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Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 93-95

Future directions in deformity correction

Senior Surgeon and Head of 3D-Surgery at University of Munich (Downtown Campus) and at Bethel Hospital Berlin, Germany

Date of Submission13-Nov-2020
Date of Acceptance13-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Peter H Thaller
MSc 3D-Chirurgie, Chirurgische Klinik Innenstadt, Nussbaumstrasse 20, D-80336 Munich
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-3719.305858

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How to cite this article:
Thaller PH. Future directions in deformity correction. J Limb Lengthen Reconstr 2020;6:93-5

How to cite this URL:
Thaller PH. Future directions in deformity correction. J Limb Lengthen Reconstr [serial online] 2020 [cited 2021 Jun 19];6:93-5. Available from: https://www.jlimblengthrecon.org/text.asp?2020/6/2/93/305858

Where do we come from, where do we go? The history of limb lengthening, reconstruction, and deformity correction gained momentum more than one hundred years ago in Europe and the USA. Circular frames and distraction osteogenesis have been practiced with more or less success when the most remarkable booster came from Kurgan/Russia with the work of Ilizarov in the 1950s: Those were methods of Ilizarov and their renown worldwide success not only for complex deformity correction but also for limb lengthening and reconstruction. Distraction osteogenesis has proved to be a reliable, powerful, and biological method of reconstruction. Other concepts for external fixation extended the armamentarium. In the late 1970s, another acceleration emerged by motorized, fully implantable systems for distraction osteogenesis – first in Munich with an electrically driven plate[1] and in the early 1980s in the former Russian Kiev, with a fully implantable ratchet-driven nail.[2] In the meantime, there was a coming and going of actuated nails with very few officially approved ones, some successful unapproved ones, and a variety of custom-made implants. The evolution of those actuators started with various ratchet-driven nails to again an electric-driven[3] to a magnetically actuated one[4] and finally to a magnet-driven nail enhanced by gearing.[5] Most of them are telescoping (for lengthening), and a few are slotted (for bone transport and lengthening). Parallel to this, in the mid-1990s, a new generation of ring fixators enriched the armamentarium of external fixation, based on a smart technical concept, the so-called Stewart platform. Most of these hexapod-driven systems have nowadays widely replaced the conventional ring fixation. Together with much further technical progress, these milestones had led to today's high level of proud surgeries.

I am honored by the invitation to highlight a few current developments, which I think might be worth watching. It is all about what we call 3D-Surgery, the surgery of bony defects, deformities, and discrepancies in lengthening. I will start with the issues in analysis and planning for surgeries, come to the aspects of intraoperative control, to current implants, techniques, and developments in progress to end with a few spaces to watch in reconstruction.

  Analysis and Planning Top

Most of us have participated in the good-old deformity planning courses related to the lower extremity: Based on two-dimensional (2D) radiographs and mainly to the technique of external fixation. For 2D radiographs, the gold standard for analysis and planning is still a long-standing bilateral radiograph with centered patellae combined with proper lateral views. In this setting, we add a low-dose torsional computed tomography (CT) scan only if torsional deformities are at stake.[6] Concerning this 2D analysis and planning, we already save much time by applying artificial intelligence or better called “algorithms” (because the term “intelligence” relates to more than any machine can deliver). Those algorithms need much programming and even more teaching, but once they run, they can calculate all our multiple values from the mechanical axis deviation to all the angles around the hip, knee, and ankle joint with high precision in a second – and the results are getting better and better with each case.[7]

Most of us remember the terms such as “center of rotation angulation” or the so-called “osteotomy rules”. Such terms mainly related to external fixation procedures lost their importance, since now at least in adults, up to 95% of our surgeries are performed with reliable and stable internal fixation methods such as intramedullary nails and plates. Now, the implants rule over the level of osteotomy and course of treatment. Now, meticulous planning becomes inevitable because making changes later in the alignment or in torsion/rotation becomes nearly impossible. It is crucial to anticipate the final result at the end of a realignment with or without detorsion, lengthening, or bone transport. Maybe that's why the simple, easy and comprehensive so-called End-Point-First (EPF) method is most appreciated in our annual international 3D-Surgery Courses.[8]

The least deformities prove to stick to the anterior–posterior and lateral views only, and 3D data sets are more and more available also with low radiation. Bi-planar low-dose radiography (like EOS) and cone-beam CTs are more and more available and might gain importance. Therefore, one of our research group's ongoing projects is defining normal values of alignment and angulations in those 3D data sets. Furthermore, already by now, we learn that 3D analysis and planning can provide a much faster and comprehensive understanding of the more complex deformities.[9]

