How should we lengthen post-traumatic limb defects? a systematic review and comparison of motorized lengthening systems, combined internal and external fixation and external fixation alone

PurposeVarious external fixation systems for lower extremity long bone deformities have been used to various degrees of success, while newer mechanical lengthening nail (MLN) systems offer the potential for improved patient outcomes. Proponents of MLNs argue that they reduce the number of operations, infectious complications, and improve quality of life; however, the evidence to support these claims is scant. This systematic review aims to evaluate the optimal lengthening system for treating post-traumatic long bone deformity.MethodsThe systematic review was conducted in accordance with PRISMA guidelines. PUBMED, EMBASE, CINAHL, and the Cochrane Library were searched for comparative studies of lengthening techniques among adult patients with axial deformities. Studies were screened and data extracted in duplicate. Treatment groups were pooled into external fixation (EF) alone, combined internal and external fixation (CIF), and mechanical lengthening nail (MLN). Outcomes were mean lengthening achieved, lengthening index, and reported complications.ResultsThirteen studies with 725 patients (mean age: 29.6 years, 74% male) were included. Nearly all of the studies were either prospective or retrospective cohort studies (n=12), with one randomized controlled trial of moderate study quality. The mean limb lengthening achieved, lengthening index, and rate of reoperation were similar among the MLN, EF, and CIF groups.ConclusionThe purported decreased the duration of lengthening and the risk of reoperation associated with MLNs was not demonstrated in this review. Patients with post-traumatic leg length deformities remain a challenging patient population to treat, with intervention being associated with high rates of infectious complications and need for revision operations.