Philip Kraus McClure

Background: Effective postoperative pain management is essential in femoral limb lengthening surgery. Although regional nerve blocks reduce pain and opioid use, their benefit in antegrade femoral intramedullary limb lengthening is unclear. This study compares postoperative pain and opioid consumption in patients receiving general anesthesia (GA) alone versus GA with a preoperative femoral or fascia iliaca nerve block. Methods: A retrospective review included 192 patients who underwent femoral lengthening with intramedullary telescoping nails between January 2012 and October 2023 at a single center. Patients were categorized into Group A (GA alone, n = 131) and Group B (GA plus nerve block, n = 61). Primary outcomes were postoperative mean and maximum pain scores in the first 24 h, total opioid pills prescribed at discharge, and total morphine milligram equivalents (MMEs) used in the Post-Anesthesia Care Unit (PACU). Non-inferiority was defined by a margin of one standard deviation for pain scores and opioid usage. Results: Demographics were similar between groups. Maximum PACU pain scores were 3.8 for Group A and 3.3 for Group B (p > 0.05); mean pain scores were 2.1 and 1.9, respectively (p > 0.05). GA alone was non-inferior for pain control. However, total opioid pills prescribed at discharge were higher in Group A (23.2) than Group B (10) (p < 0.05). PACU MME usage was also higher in Group A (26 vs. 18.4 ± 15 mg, p < 0.05), though non-inferiority criteria were met. Conclusions: GA alone is non-inferior to GA with nerve block for postoperative pain management following antegrade femoral intramedullary limb lengthening. Although patients without a nerve block received more opioids at discharge, their pain control remained similarly effective. Given potential risks and the lack of clear pain reduction benefits, routine nerve block use may not be warranted. Decisions regarding nerve block application should be individualized, considering patient preferences, surgeon recommendations, and anesthesiologist input.

» NF1 Link and Pathophysiology: Congenital pseudarthrosis of the tibia (CPT) is strongly associated with neurofibromatosis type 1 (NF1), where loss of normal NF1 gene function impairs bone formation and promotes fibrous hamartoma, resulting in recurrent tibial nonunion. » Classifications and Diagnostics: Multiple radiographic classifications (Andersen, Crawford, Boyd, Paley, etc.) guide clinical decision making, while newer imaging (magnetic resonance imaging, quantitative ultrasound) refines diagnosis and helps tailor interventions. » Treatment Modalities: Strategies range from nonoperative bracing (prefracture) to surgical approaches such as intramedullary rods (standard or telescopic), free vascularized fibular grafts, ring fixators (Ilizarov), and “cross-union” procedures—often combined with pharmacologic agents such as bone morphogenetic proteins (BMPs) or bisphosphonates. » Mixed Results With Pharmacologics: While rhBMP and bisphosphonates address bone catabolism and anabolism, neither agent alone has consistently succeeded in NF1-related CPT; combination regimens may offer better outcomes but require more robust research. » Future Directions: Ongoing studies explore early surgery (vs. waiting until age 2-3) and guided growth to address tibial bowing, molecular therapies (e.g., MAPK kinase and Src homology 2 containing protein tyrosine phosphatase 2 inhibitors), and refined fixation techniques. The management of CPT continues to evolve as genetic and cellular mechanisms become clearer.

