External Fixation Index Research Articles

Tibial lengthening over an intramedullary nail in patients with short stature or leg-length discrepancy: a comparative study

The aim of this study was to review our experiences with tibial lengthening over an intramedullary nail in comparison to the conventional Ilizarov method. We performed a retrospective comparison of tibial lengthening using the conventional Ilizarov method (group A: 23 limbs in 13 patients) versus over a nail (group B: 51 limbs in 26 patients). The percentage increase in tibial length, lengthening index, external fixation index, consolidation index and complications were assessed. The mean gain in tibial length was 7.4 cm, which represents a mean increase of 26.0%. There was no difference in lengthening index or consolidation index; however, the patients in group A wore the external fixator longer than those in group B (281.5 versus 129.0 days), which represents a larger external fixation index (40.0 versus 17.4 day/cm). Group A had a higher complication rate (1.0 versus 0.47 per tibia) than group B. Tibial lengthening over an intramedullary nail confers advantages over the conventional Ilizarov method, including shorter time needed for external fixation and lower complication rates.

Complications and outcome of tibial lengthening using the Ilizarov method with or without a supplementary intramedullary nail

We compared the complications and outcome of tibial lengthening using the Ilizarov method with and without the use of a supplementary intramedullary nail. In a retrospective case-matched series assembled from 176 patients with tibial lengthening, we matched 52 patients (26 pairs, group A with nail and group B without) according to the following criteria in order of importance: 1) difference in amount of lengthening (± 2 cm); 2) percentage difference in lengthening (± 5%); 3) difference in patient's age (± seven years); 4) aetiology of the shortening, and 5) level of difficulty in obtaining the correction. The outcome was evaluated using the external fixator index, the healing index and an outcome score according to the criteria of Paley. It was found that some complications were specific to group A or B respectively, but others were common to both groups. The outcome was generally better in lengthenings with a nail, although there was a higher incidence of rectifiable equinus deformity in these patients.

Enhancing bone healing during distraction osteogenesis with platelet-rich plasma

Gradual limb lengthening with external fixators using distraction osteogenesis principles is the gold standard for treatment of limb-length discrepancy. However, long treatment time is a major disadvantage of the current lengthening procedures. Efforts to decrease the treatment include biological and biomechanical factors. Injection of platelet-rich plasma (PRP) is a biological method to enhance bone healing during distraction osteogenesis. We hypothesised that PRP can enhance bone healing during limb lengthening. We report our experience with the use of PRP during distraction osteogenesis. This retrospective study included 19 patients divided into the standard group of 10 patients who did not receive PRP and the PRP group of nine patients who received PRP at the end of the distraction phase. The study variables included external fixator time, external fixation index, and complications during treatment. The PRP group had statistically significantly shorter treatment time (p=0.0412). Injection of PRP into regenerate bone might be an effective method to shorten treatment time during limb lengthening and lead to better functional outcomes and improved patient satisfaction.Level of evidence: Level IV, therapeutic study.

Callus patterns in femoral lengthening over an intramedullary nail

Our objectives were to evaluate callus patterns seen in femoral lengthening over an intramedullary nail by Li classification regarding shape and type and to predict the result while using the nail to reduce the external fixation period and its complications. Eight hundred digital radiographs of 15 patients with 15 segments of femur shortening who underwent femoral lengthening with a monolateral external fixator over an intramedullary nail were analyzed retrospectively by four observers. Each radiograph was studied for callus shape, feature type, and callus density using pixel values. The classification was tested for concurrence and reproducibility by interobserver studies and callus patterns were compared with treatment indices to evaluate how they correlated with the outcome. Mean length gained was 4.5 cm (range: 2-8 cm). External fixator index (EFI) was 21.68 days/cm. Average distraction consolidation index (DCI) was 48.49 days/cm. Fusiform callus was seen in three cases, cylindrical in seven, and lateral in five. The homogenous pathway had higher DCI (43.7) than the heterogeneous pathway (32.9), and mixed pathways making up the rest had a DCI of 50.1. Pixel value of callus showed gradual increase in density until 20-24 weeks, then density gradually fell for 8 weeks, again increased after 32 weeks, again gradually fell, and was comparable to adjacent normal bone by 44-48 weeks. Our results suggest that the Li classification can be satisfactorily applied to lengthening procedures over intramedullary nails. The radiologic pattern and pixel value of regenerate can be correlated with the clinical outcome and can be an aid of prognostic value for the surgeon.

