what-when-how
In Depth Tutorials and Information
(A)
(B)
(C)
FIGURE 46.5
(A) A femur fracture in a patient with type III OI. (B) The fracture is treated by multiple osteotomy and stabilization using a
Rush rod. (C) With subsequent growth, the nail migrates through the anterior cortex and deformity occurs distal to the implant.
in treating deformity, reducing the number of frac-
tures and increasing the interval between revision
surgeries.
60,79,87
In an attempt to eliminate the problems associ-
ated with loosening and disengagement of the T-piece,
Wilkinson et al.
63
introduced a modified telescopic
implant, the Sheffield rod, which had a larger and fixed
T-piece on the sleeve portion of the rod. In a recent
retrospective study, Nicolaou et al.
89
reported excel-
lent long-term functional outcomes using the Sheffield
device. At a mean age of 24.7 years at the time of latest
follow-up, all of their patients were satisfied with the
results of the procedure. Insertion of the rods through
arthrotomies at the knee and ankle was not associated
with high morbidity or symptoms, although symptoms
related to the trochanteric entry were fairly common.
Due to concern about the need to perform an exten-
sive arthrotomy to insert a telescoping nail in the tibia,
and to avoid joint damage during revision surgery, Cho
et al.
90
described an interlocking telescopic nail sys-
tem that avoids the need to violate the distal joint. The
device uses a hollow sleeve component similar to that
used in the Sheffield device, but the obturator compo-
nent has a hole at its distal tip to receive an interlock-
ing pin (
Figure 46.7
). The pin has a threaded tip to
minimize the risk of backing out. The authors noted
this device to be easier to insert and remove compared
to the other conventional extensible nails with a T-piece
anchor.
Fassier and Duval introduced a new telescopic
implant in which the end of each component is
threaded to allow screw-type fixation at both ends
of the bone (
Figure 46.7
). When placed in the femur,
the nail obviates the need for arthrotomy of the knee
(
Figure 46.8
); when used in the tibia, it eliminates the
need for arthrotomy of the ankle. Birke et al.
91
recently
retrospectively reviewed the result of 15 consecutive
Fassier-Duval roddings in nine patients with OI fol-
lowed for a minimum of 1 year. After a relatively short
follow-up, the authors noted no complications in nine
of the roddings, while four implants had migrated,
three of which did not telescope.
FIGURE 46.6
Deformity of the femur is corrected by multiple
osteotomy and stabilization with a Bailey-Dubow nail. As the bone
grows, the nail elongates.
time, the patients would outgrow the implant, allowing
angulation or fracture to occur at levels of unsupported
bone (
Figure 46.5
). The time between insertion and
replacement of the nail averaged between 2 and 3 years
in most series.
60,65,74-80
In an attempt to increase the time between revision
surgeries, Bailey and Dubow
81
introduced an exten-
sible intramedullary device. The original implant con-
sisted of an outer tubular sleeve and an inner obturator
that telescoped together. At the outer end of each com-
ponent was a small T-shaped piece that was seated in
the epiphysis. The T-piece at the end of the sleeve por-
tion could be unscrewed and replaced with a drill
bit to facilitate insertion. The nail was designed with
the intention that it could elongate as the child grew
(
Figure 46.6
).
Although early clinical studies reported a low com-
plication rate and generally favorable outcome with
the Bailey-Dubow nail,
79,82
later reports suggested
higher complication rates most often related to proxi-
mal migration of the implant and detachment of the
T-piece.
60-62,75,80,83-88
Despite these problems, many
investigators concluded that the Bailey-Dubow tech-
nique represented an improvement over solid nails