  Intraoperative Control Top

It seems like the hype of navigated surgeries couldn't spread into the practice of limb lengthening and deformity correction. For about 20 years, the X-ray grid technique serves well with 4–5 c-arm shots, is time saving, and has good reliability.[10] The Cam-C project might help us even to reduce this minor amount of radiation in future. Cam-C is the combination of a c-arm and a video camera mounted to the c-arm, which shows the same field of view in real time via a radiolucent mirror. After matching one X-ray shot to the video camera, the video recognition software can take over and, for example, recognize changes in the position of the c-arm (e.g., hip, knee, and ankle) or navigate minor objects, for example, for navigated interlocking of intramedullary nails.[11]

  Techniques and Implants Top

To start with external fixation, it seems like hexapod ring fixators have widely replaced conventional ring fixation and the colinear wire for bone transport begins to replace pins or Schanz screws or double wires/cables.[12] Currently, the most exciting space to watch in external fixation is to apply transverse distraction, not for the growing bone but to improve the healing of more distal structures. There is a word I guess which was initiated by Ilizarov and later transformed which means “infection is burned by the fire of distraction osteogenesis”– in my personal experience, I would confirm and even extend the word to “healing is enhanced, and infection is burned by ….” The most promising results for transverse distraction have been published for diabetic foot syndrome[13] (you can find a link related to Fig. 5 in that paper for a video worth viewing).

Among fully implantable intramedullary lengthening systems, the magnetically driven nails have won the race. The current technology is magnetic actuation enhanced by gearings. This technique undoubtedly represents the current state of the art because there is no other officially approved implant that can provide patient-controlled action in both directions. Additionally, the miniaturization to nail diameters of 8.5 mm only and also fully weight bearable implants are remarkable. The latest magnet-driven, slotted bone transport nails celebrated the one hundredth clinical application a few months ago. New actuator technologies such as shape memory alloys are on the horizon. They might provide high distraction forces. Metin Kuccukaya implanted the first nail of the aforementioned magnet-driven lengthening nail. Currently he conducts a first clinical study on shape memory alloy: nitinol-driven nails. Minor issues to mention might be nailing techniques such as instruments for minimally invasive protection of joints, bones, and soft tissues.[14] Bending of nails for deformity correction or a better fit[15] also might be a new option, since formerly we only have bent plates.

Concerning plates, the last milestones occurred many years ago with various locking and polyaxial interlocking screws. Worth watching will be the magnetic technology transferred to lengthening plates for distraction osteogenesis. Since September 2020, still with limited availability, these implants will close the gap to smaller anatomy, compared to motorized nails.

For the reconstruction of defects, we all know a huge variety of more of less biologic alternatives such as grafting techniques and internal prostheses, but still distraction osteogenesis undoubtedly has the highest potential for later remodeling. In this context, fibula expansion might become a stable and time-saving option combining the potential of radial instead of longitudinal distraction osteogenesis with autografting and nailing.[16]

Moreover, finally, another space to watch is osseointegration, also called endo-exo prostheses. Sooner or later, we might experience a long and ambitious course of patient treatment with finally a hardly acceptable result or even amputated, but much too late. In our last international 3D-surgery course, Kevin Tetsworth gave a talk titled “Osseointegration: The Ultimate Post-traumatic Limb Reconstruction?” Having seen and talked to some of the Kevin's patients in Australia, I'm considering to shift the fine line of pushing the limits in limb salvage thoughtfully.

Now, to close, I'd be proud if I could provide an outlook of the 3D-Surgery view on the current trends of our beloved profession. My dear readers, I'm sure you will be able to add a lot more, and I would be glad for future exchange whenever, wherever.

Stay healthy!

Sincerely Yours!