Hemicallotasis for correction of varus deformity of the proximal tibia using a unilateral external fixator

BackgroundGradual correction of varus deformity of the proximal tibia is generally accepted and produces good results. However, most studies have used circular external fixators, which are complex and cause patient discomfort. This study was undertaken to determine the efficacy of hemicallotasis with a unilateral external fixator for correction of varus deformity of the proximal tibia. MethodsThirteen patients (21 legs, 8 bilateral) were included in this study: 6 with constitutional bowing, 3 with a malunion, 2 with Blount's disease, and 2 with Turner syndrome. There were 7 males and 6 females of mean age 21 years (range 13–40). With an oblique osteotomy on the proximal tibia, a unilateral external fixator was placed on the medial side. Using a distraction of 1 mm/day, the external fixator was removed after consolidation of the callus. ResultsSurgery corrected medial proximal tibia angle from a preoperative average of 75.1° (64°–81°) to 88.6° (86°–90°) at final follow-up. Average tibiofemoral angle improved from −7° to 6.8°. The duration of external fixation averaged 101.3 days and the external fixation index was 70 days/cm. No patient had a limited ambulation, and all recovered preoperative range of knee motion (mean 130.1°) at final follow-up. Seven minor complications (pin tract infection, clamp loosening) and 1 major complication (uncorrected genu procurvatum) were observed. ConclusionsHemicallotasis using a unilateral external fixator was found to be a safe and simple corrective procedure for varus deformity of the proximal tibia, with few complications.

Tibial lengthening over humeral and tibial intramedullary nails in patients with sequelae of poliomyelitis: a comparative study

Leg discrepancy is common after poliomyelitis. Tibial lengthening is an effective way to solve this problem. It is believed lengthening over a tibial intramedullary nail can provide a more comfortable lengthening process than by the conventional technique. However, patients with sequelae of poliomyelitis typically have narrow intramedullary canals allowing limited space for inserting a tibial intramedullary nail and Kirschner wires. To overcome this problem, we tried using humeral nails instead of tibial nails in the lengthening procedure. In this study, we used humeral nails in 20 tibial lengthening procedures and compared the results with another group of patients who were treated with tibial lengthening over tibial intramedullary nails. The mean consolidation index, percentage of increase and external fixation index did not show significant differences between the two groups. However, less blood loss and shorter operating time were noted in the humeral nail group. More patients encountered difficulty with the inserted intramedullary nail in the tibial nail group procedure. The complications did not show a statistically significant difference between the two techniques on follow-up. In conclusion, we found the humeral nail lengthening technique was more suitable in leg discrepancy patients with sequelae of poliomyelitis.

Fixator-assisted nailing and consecutive lengthening over an intramedullary nail for the correction of tibial deformity

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed. The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60). One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation. We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.

Tibial Lengthening Over an Intramedullary Nail

Tibial Lengthening Over an Intramedullary Nail

Limb lengthening with a submuscular locking plate

Ten patients, who were unsuitable for limb lengthening over an intramedullary nail, underwent lengthening with a submuscular locking plate. Their mean age at operation was 18.5 years (11 to 40). After fixing a locking plate submuscularly on the proximal segment, an external fixator was applied to lengthen the bone after corticotomy. Lengthening was at 1 mm/day and on reaching the target length, three or four screws were placed in the plate in the distal segment and the external fixator was removed. All patients achieved the pre-operative target length at a mean of 4.0 cm (3.2 to 5.5). The mean duration of external fixation was 61.6 days (45 to 113) and the mean external fixation index was 15.1 days/cm (13.2 to 20.5), which was less than one-third of the mean healing index (48 days/cm (41.3 to 55). There were only minor complications. Lengthening with a submuscular locking plate can successfully permit early removal of the fixator with fewer complications and is a useful alternative in children or when nailing is difficult.

