure 18 The intramedullary nail is inserted and locked statically {proximally and distally). (Color version of figure is available on. line.) Figure 17 The cransation and angulation effects may be performed manually, and then the monoateral fixator may be ‘mounted, (Color version of figure ts available online.)0 ‘M_Kocaoglu and FE Bilen Figure 19. OnFAN for correction of long bone deformities m A B Figure 22 4 paticot with a left femoral deformity, Proximal femoral Fiera 24-4 patient with a “windswept deformity” (A), and the cinial picture atthe end ofthe treatment (8). (Com M, Kocaoglu and FE. BilenFAN for correction of long bone deformities References 1 Paley D, HerznberaJE, Paremain G.tal: Femoral lengthening oseran intramedullary nal A matched-case comparison with Izator femoral lengthening, J Bone Joint Surg Am 79:1464-1480, 1997 Ep 1, Kecaoglu M, Rashid H: Reconstueton of segmental bone defers devo chronic osteomyelitis with use ofan ester faator and Inamedallry nal Surgical technique. Bove Joint Surg Am 88Supp! 2):183-195, 2007 Ben FE, Kocaoglu M Ep L tal: Foator-asisted naling and eon- secutive lengthening over an intramedullary ail fr the orestion of tibial deform. | Bone Join Surg Br 92:146-152, 2010 Erp L, Kocaoglt M, Yuso NM, tal: Distal iba reconstructon wih tse of cular estral fixator and an intramedllagy nal. 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