Use of a Motorized Intramedullary Bone Transport Nail for Trauma: Tips, Tricks, Corticotomy Techniques, and Rate and Rhythm.

SUMMARY: The introduction of internal magnetic nails (IMNs) for bone lengthening and bone transport has given us exciting new tools with which to treat segmental bone loss. Distraction osteogenesis has a long record of success in recreating even large segments of bone, but the availability of IMNs now offers the possibility of performing distraction osteogenesis without the drawbacks of external fixation. However, there are aspects of treatment with IMNs that are critical to understand to achieve success and minimize complications. These include assessment of feasibility in relation to available bone stock and segment configuration, the condition of the soft tissue envelope, and the presence of contamination or infection. They also include execution aspects such as bone end preparation, nail placement, need for and positioning of adjuvant fixation, corticotomy techniques, rate and rhythm of distraction, staged screw exchange, docking site preparation, and nail extraction. We discuss these issues in detail and introduce some novel techniques not previously described including the comminuted wedge osteotomy, testing of the nail with initial compression, and retention plug application for nail extraction to assist in optimizing success in certain clinical situations.

Optimizing Bone Defect Reconstruction-Balanced Cable Transport With Circular External Fixation.

Distraction osteogenesis has proven effective in the management of tibial bone loss from severe trauma and infection. Unfortunately, pain and scarring from wires and half pins dragging through the skin and the required prolonged time in the external fixator make treatment difficult. Cable bone transport has been shown to improve cosmesis and decrease pain during transport. However, the published methods have limitations in that they have poor control of transport segment alignment, do not allow for lengthening of the limb, and do not permit weight bearing during the treatment process. We describe a novel method of cable bone transport that addresses each of these limitations with excellent control of alignment including the transport segment, easy conversion to allow limb lengthening, and full weight bearing throughout the treatment process. In addition, the method facilitates multifocal transport and safe conversion to intramedullary nail fixation, both of which can be used to substantially shorten the time of reconstruction.

Definitive Management of Distal Tibia and Simple Plafond Fractures With Circular External Fixation.

Obtaining optimal results in the treatment of extraarticular distal tibia fractures can be challenging. Plate and screw and intramedullary fixation have proven to be effective treatments, but are associated with significant complication rates when used for open fractures and patient with severe medical comorbidities. External fixation is a third alternative that is less often employed, but provides a very effective means of treatment. Circular external fixation offers great flexibility in obtaining anatomic alignment and stable fixation for even the most challenging distal tibia fractures. In addition, it provides advantages in limiting the risk of deep infection, dealing with bone loss, and obtaining soft tissue coverage. The greater ease of treatment and potential economic advantage in patient cohorts with low complication rates, such as closed fractures, supports the preferential use of internal fixation. However, circular external fixation may be the preferred treatment for patients with higher-grade open fractures, a poor soft tissue envelope with limited fixation options distally, and major comorbidities (diabetes, immune deficiency) with an associated high risk of complications.