Analysis of callus pattern of tibia lengthening in achondroplasia and a novel method of regeneration assessment using pixel values

To relate morphology of new bone formation to outcome after tibial lengthening performed in patients with achondroplasia. A retrospective analysis of 60 tibial segments in 30 achondroplasia patients was performed. There were 22 female patients and eight male patients, with a mean age of 9.8 years. New bone formation was classified by shape, homogeneity and density. Pixel values in relation to original bone were measured using a picture-archiving communication system (PACS). Clinical outcome was described by the external fixator and maturation indices. Mean lengthening was 9.2 cm (range 3-12.7 cm). The mean external fixator index was 23.4 (range 15.1-50). The mean maturation index was 12.3 days/cm (range 6-40 days/cm). Homogeneous pathways were associated with the best clinical results (fixator index 20.4, maturation index 10.8), followed by heterogeneous pathway (external fixator index 26.5, maturation index 16.8) and radiolucent pathway (fixator index 31.2, maturation index 21.4). Both cylindrical (external fixator index 25.2, maturation index 14.5) and concave (external fixator index 26.6, maturation index 16.3) callus shapes were favourable. Mineralization of new bone became equal to that of normal bone within 16 weeks (mean) for homogeneous pathway, 12 weeks for heterogeneous pathway and 32 weeks for lucent pathway. The type of new bone formation seen on radiographs is related to clinical outcome, with homogeneous pathways being the most favourable ones.

Ankle fusion for bone loss around the ankle joint using the Ilizarov technique

We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site. Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients.

Treatment of infected nonunion with large skeletal defects

To investigate the curative effect of managing infected nonunion with large skeletal defects utilizing debridement and granulated cancellous bone grafting. Nineteen patients (20 sites) of infected nonunion with large skeletal defects in tibiae (n = 18) or ulna/radii (n = 2), 18 males and 1 female aged 31.3 (8 - 51), were treated with debridement, external fixation, and granulated cancellous bone grafting, 14 patients (15 sites) by cancellous bone autografting and 5 patients (5 sites) by cancellous bone allografting. Follow-up was conducted for 32.7 (20 - 56) months. Out of the 5 patients receiving allografting, 3 gained bone union with an external fixator index of (2.22 +/- 0.84) months/cm, 2 developed nonunion and subsequently gained union after receiving cancellous bone autografting, and no infection recurrence all of the 5 patients were found. Out of the 14 patients (15 sites) undergoing autografting, 2 patients (2 sites, 13.3%) developed nonunion due to recurrent infection resulting in absorption of autograft, subsequently received debridement and autografting once again, and gained bone union and infection eradication; 12 patients (13 sites, 86.7%) gained bone union with an external fixator index: of (1.96 +/- 0.74) months/cm. Re-fracture occurred in 3 patients (4 sites) and was cured by using cast immobilization (1 case), external fixator (1 case), or internal fixation (1 case). Granulated cancellous bone autografting is a suitable method for managing infected nonunion with large skeletal defects. And cancellous bone allografting has a higher incidence of re-nonunion and longer time for using external fixator.

