different generations of telescopic nails methods of applications

1. Telescopic Nails
in Osteogensis Imperfecta
Shady Mahmoud
Assistant lecturer
Orthopaedic surgery department - Ain
Shams University

2. What is OI?
 A hereditary disease (AD or AR) caused in 70% of cases
by a mutation of 1 or 2 genes (COL1A1 and COL1A2),
which encode type 1 collagen (1)
 It is approximately 1 in 10,000 live births
The major clinical features of OI are:
 Bone fragility with or without multiple fractures,
osteopenia, and skeletal deformities of long bones
 Spine deformity in the form of scoliosis in 39% to 80%
 Craniocervical abnormalities are also associated as
basilar invagination, basilar impression, and platybasia (2)

3. How is it classified?

4. How to treat bone fractures and
deformities?
 Prevention:
Pamidronate, has shown its efficacy in
reducing fracture rates and pain,
enhancing bone density parameters,
and improving the quality of life in these
children. (2)
So, they start standing at a
younger age than the past (3)
However, it
has no effect on preexisting bone
deformities (2)

5.  Treatment:
Most fractures can be treated by
immobilization especially if < 2 years.
However, surgical treatment is
sometimes required (long bones in > 2
years) (3)

6. What not to do?
 Plates
Screw fixation in fragile bone is poor
Plates create stress risers and fractures above
and below the plate are likely to occur

7.  Skeletal traction
- The traction pin may cut
through the bone
- Damage to the growth plate
may occur

8. What to do?
Intramedullary rods for long bone
fractures and deformities are the
treatment of choice (3)

9. Solid
 Rush pins or K wires
 Sofield - Millar procedure :
multiple realignment (“shish
kebab”) osteotomies over a
nontelescopic intramedullary rod
(4)
 The revision rate is high as 73%,
and complications such as rod
migration are common. (4)
 So, it is better used in
adolescents and patients with
limited growth potential (popcorn
physis) (3)

10. Telescopic
 4 main types are developed:
Bailey-Dubow, Sheffield, Fassier-Duval, and
interlocking telescoping rods
 These rods have a female hollow nail anchored
in the proximal epiphysis of the long bone and a
male solid nail anchored to the distal epiphysis.
They are elongated as the child grow. So, less
revision rates compared to solid (4)

11.  According to a study (5)
, Mobility status and bone
growth were better in telescopic than in solid
rods.
 The overall implant related complication rate
was 28.6% in telescoping in comparison to
68.4% in solid ones. (5)
 Rod migration was twice more common in solid.
 Bone outgrowing the rod and breakage of rods
with fracture was seen in solid rods only.
 The three-year survival rate for telescoping rods
was 92.9% in contrast to 68.4% for solid rods.
 The reoperation rate was 7.2% in telescoping
and 31.6% in solid rods. (5)

12.  Rod diameter:
Larger diameter gives more stability but causes bone loss
around the rod
Therefore, thinner rods are recommended acting as
internal tutor and not replacing the bone
Leaving 2 mm around the rod in any plan is a safe method(3)
 Rod length:
Pre-operative templates are essential taking into account
the osteotomies needed to straighten the bone.
Measure the length (L) between greater trochanter and
distal growth plate
Female rod length is (L) - 7 mm
Male rod length is (L) + (10-15) mm

13. Methods of fixation
 Open osteotomy:
Better in narrow marrow
diameter (distal
segment is reamed)
But, more soft tissue
damage and risk of
devascularization (3)

14.  Percutaneous
osteotomy:
Limited use in narrow
diameter but has the
advantage of soft
tissue respect

15. According to the need of
arthrotomy they are divided into:
 Those need:
Bailey-Dubow
Sheffield
 Those do not need:
Fassier-Duval
Interlocking

16.  Those need arthrotomy has limited use in
tibia compared to femur as they have a
higher complication rate compared to
femoral rodding (3)
 The surgical trauma to the ankle ligaments
and the permenant damage to most of the
wieght bearing surface of the ankle joint
limit its use (3)

17. Bailey-Dubow
 T piece is not a component of the rod and has to
be attached to it
 No locking mechanism ensures the fixation to
epiphysis
 Need arthrotomy for insertion
 The reoperations rates are 21% - 32% (4)

18. Complications of Bailey and Dubow:
 Proximal rod migration
 Disengagement of the
epiphyseal T-piece (6)
 Bending
 Infection

19. Sheffield
 Design with a fixed T-piece on either end
 It is rotated intraoperatively for better fixation
within the epiphysis (4)
 The reoperation rate is 20% (4)
 Need arthrotomy for insertion

20. Fassier-Duval
 The anchorage is achieved through
screw type fixation by threaded
portions at the proximal and distal ends
with improved “screw-in” fixation (4)
 The advantage of this rod over the
traditional Bailey-Dubow and Sheffield
rods is the single proximal entry
point(2)
 Reoperation rate is 13% in a study on
15 patients (4)
 FD rods are safe and pose no risk of
migration, heating effects, or artifact
when undergoing an MRI of the spine
using a 1.5 T magnet (2)

21. No arthrotomy
Open Percutaneous

22. Interlocking
 The female rod is the same as Sheffield telescopic
rod system while The male rod has a hole at its
distal tip to receive the interlocking pin (7)
 A revision rate of 9% at 2 years and 28% at 3
years.(4)
 No need for
arthrotomy
 proximal migrat-
-ion is 12.5 %(7)

23. Refrences
 1) Zeitlin L, Fassier F, Glorieux FH. Modern approach to children with osteogenesis imperfecta.
In: Journal of Pediatric Orthopaedic B. Johari A ,ed. Philadelphia, Pa:Lippincott Williams &
Wilkins; 2003 Mar;12(2):77-87.
 2) Makhdom A, Kishta W, Saran N et al. Are Fassier-Duval Rods at Risk of Migration in Patients
Undergoing Spine Magnetic Resonance Imaging?. In: Journal of Pediatric Orthopaedic
Hensinger r, Thompson G, eds. Philadelphia, Pa: Lippincott Williams & Wilkins; 2015 Apr-
May;35(3):323-7
 3) Fassier F, Glorieux F. Osteogenesis imperfecta. In: surgical techniques in orthopaedics and
truamatology. Duparc DJ, ed. Philadelphia, Pa: Mosby Elsevier; 2003, 55-050-D-30
 4) Birke O, Davies N, Latimer M, et al. Experience With the Fassier-Duval Telescopic Rod: First
24 Consecutive Cases With a Minimum of 1-Year Follow-up. In: Journal of Pediatric Orthopaedic
B. Johari A ,ed. Philadelphia, Pa:Lippincott Williams & Wilkins; 2011 Jun;31(4):458-64
 5) EL-ADL G, KHALIL M, EL-LAKKANY r, et l. Telescoping versus non-telescoping rods in the
treatment of osteogenesis imperfecta. In : acta orthopaedic belgica. Barbier O, De Smet L ,eds.
2009, 75, 200-208
 6) LANGSTEVENSON A, SHARRARD W. INTRAMEDULLARY RODDING WITH BAILEY-
DUBOW EXTENSIBLE RODS IN OSTEOGENESIS IMPERFECTA. In: The Journal of Bone &
Joint Surgery. Swiontkowski M, ed. Needham, MA: JBJS. 1984 Mar;66(2):227-32.
 7) Joon Cho T, Ho Choi I, Chung C, et al. Interlocking Telescopic Rod for Patients with
Osteogenesis Imperfecta. In: The Journal of Bone & Joint Surgery. Swiontkowski M, ed.
Needham, MA: JBJS. 2007;89:1028-1035