Bilateral distraction osteogenesis with intramedullary nails for stature increase. Our early experience

Title : Bilateral distraction osteogenesis with intramedullary nails for stature increase. Our early experience

Abstract:

Distraction osteogenesis is a therapeutic principle which has been known for more than six decades.  The introduction of elongating intramedullary nails in the last 20 years- initially in the form of mechanical nails (Albizzia® nail, g-nail®) and subsequently in the form of magnetically expanding nails (Precise®, Nuvasive®) - aimed to make the whole treatment process more comfortable and safer for the patient. Despite the initial enthusiasm,  it soon became apparent that there were limitations with the use of these devices. The ratcheting mechanism of the mechanical nails was sometimes too painful to activate and the magnetic nails developed lytic lesions in the bone which eventually led to the withdrawal of the magnetically lengthening implants from the market. Concurrently with, and despite, the above, these internal methods of bone lengthening increased the public interest  about its cosmetic applications, i.e. the cosmetic body stature increase in otherwise healthy individuals. Cosmetic orthopaedic surgery is a newly introduced, controversial concept in Orthopaedics and has already triggered ethical considerations. In this lecture we present our experience with the use of intramedullary nails  for bilateral lengthening in the femur and tibia for cosmetic stature increase. In the last 5 years, we have treated patients from all over the world. We currently have: 33 patients who were treated with bilateral femoral lengthening with magnetic nails (Precise® and Stryde®)  with more than 2 years minimum follow-up. 23 patients who were treated with bilateral femoral lengthening with mechanically expanding nails (G-nails®) with more than 1 year minimum follow-up and 14  patients who were treated with bilateral tibial lengthening with magnetic nails or external fixators, with more than 2 years follow-up. The following parameters were calculated for each patient and were analysed with descriptive statistics :
Percentage change of  haemoglobin pre-operatively and on the first and third postoperative day. 
Number of units of blood products that were transfused.
Visual analogue scale pain score postoperatively at regular intervals.
Range of movement of hip and knee pre-operatively and postoperatively at regular intervals.
Desired lengthening goal.
Lengthening index (cm/day).
Percentage success in reaching the set lengthening goal.
Disability Rate Index (DRI) pre-operatively and at 1 and 2 year post-operatively.
Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Dysphoria pre-operatively and at 1 and 2 year post-operatively.

Complications: In addition, in relation to the withdrawal of magnetic nails from the market due to their early biocompatibility issues,  we have collected and analysed specific radiological data from 36 patients with Stryde® nails.  We looked for signs of osteolysis, or periosteal reactions or combinations of these.

Based on our experience: All Stryde® nails (now banned from the market) should be monitored clinically and radiologically at regular intervals until implant removal. Implant removal is recommended  as early as possible after consolidation of the regenerate. Bilateral femoral lengthening with mechanically expanding nails is an efficient and safe procedure, allowing full weight bearing mobilization from the day of surgery. Close monitoring of the bone healing response, daily home support and increased patient’s commitment and compliance are required during the first three weeks of the lengthening period. Implant related symptoms and bone lesions may influence a patient's functional outcome. Patient compliance and management of their expectations is crucial for a successful outcome.

Biography:

Mr Dimitrios Giotikas is a leading consultant surgeon in trauma and orthopaedics based in London, UK and Athens, Greece. He specialises in limb lengthening, management of bone infections, nonunions and limb deformities alongside knee surgery, complex orthopaedic trauma and stature increase treatment. In the UK, he privately practises at 10 Harley Street (Consulting Rooms) and Woodlands Surgery from 2012 until 2019 He worked full time for the NHS in some of the most prestigious  NHS trusts like Cambridge University Hospitals NHS Foundation Trust, Oxford University Hospitals NHS Foundation Trust and Brighton & Sussex University Hospitals NHS Foundation Trust. Until 2020 he kept an honorary consultant post with Brighton & Sussex University Hospitals NHS Foundation Trust for clinical research. He is highly qualified. He graduated from the Military Medical Academy of the Greek Army and from the Medical School of Aristotelian University of Thessaloniki in Greece, beginning his career as a medical officer in the Hellenic Army. He was deployed in the war zone of Afghanistan and has served as commanding officer of medical units of the Marine special forces of the Greek Army. He then went onto specialise in trauma and orthopaedic surgery, qualifying in 2008, and then began his subspecialisation training in complex trauma and limb reconstruction at Cambridge University Hospitals NHS Foundation Trust. In 2013, Mr Giotikas obtained prestigious membership of the Hellenic College of Trauma & Orthopaedic Surgeons, and three years later in 2016 he was awarded a PhD from the Medical School of University of Thessaly, Greece. His research into minimally-invasive techniques in total knee replacement. His PhD paper has received hundreds of citations. He is also a respected name in medical education, and in 2017 he was appointed as an honorary senior clinical lecturer at the Faculty of Medical Science at Anglia Ruskin University in Cambridge. From 2014 until 2018 he was a tutor at Medical School of Cambridge University. He has also been a tutor for international specialty training trauma courses in Yangon, Myanmar. Further to his published PhD research, Mr Giotikas' work has been published in various peer reviewed journals and he is a member of various professional bodies. These include the British Orthopaedic Association, British Medical Association, British Limb Reconstruction Society, Hellenic College of Orthopaedic Surgeons, the Hellenic Association of Orthopaedic Surgery and Traumatology and AO Trauma International. He is also registered with the General Medical Council since 2011 and has been revalidated most recently in 2021.