what-when-how
In Depth Tutorials and Information
FIGURE 47.3
Well-positioned telescopic intramedullary rod in
femur, anchored in the greater trochanter proximally and the distal
femoral epiphysis distally.
FIGURE 47.4
Fractures may occur with rods in position necessi-
tating rod revision.
high complication rates when used in OI patients.
6
Patients with metaphyseal and epiphyseal deformi-
ties may still need plate and screw stabilization, some-
times augmented by intramedullary rodding. Ideally,
surgical management attempts to maximize the func-
tion by anatomically aligning bones and joints, thus
assisting the healing or prevention of fractures in grow-
ing children. The complication rates from rodding the
long bones, however, remain high, with rod failures as
high as 60% in 2 years. Despite excellent rodding and
medical management, children with OI may continue
to fracture. This may be related to the underlying dis-
ease or may be related to increased activity levels by
the patients (
Figure 47.4
). In a study of 72 patients with
OI, one-third of all patients went on to fracture within
5 years of surgical treatment.
1
Surgeons need to plan
interventions that take into account the need for fur-
ther surgery, and set appropriate patient and parental
expectations that despite the best treatment protocols,
fractures and deformity remain an unsolved problem in
OI patients.
incisions were required to perform this procedure, and
multiple osteotomies increased the possibility of non-
union at multiple sites.
8
Over time both the manage-
ment of the bone and the designs of the rods changed.
As an increased understanding of the importance of soft
tissue attachments to bone occurred in studies of bone
healing, minimally invasive techniques for osteotomies
and internal fixation of fractures and osteotomies devel-
oped. Preservation of the soft tissue attachments and
thus blood supply to the bone has led to early healing
and few complications in reported series.
1,3,5,9,10
In terms
of the bone, fewer osteotomies placed as close as pos-
sible to the actual site of deformity replaced the wide
excision, multiple osteotomy technique. Better cosmesis
was attainable from avoiding extensile approaches, but
the issue of bone healing remains challenging, particu-
larly in the tibia.
11,12
Restoration of a normal mechani-
cal axis of the long bone is the appropriate surgical goal,
with placement of the intramedullary rod centrally in
the intramedullary canal, metaphysis and in the epiphy-
sis of the distal femur and distal tibia whenever pos-
sible. Failure to correct the anatomical axis of the long
bones, and non-central placement of the intramedul-
lary fixation, is believed to increase the risk of refracture
and failure of the rods to telescope. The surgeon is often
faced with a decision to accept an off-center position of
the rod or rod tip, or to proceed with another osteotomy
to allow centralization. In general, more osteotomies
and a central position are preferred, although this is an
Rodding Technique Evolution
Historically, the shishkabob technique was popular-
ized for treatment of OI by Sofield.7
7
Using an extensile
approach to the limb, the bone was widely dissected
and removed to be osteotomized into many segments
outside of the body. The small bone pieces were strung
on a rod and placed back into the surgical bed. Large
