Multicentre Review of Intramedullary Lengthening Nails: A Middle-Income Country Perspective

Background: Lengthening nails (ILN) are an established method of limb reconstruction for leg length discrepancy (LLD). Literature on these nails is predominantly from developed countries, with more accessible resources for the procurement of devices and post-operative therapies. This paper aims to present the results and lessons learned from four tertiary level limb reconstruction units working within two middle-income countries (MIC). Methods: Ethical approval was obtained from all four units. All ILN (PRECICE II, NuVasive, USA) undertaken between 2013 and 2020 were included. Demographics, etiology, surgical approach, and information about the planned versus achieved correction were compared. Data on time to consolidation and complications were recorded with a 12-month minimum follow-up. Complications were classified according to the Black et al. criteria. Results: Sixty limb segments lengthened in 56 patients, of which 46 were femora, 12 tibiae and two humeri. Etiology of LLD was predominately posttraumatic (33%), congenital (26%), and growth plate injuries (22%). Mean distraction length was 46 mm (20-90 mm). Fifty-four segments (90%) had <5 mm discrepancy of planned distraction lengths. Mean healing index was 34.6 days/cm (range: 18-180 days/cm). Thirteen patients experienced complications, of which ten required further surgery. Conclusion: The findings of our work support the use of intramedullary ILN in MIC with equivalent complication rates and healing indices compared to the literature. Patient compliance and remote geography were not an issue during treatment. The lack of access to weekly rehabilitation therapy did not seem to impact the majority of patients. Reusing nails for extensive LLD cases were safe but should be used with caution.