Fixator-Assisted Acute Femoral Deformity Correction and Consecutive Lengthening Over an Intramedullary Nail

External fixators are being used frequently in standard limb-lengthening and deformity-correction procedures. Lengthening over an intramedullary nail has been a successful technique, and fixator-assisted intramedullary nailing has provided satisfactory results for the correction of selected deformities. We report a combined technique for the treatment of femoral deformities associated with shortening. Between 1997 and 2005, twenty-eight femora in twenty-five patients with a median age of twenty-seven years underwent reconstruction with an intramedullary nail and a unilateral fixator. The mean amount of shortening was 6.33 cm, and the mean preoperative mechanical axis deviation was 33.86 mm. Deformity correction was performed acutely and secured by the intramedullary nail, which was locked distally, and the same external fixator that was used for the deformity correction was utilized for lengthening. At the end of the distraction period, proximal locking screws were placed in the intramedullary nail and the external fixator was removed. At the time of follow-up, deformity correction and bone healing were assessed clinically and radiographically, complications were noted, and the functional results were assessed. The mean duration of follow-up was forty months. The mean duration of the external fixation was 83.29 days, and the mean external fixation index was 14.98 days/cm. The mean amount of lengthening was 6.02 cm. The mean amount of mechanical axis deviation at the end of the treatment was 11.29 mm. The mean bone healing index was 36.66 days/cm. A knee flexion contracture developed in one patient and resolved after intensive rehabilitation. One patient underwent two revisions because of Schanz screw displacement secondary to cortical fracture, and four patients with minor pin-track infections were treated successfully with local wound care and oral antibiotics. While femoral lengthening and deformity correction can be obtained with classic methods for application of an external fixator, the long period of external fixation, patient discomfort, and plastic deformation of the regenerated bone after removal of the fixator are major disadvantages. Two techniques, fixator-assisted nailing and lengthening over an intramedullary nail, were combined in this series. The duration of the external fixation was reduced compared with that required for classic treatment with an external fixator and patient comfort was increased. In addition, the intramedullary nail prevented fracture and deformation of the regenerated bone.

Applications of external fixation for management of complications associated with musculoskeletal tumors and related surgery

We evaluated the results of, and the course of treatment with, external fixation (EF) in treating complications associated with bone tumors and related surgery. Eighteen patients (9 males, 9 females; mean age 19 years; range 6 to 35 years) who were treated with EF were evaluated in three groups. Histologic diagnoses were osteosarcoma (n=3), Ewing's sarcoma (n=3), hereditary multiple exostosis (n=3), chondrosarcoma (n=2), synovial sarcoma (n=2), Ollier's disease, giant cell tumor of bone, desmoid fibroma, chondromyxoid fibroma, and enchondroma. Complications secondary to bone tumors (n=4) and occurring following limb salvage surgery (n=14) were treated with Ilizarov circular EF in nine patients, unilateral EF in six patients, and both in three patients. The first group included eight patients who were treated with EF for infection and nonunion or deformity following surgery. The mean shortening was 10.6 cm, the mean lengthening was 9.7 cm, and the mean external fixator index was 48.8 days/cm. One patient developed fracture of the free vascularized fibula graft after EF removal, and amputation was required in two patients. The second group consisted of six patients who had shortening secondary to tumor surgery. The mean shortening was 7.5 cm, the mean lengthening was 6.5 cm, and the mean external fixator index was 28 days/cm. In this group, the major complications were implant failure and knee stiffness. The third group included four patients with deformity and shortening secondary to multiple exostosis (n=3) and Ollier's disease. The mean shortening was 7.5 cm, the mean lengthening was 6.5 cm, and the mean external fixator index was 57.2 days/cm. One patient developed ulnar shortening of 2 cm after growth. The use of EF in the management of complications associated with bone tumors and related surgery yields successful results especially in young patients.