Background: Recently, limb lengthening devices have shifted from external fixators to telescoping magnetic intramedullary lengthening nails (MILNs), which lengthen strictly along the bone's anatomic axis. Baumgart proposed the reverse planning method, overcorrecting lateral shift with a distal osteotomy and slight varus angulation. The untested assumption that antegrade lengthening along the anatomic axis causes lateral mechanical axis deviation (MAD) prompted our study, which examines MILNs' effect on lower limb alignment. Methods: We retrospectively evaluated records for 154 femoral antegrade MILNs inserted in 122 adult patients for limb lengthening. We excluded patients who underwent concomitant corrective osteotomies or tibial lengthening, or who had malunion, nonunion, mechanical failure, or revision surgery for any reason. Long-leg standing radiographs were taken preoperatively, at the end of lengthening, around 3 months postoperatively, and at the culmination of consolidation (approximately 6 months postoperatively). MAD and anatomic mechanical angle (AMA) were assessed as primary outcomes at each radiographic time point for sequential comparison. The predicted MAD was derived from the trigonometric formula (Predicted MAD = lengthening × sin [AMA]). Results: Average preoperative MAD was 2.4 mm medial (SD = 10.6), diminishing to 1.9 mm medial (SD = 13.2) by the end of lengthening. On assessment at consolidation, average MAD had equilibrated back to 2.6 mm medial. Our results showed a net shift of 0.18 mm, whereas the predicted shift was 5.4 mm. The mean preoperative AMA was 5.9 mm (SD = 1.49). At the end of lengthening, the average AMA had decreased to 4.8 mm (SD = 1.4). Conclusion: Our data indicated minimal to no impact on the mechanical axis or joint alignment of the lower limb after antegrade lengthening using a telescoping femoral MILN in a deformity-free femur. Study results suggested that the femur typically realigned in a way that minimized mechanical deviation while preserving joint alignment. Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Magnetic intramedullary lengthening nails (MILNs) have become an increasingly popular method for long-bone distraction osteogenesis as a means of overcoming the limitations of bone lengthening with an external fixator. While factors such as nail diameter, alignment, and other mechanical characteristics have been associated with an increased risk of nail breakage, the relationship between the percentage of maximum lengthening utilized and nail breakage remains unexplored. We specifically assessed overall complications, with and without the inclusion of contractures, based on the amount of distraction (25% to 60%, 61% to 90%, and 91% to 100% of maximum). Methods: We retrospectively reviewed the records for 176 pediatric patients and 109 adult patients who had undergone limb lengthening and had ≥24 months of follow-up. The cohort was further stratified by the amount of distraction: 25% to 60% (n = 75 children and 30 adults), 61% to 90% (n = 72 children and 29 adults), and 91% to 100% (n = 29 children and 50 adults). The mean ages were 14.53, 13.53, and 12.49 years, respectively, in the pediatric cohorts and 27.1, 34.3, and 23.8 years, respectively, in the adult cohorts. The percentages of males and females were 48% vs. 52%, 54.2% vs. 45.8%, and 48.3% vs 51.7%, respectively, in the pediatric cohorts and 56.7% vs. 43.3%, 51.8% vs. 48.2%, and 58% vs. 42% in the adult cohorts. Complications included contractures, loss of length, bone fracture, axial deviation, nail failure, failure to lengthen, nail fracture/failure, and screw failure. Analysis of variance (ANOVA) was conducted to compare mean complications across the 3 distraction categories, and Tukey pairwise t tests were performed to compare mean complications between individual distraction categories. Results: Without contractures, complication rates were similar between the pediatric cohorts (p = 0.09): 4.0% (25% to 60% distraction), 13.9% (61% to 90% distraction), and 6.9% (91% to 100% distraction). With contractures included, complication rates were greatest in the 61% to 90% pediatric cohort (38.9%), followed by the 91% to 100% cohort (27.6%) and the 25% to 60% cohort (13.3%) (p = 0.002). Similarly, the adult population had a homogeneous rate of complications without the inclusion of contractures (p = 0.13). Likewise, we observed a similarly variable distribution with contractures considered, with the greatest frequency in the 91% to 100% group (36%), followed by the 61% to 90% group (31%) and the 25% to 60% group (10%) (p = 0.04). Conclusions: This is the first study to explore the relationship between the percentage of nail lengthening and nail complications. The speculation that full extension of the nail could lead to increased nail bending or breakage was not consistent with our findings. This finding was consistent whether contractures were included or not. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: There has been historical concern that the use of intramedullary nails could present undue risk of osteonecrosis of the femoral head due to compromise of the femoral blood supply. Intramedullary lengthening nails are rapidly becoming commonplace in lengthening procedures. As such, the primary objective of this study was to analyze the rates of osteonecrosis following femoral lengthening. The secondary objective was to characterize general trends in femoral lengthening. Methods: This retrospective cohort study evaluated patients who had undergone femoral lengthening at a single institution from 2012 to 2021. Retrospective chart review and radiographic evaluation of osteonecrosis were conducted. The primary end point was radiographic evidence of osteonecrosis. The secondary variables were the starting point of the femoral nail, the total amount of lengthening, and the time to consolidation. Results: Two hundred and forty-seven patients were included in the analysis, including 111 males and 136 females, with a mean age of 17 years. No patient had radiographic evidence of osteonecrosis (0%) or coxa valga (0%). The average amount of lengthening was 4.88 cm (range, 1.5 to 8.5 cm). No patient had any extensive complications, such as alterations in the proximal femoral anatomy. Conclusions: This largest study to date investigating complications following femoral lengthening using intramedullary lengthening nails revealed that femoral lengthening is a well-tolerated procedure, and osteonecrosis is an infrequent complication. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose Previous studies have shown that subtrochanteric femoral fractures treated with intramedullary nails might lead to varus-procurvatum malalignment. Similar results have been reported when using antegrade intramedullary lengthening nails (ILNs). The purpose of our study is to examine if antegrade telescoping intramedullary lengthening nails lead to varus-procurvatum malalignment of the proximal femur and what are possible predictors of that shift. Methods In this retrospective, single centre study, five surgeons performed 537 femoral ILN. 347 antegrade PRECICE nails were selected after applying exclusion criteria. The following exclusion criteria were applied, intentional angular deformity correction, retrograde femoral lengthening and concomitant tibial lengthening. After further exclusion criteria were applied, we retrospectively inspected 201 PRECICE nails inserted in 158 paediatric and adult patients (average age 19.9 years) that underwent IM nail limb lengthening. Follow-up was at least one year by which time all osteotomies were healed. Results Mean lengthening was 4.7 cm per lengthening surgery with some patients needing multiple lengthening for large discrepancies. Of the 201 nails, trochanteric entry was used in 127 procedures and piriformis entry was used in 74 of them. With pre-op Osteotomy Level Coefficient (OLC) of 0.3. The preoperative neck shaft angle (NSA) was significantly reduced from 130.6 to 127.4 degrees at the end of lengthening (P < 0.05). There was no discernible correlation between the OLC and change in NSA. The trochanteric entry point was associated with a greater tendency to reduce the NSA (Mdif = -4.1, SD = 6.5) as compared to the piriformis entry point (Mdif = -3, SD 6.4) (P < 0.05). No significant change in anatomic medial proximal femoral angle (aMPFA) was noted between pre- and postoperative time points, nor between trochanteric and piriformis entry groups. Conclusion Our study investigated the risk of iatrogenic varus deformity of the proximal femur following intramedullary limb lengthening procedures. We identified the osteotomy site as the most significant risk factor for developing iatrogenic varus, while the nail insertion point did not significantly predict this complication, showing comparable results for both trochanteric and piriformis entry points. Additionally, our study is the first to identify a correlation between the level of osteotomy and coxa-valga correction. We hypothesize that a higher osteotomy level might be beneficial for patients undergoing limb lengthening who also present with coxa-valga deformity. Level of evidence IV.

