Fig. 1 The reverse rule of thumbs method for planning blocking screw placement in deformity correction with intramedullary nailing.
Source: Dabash S, Zhang DT, Rozbruch SR, et al: Blocking screw-assisted intramedullary nailing using the reverse-rule-of-thumbs for limb lengthening and deformity correction. 2019;14(2):77-84. Available through the Creative Commons Attribution 4.0 International License (


Published 12/31/2023
Mani Kahn, MD, MPH; Paul Matuszewski, MD; Stephen Quinnan, MD

Nailed It: Post-Traumatic Deformity Correction Using Intramedullary Nails Is Gaining Popularity

Life after severe traumatic limb injury can be dramatically and permanently affected, even when adherence to modern principles and interventions can successfully achieve soft-tissue coverage and fracture union. When major complications are encountered, the physical, mental, and financial burdens carried by patients can be magnified. As Mackenzie and Bosse et al. revealed with the Lower Extremity Assessment Project, patients presenting with limb-threatening injuries are more impacted by their preinjury economic, social, and psychologic factors than initial treatment decisions. Those who suffer trauma and postinjury complications represent a subset of patients who may encounter further challenges receiving much-needed care.

One such complication after long-bone fracture is persistent deformity. If it is left unaddressed, functional compromise and progressive arthritis of adjacent joints can be debilitating. Ring fixators have been used for decades to address diaphyseal and metaphyseal fractures that develop persistent angular, translational, axial, and/or rotational deformities. Gavriil Ilizarov was the first to describe an entirely new behavior of bone he discovered in the 1950s in Kurgan, Russia.

Utilizing the tension stress effect, distraction osteogenesis is employed with a low heat corticotomy and gradual realignment using ring fixators, stabilizing proximal and distal bone segments. This process forms new bone, or “regenerate,” between the distracted fragments as it realigns the segments. This can be done with hinges and geometric calculations by the surgeon or with struts arranged in a hexapod arrangement, which takes advantage of a computer program that allows surgeons to define deformity parameters and a correction protocol patients can use to guide their treatment course.

However, patients can have challenges accessing surgeons who are trained at treating deformity, and those at risk for complications after trauma due to pre-injury and societal factors may be deemed poor candidates for this lengthy and challenging process—sometimes for good reason, as it is well understood that ring fixators impose a psychologic burden. The treatment course can be lengthy, be painful, and require serial in-person physician visits, and it often comes with reoperations and rehospitalizations related to pin-site infections, premature consolidation, treatment failure, and patient compliance issues. Even if successful in completing the deformity correction portion of treatment, consolidation can take months, and patients are limited in returning to function as they wear their ring fixators as literal and figurative anchors. Once the fixator does come off, the risk of regenerate fracture and infection persists, as do the unseen scars of the limb-realignment process.

To mitigate the associated challenges of external fixators, the use of intramedullary nailing in place of or in conjunction with other methods is gaining popularity. The treatment of malunited fractures with intramedullary fixation historically has had limitations that made it less frequently used for these indications. Advances in hardware design, methods of realignment, technologies that allow the use of complementary antibiotics, and osteo-tomy techniques have helped deformity and trauma specialists overcome these limitations.

Intramedullary nails are typically less invasive and allow for avoiding wide exposure through sometimes tenuous soft-tissue envelopes in the post-traumatic deformity patient. They are thought to be biologically friendly, and this can have implications on osteotomy healing. They have the biomechanical advantage of being a load-sharing device that is in line with the anatomic axis of long bones, which can allow earlier weight bearing. With the advancement in nail design with increased proximal and distal interlocking options, polyaxial interlocking options, and fixed-angle interlocking screws, improved stability of short-bone segments can make this an acceptable fixation alternative in some deformity patterns, when historically this would not have been available as a treatment alternative.

As popularized by Rozbruch et al., using blocking screws and intraoperative external fixators can aid with intraoperative deformity correction planning and implementation (Fig. 1). With this technique, blocking screws are left in place for added biomechanical stability, and external fixators are removed. Hence, a treatment course where patient experience was previously centered on the burdens associated with managing external fixators can transition into a silent weapon that the patient never sees.

Osteotomy planning and implementation can be just as, if not more, important than implant selection. For acute deformity correction, opening wedge, closing wedge, neutral wedge, and dome osteotomies have traditionally been used. As described by Tetsworth and colleagues, the use of 3D-printed models can aid surgeons with acute deformity correction and planning. 3D imaging and printing have also aided in the development of cutting guides and even truss cages stabilized by intramedullary nails to manage deformities with bone defects. The clamshell osteotomy described by Purcell et al. is a powerful tool in managing complex deformities in diaphyseal bone by bypassing complex deformity with an open but biologically friendly approach. Quinnan et al. described a percutaneous wedge osteotomy where a wedge is created, but instead of being removed, it is fragmented with a series of percutaneously placed drill bits and osteotomes and left in place as autograft after realignment.

Despite the numerous technological advances, there can be a multitude of reasons why gradual deformity correction with a ring fixator has remained the treatment of choice. For example, acute deformity correction can put soft tissues and vital structures at risk for traction-related injuries. Other examples are the presence or history of infection or the need for angular deformity correction and lengthening. There are technologies available to utilize intramedullary nailing in these scenarios, though it remains a topic of active clinical investigation.

One method to still take advantage of the benefits of intramedullary nailing in these situations is to complete a deformity correction gradually with a ring fixator and then convert to intramedullary nailing. This has been permitted by combining techniques of extramedullary pin and wire fixation and nailing jigs that are designed specifically to accommodate ring fixators, plus utilizing intramedullary debridement with a reamer irrigator aspirator and protecting implants from infection with antibiotic cement-coated nails. The latter two techniques also allow attempted single-stage treatment of infection and deformity with intramedullary nails.

The ability to forego the ring fixator in the context of limb-length discrepancy is now possible with the advent of internal lengthening nails. As described by Rozbruch et al., internal lengthening nails can be placed at separate sites or at the same site as a deformity correction so that realignment and lengthening can be achieved with internal hardware. Combining the above technologies and techniques is often necessary to push the boundaries of post-traumatic deformity correction.

In conclusion, due to recent advances in technology and technique, intramedullary fixation can be leveraged in a previously unachievable manner to provide the most powerful option for treatment of many malunited diaphyseal and metaphyseal fractures in a patient-centered fashion that can help meet the complex needs of a vulnerable subset of patients. Future advances in this technique will likely offer further patient-centered advantages. The hope of this article is to promote interdisciplinary approaches to further advance the science of deformity correction.

Mani Kahn, MD, MPH, is an assistant professor, chief of the orthopaedic trauma division, and orthopaedic surgery residency program director at Albert Einstein College of Medicine in Bronx, New York. He specializes in trauma and limb deformity at Montefiore Medical Center in the Bronx. Dr. Kahn serves on the executive board of the Limb Lengthening and Reconstruction Society.

Paul E. Matuszewski, MD, is an associate professor of orthopaedic traumatology and chief of the orthopaedic trauma service at the University of Kentucky. In addition to trauma, he specializes in limb lengthening, deformity correction, and the treatment of osteomyelitis. He serves as an executive board member of the Limb Lengthening and Reconstruction Society.

Stephen Quinnan, MD, is a clinical professor of surgery at Florida Atlantic University and serves as both chief of orthopaedic trauma and head of the Amputee Optimization Program at the Paley Orthopedic and Spine Institute at St. Mary’s Medical Center in West Palm Beach, Florida. He is also director of orthopaedic research and education at St. Mary’s. Dr. Quinnan currently serves as the president of the Limb Lengthening and Reconstruction Society.


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