Femoral Deformity Correction in Children and Young Adults Using Taylor Spatial Frame

The Taylor spatial frame (TSF) has been used commonly in children and young adults. Its use in the tibia is more extensively studied and applied than in the femur. We asked whether normal alignment can be achieved with accuracy during correction of femoral deformities while avoiding major complications in children and young adults. We retrospectively reviewed the clinical and radiographic records of 20 patients (22 limbs), ages 5.9 to 24.6 years, who underwent a TSF for femoral deformity. Etiology included a number of diagnoses of the pediatric age. Minimum followup was 4.5 months (mean, 15.7 months; range, 4.5-35 months). The mean time in frame was 6.2 months (range, 2.6-19 months). Frontal and sagittal plane deformities were corrected to within normal values. A mean limb lengthening of 4.9 cm (range, 1.5-9 cm) was performed in eight femora in seven of which the limb length discrepancy was a secondary concern. External fixation index in the lengthening subgroup was 2.2 months/cm. The 15 complications in 13 limbs included pin tract infection, knee stiffness, delayed union, skin irritation, and posterior knee subluxation. No complications occurred in nine limbs. Computer-assisted femoral deformity correction with six-axis deformity analysis and the TSF is an accurate and safe technique in children and young adults. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Limb Lengthening and Then Insertion of an Intramedullary Nail: A Case-matched Comparison

Distraction osteogenesis is an effective method for lengthening, deformity correction, and treatment of nonunions and bone defects. The classic method uses an external fixator for both distraction and consolidation leading to lengthy times in frames and there is a risk of refracture after frame removal. We suggest a new technique: lengthening and then nailing (LATN) technique in which the frame is used for gradual distraction and then a reamed intramedullary nail inserted to support the bone during the consolidation phase, allowing early removal of the external fixator. We performed a retrospective case-matched comparison of patients lengthened with LATN (39 limbs in 27 patients) technique versus the classic (34 limbs in 27 patients). The LATN group wore the external fixator for less time than the classic group (12 versus 29 weeks). The LATN group had a lower external fixation index (0.5 versus 1.9) and a lower bone healing index (0.8 versus 1.9) than the classic group. LATN confers advantages over the classic method including shorter times needed in external fixation, quicker bone healing, and protection against refracture. There are also advantages over the lengthening over a nail and internal lengthening nail techniques. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Distraction osteogenesis for correction of three-dimensional deformities with shortening of lower limbs by Taylor Spatial Frame

Surgical results of correction of three-dimensional deformities with shortening of lower limbs by simple two-ring system of Taylor Spatial Frame have been reported. The deformities were caused by various kinds of skeletal disorders. Ten cases were successfully corrected using distraction osteogenesis, being one case showed recurrence of deformity due to the nature of the disease. The ranges of corrected deformities were 5 degrees-55 degrees in coronal angulation, 2 degrees-47 degrees in sagittal angulation, and 5 degrees-40 degrees in rotational deformities. Amount of lengthening ranged from 1.2 to 6.0 cm. Pin-site infection occurred in five cases, being no other complications. External fixation index was longer in a group of rotational correction over 10 degrees. The current report seems the first series of cases with four-dimensional deformities treated by distraction osteogenesis by TSF and may help to determine the indication of use of TSF in case of treatment of patients suffering from deformities in the lower limbs.

Tibial Lengthening Over an Intramedullary Nail with Use of the Ilizarov External Fixator for Idiopathic Short Stature

The details regarding bone formation and complication rates associated with tibial lengthening over an intramedullary nail with use of the Ilizarov external fixator have not been reported, to our knowledge. The purpose of this study was to review our experiences with this procedure, performed in individuals with idiopathic short stature. In addition, we compared the results of lengthening over a nail, in terms of the observed bone formation and the complications, with those of the conventional Ilizarov method. Eighty-eight tibiae in forty-four individuals with a mean preoperative height (and standard deviation) of 153.7 +/- 7.2 cm were included in the study. Thirty-two tibial lengthening procedures were performed with the conventional method and fifty-six, with a nail. The increase in the length of the tibia, the external fixation index, the healing index, and complications were assessed. Three specific concerns, including mobility during the lengthening procedure, the time interval before the patient could return to previous activities after completion of the lengthening, and physical activities at the time of final follow-up, were also assessed. The mean final height was 160.1 +/- 7.0 cm, and the mean gain in tibial length was 6.2 cm (20.0%). There was no difference in the mean gain in tibial length or the healing index between the groups; however, the external fixation index was lower and there were fewer complications per tibia in the group treated with the lengthening over a nail. The individuals treated with lengthening over a nail coped better with outdoor activities during the treatment period than the individuals treated with the conventional Ilizarov method; however, there was no difference in the time until the individual returned to previous activities or in the ability to carry out physical activities at the time of final follow-up between the groups. Tibial lengthening with use of the Ilizarov external fixator over an intramedullary nail results in new bone formation of a quality equal to that obtained with the conventional Ilizarov method; however, it reduces the duration of external fixation and the rate of complications.