In the modern digital era, social media platforms, such as TikTok, have become significant sources of medical information for the general public. This study explores the content of TikTok videos related to cosmetic limb lengthening to understand the quality and accuracy of information shared. The 50 most-viewed English-language videos tagged with #Heightsurgery and #lengtheningsurgery on TikTok were analysed by two independent reviewers. The analysis covered creator demographics, video format, and predominant themes. Each video was also evaluated for medical accuracy and scored for clarity and actionability using the patient education materials assessment tool (PEMAT). The selected videos amassed 186.5 million views, 7.9 million ‘likes,’ 1,52,000 ‘shares,’ and 67,000 comments. Nearly half (47%) were produced by healthcare professionals (HCPs), with orthopaedic surgeons accounting for 70% of the HCP contributors (32.9% of total creators). Medically accurate content was found in 60% of all videos, with 80% of HCP videos featuring accurate information. Educational content dominated (72%), with the remainder being anecdotal (28%). Tone varied, with videos presenting either positive (50%), negative (32%), or neutral (18%) perspectives. Common themes included post-operative experiences (30%), medical education (15%), surgical techniques (12%), risks vs benefits (10%), and treatments for achondroplasia (10%). Concerns about pain, fear, permanent injury (24%), cost (10%), and a lack of understanding of procedures (10%) were also frequently mentioned. Notably, there was no focus on racial or socio-economic barriers in any of the videos. The average understandability and actionability scores, according to the PEMAT, were 67.5 and 67.15%, respectively. The widespread popularity of these videos underscores the growing role of social media in disseminating medical information. This analysis highlights the need for HCPs to leverage platforms like TikTok to provide accurate, reliable information and address common concerns, misconceptions, and fears surrounding cosmetic limb lengthening. Ramlawi AA, Sidani M, Missi C, et al. Accuracy and Actionability of TikTok Content on Cosmetic Limb Lengthening: A Comparison between Healthcare Professional and Non-professional Sources. Strategies Trauma Limb Reconstr 2025;20(2):90–93.

Background: Limb lengthening procedures are performed for various indications, including limb length discrepancies (LLDs) and short stature. This systematic review and meta-analysis compares the efficacy and safety of the newer motorized intramedullary lengthening nails (MILNs) with the traditional alternative techniques (ATs) for femoral limb lengthening. Methods: We conducted a comprehensive literature search in the Medline, Embase, Cochrane, Web of Science, and Scopus databases, inclusive of all dates through July 1, 2023, and without language restrictions. Factors mediating outcomes included problems, obstacles, complications, total adverse events, healing/consolidation index, time to full weight-bearing, lengthening accuracy, percentage of lengthening goal achieved, and duration of hospital stay. Effect sizes were quantified using STATA 17.0. Statistical algorithms employed were random effects model standardized mean differences (SMDs) for continuous outcomes and log risk ratios (RRs) for dichotomous outcomes, both with 95% confidence intervals (CIs). Results: Our meta-analysis included 10 studies comparing MILN with AT: 180 femurs in the MILN group and 160 femurs in the AT group. This was exclusively comprised of retrospective cohort studies. When compared with AT, limb lengthening procedures utilizing MILNs had significantly lower problems (log RR, −1.35; 95% CI, −1.93 to −0.77; p < 0.001), complications (log RR, −0.56; 95% CI, −0.90 to −0.22; p = 0.001), and total adverse events (log RR, −0.69; 95% CI, −1.17 to −0.21; p = 0.005), as well as a superior bone healing index (SMD, −0.80; 95% CI, −1.32 to −0.28; p = 0.003). However, no significant differences were found in obstacles, percentage of lengthening goal achieved, lengthening accuracy, time to full weight-bearing, and duration of hospital stay. Conclusion: Limb lengthening with MILNs vs. AT may offer more favorable patient outcomes, lowering risk for problems, complications, and total adverse events, while optimizing the bone healing/consolidation index. However, the limitation of nonrandomized retrospective studies and high heterogeneity should be acknowledged. Level of Evidence: Level II (meta-analysis of cohort studies). See Instructions for Authors for a complete description of levels of evidence.