  References Top

Witt AN, Jäger M, Bruns H, Küsswetter W, Hildebrandt JJ, Cramer R, et al. Operative lengthening of the femur with a fully Implantable distraction device. Arch Orth Traum Surg 1978;92:291-6.  Back to cited text no. 1
Bliskunov AI. [Intramedullary distraction of the femur (preliminary report)]. Ortop Travmatol Protez. 1983:59–62.  Back to cited text no. 2
Betz A, Baumgart R, Schweiberer L. First fully implantable intramedullary system for callus distraction Intramedullary nail with programmable drive for leg lengthening and segment displacement. Principles and initial clinical results. Chirurg 1990;61:605-9.  Back to cited text no. 3
Thaller PH, Fürmetz J, Wolf F, Eilers T, Mutschler W. Limb lengthening with fully implantable magnetically actuated mechanical nails (PHENIX(®))-Preliminary results. Injury 2014;45 Suppl 1:S60-5.  Back to cited text no. 4
Kirane YM, Fragomen AT, Rozbruch SR. Precision of the PRECICE® Internal Bone Lengthening Nail. Clinical Orthopaedics and Related Research®. 2014 Mar 28. Available from: http://link.springer.com/10.1007/s11999-014-3575-0. [Last accessed on 2014 Sep 01].  Back to cited text no. 5
Thaller PH, Baumgart R, Burghardt R, Knuellig S, Buerklein D, Mutschler W. Digital Imaging in Lower Limb Bone Deformities - Standards and New Perspectives. In: Elsevier International Congress Series 1281. 2005. p. 154-8.  Back to cited text no. 6
Goksu AF, Kopuklu O, Gursu HM, Thaller PH. Application of Artificial Intelligence in Lower Limb Deformity Analysis and Preoperative Planning. 4th Combined Congress of the ASAMI-BR & ILLRS. Liverpool 08/2019. Abstract/Podium: Available from: https://eventshake.app/asami_posters/. [Last accessed on 2020 Nov 20].  Back to cited text no. 7
Wolf F, Fuermetz J, Degen N, Thaller PH. End Point First (EPF): An Universal Method for Preoperative Planning in Deformity Correction Procedures. 4th Combined Congress of the ASAMI-BR & ILLRS. Liverpool 08/2019. Abstract/Podium: Available from: https://eventshake.app/asami_posters/. [Last accessed on 2020 Nov 20].  Back to cited text no. 8
Fürmetz J, Sass J, Ferreira T, Jalali J, Kovacs L, Mück F, et al. Three-dimensional assessment of lower limb alignment: Accuracy and reliability. Knee 2019;26:185-93.  Back to cited text no. 9
Chen F, Fuermetz J, Wolf F, Degen N, Böcker W, Thaller PH. Intraoperative Control of Lower Limb Alignment - Accuracy of the X-Ray Grid Method compared with a Long Standing Radiograph. 4th Combined Congress of the ASAMI-BR & ILLRS. Liverpool 08/2019. Abstract: Available from: https://eventshake.app/asami_posters/. [Last accessed on 2020 Nov 20].  Back to cited text no. 10
Diotte B, Fallavollita P, Wang L, Weidert S, Euler E, Thaller P, et al. Multi-modal intra-operative navigation during distal locking of intramedullary nails. IEEE Trans Med Imaging 2015;34:487-95.  Back to cited text no. 11
Thaller PH, Fuermetz J. Cable Technique with a Medial Monorail for Bone Transport and Extended Soft Tissue Access for Reconstruction of More Than 16 cm of Tibial Bone. In: Rozbruch SR, Hamdy R, editors. Limb Lengthening and Reconstruction Surgery Case Atlas. Cham: Springer International Publishing; 2014. p. 1-8. Available from: http://link.springer.com/10.1007/978-3-319-02767-8_294-1. [Last accessed on 2016 Mar 03].  Back to cited text no. 12
Chen Y, Kuang X, Zhou J, Zhen P, Zeng Z, Lin Z, et al. Proximal Tibial Cortex Transverse Distraction Facilitating Healing and Limb Salvage in Severe and Recalcitrant Diabetic Foot Ulcers. Clin. Orthop. Relat. Res. 2019.00:1-16. Available from: http://links.lww.com/CORR/A270. [Last accessed on 2020 Nov 20].  Back to cited text no. 13
Wolf F, Bösl S, Degen N, Fürmetz J, Thaller PH. Impacted Steel Sleeves for a minimally invasive approach in intramedullary nailing. Injury 2019;50 Suppl 3:4-10.  Back to cited text no. 14
Thaller PH, Fürmetz J, Degen N, Eilers T, Euler E, Wolf F. Intraoperative customization of intramedullary nails First results. Injury 2019;50 Suppl 3:11-6.  Back to cited text no. 15
Bachmeier A, Bader R, Militz M, Oehlbauer M, Schreiber U, Thaller PH. Reconstruction of Extensive Long Bone Defects by Radial Distraction Osteogenesis and Transplantation of the Enhanced Fibula. 4th Combined Congress of the ASAMI-BR & ILLRS. Liverpool 08/2019. Abstract: Available from: https://eventshake.app/asami_posters/.[Last accessed on 2020 Nov 20].  Back to cited text no. 16


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