Ilizarov External Fixation and Then Nailing in Management of Infected Nonunions of the Tibial Shaft

Ilizarov technique is useful in the management of infected nonunions of the tibia. Its main drawback is the long duration of external fixation (EF) with marked patient discomfort. Several techniques have been described for early removal of EF to avoid this problem. Between September 2000 and October 2001, a prospective study at a tertiary trauma center was performed. Thirty-three patients with infected nonunion of the tibial shaft were included. The eradication of infection was by debridement, followed by limb reconstruction using segment transport technique with Ilizarov EF system. When the transported segment reached the docking site, we offered the patients removal of EF, and replacement by intramedullary (I M) fixation with bone graft at the docking site. Advantages and risks were explained to all patients. Patients (N = 17) who accepted this technique were compared with patients (N = 16) who preferred to continue in EF till full bone union, with bone graft at the docking site used in both groups. Mean age of the patients was 29 years, and mean duration of nonunion was 12.6 (range, 6-22) months. Average duration of follow-up from the date of presentation was 36 (range, 22-48) months. Main outcome measurements were assessment of bone and functional outcome using the classification of the Association for the Study and Application of the Method of Ilizarov, EF index, radiographic consolidation index, healing time, duration of EF, and complications The average duration of EF in the first group was 3.1 month, meanwhile in the second group it was 8.5 months. The Association for the Study and Application of the Method of Ilizarov bony and functional outcome assessment score showed no statistically significant difference between the two techniques on follow-up. Early removal of EF and replacement by intramedullary nail can achieve complete healing for infected nonunion of the tibial shaft with shorter duration of EF; nearly one-third the usual duration of EF and give the same functional and bony outcome as the classic technique. It is a relatively safe technique but the risk of infection recurrence must be explained to the patient.

Submuscular plating after distraction osteogenesis in children

Although distraction osteogenesis has solved limb length discrepancies, many complications are inevitable from long duration of external fixation. Use of intramedullary nails for early removal of fixators has its own challenges especially in pediatric age group. To facilitate early removal of external fixators in children, we tried a novel method of submuscular plating over the distraction callus, which is described, and the results and complications of this technique are presented. In eight children (four girls and four boys), of limb lengthening (four cases) and bone transport (four cases) done in three femurs and five tibiae with external fixators (five Ilizarov ring fixators and three monofixators), submuscular plating was done over the distraction callus. The causes of limb length discrepancy included traumatic and septic growth arrest, congenital pseudoarthrosis of tibia, fibular hemimelia, tumor salvage, and Perthes' disease. The purpose of plating was to remove the external fixator earlier after achieving the target length. Mean age of plating procedure was 11.62 years, and mean amount of distraction was 5.47 cm. In all patients, the distraction callus healed on maintaining its length or correcting into the original alignment. The mean external fixation index was 26.93 days/cm and healing index was 52.01 days/cm. One complication of superficial pin-track infection occurred, which resolved completely with conservative treatment. None of the patients developed deep infection or implant failures. The mean follow-up after plating was 28 months (range, 18-62 months). Submuscular plating over the distraction callus may be a successful method that permits early removal of fixator with fewer complications. This method can be a useful alternative in children or when nailing is difficult.