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Limb Lengthening and Complex Reconstruction Service

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We believe there is a solution to everyone's skeletal problem.

Welcome to the Limb Lengthening and Complex Reconstruction Service where we specialize in limb lengthening and deformity correction for adults and children. We provide opportunities for individuals who previously had no treatment alternatives.

By engaging our patients in a detailed discussion and conducting a thorough exam, we will arrive at a sophisticated diagnosis. Our skill with a variety of bone reconstruction techniques enables us to sculpt bone and even create bone where there was none. Our synergetic relationship with the Hospital provides access to state-of-the-art orthopedic equipment and to other bone health experts.

Limb lengthening is also performed by surgeons in the Pediatric Orthopedic Service.

Limb lengthening has proven to be a very powerful and effective procedure.

Limb lengthening is possible and has been performed successfully for over 50 years in Kurgan, Russia. Gavriil A. Ilizarov developed the concept in 1951 after seeing many WWII veterans who had leg fractures that had not healed (nonunions).

Three photos of Gavriil IlizarovIlizarov first developed an external fixation frame that was placed around the leg. Knowing that compression of the fracture would help stimulate bone healing, he built a frame that had this capacity. He instructed a patient to gradually compress the nonunion by turning a rod. However, the patient turned the rod the wrong way and caused distraction (separation) of the fracture. Ilizarov noticed that new bone had formed in the gap between the bone ends. This was the beginning of much research and development that showed that limb lengthening was possible, safe and effective.

Ilizarov and his colleagues performed thousands of limb lengthening procedures in Kurgan, Russia. Russian politics, however, made education and communication with the Western world very difficult. Finally, Italian surgeons started performing and improving the procedure in the early 1980s and a large center soon developed in Lecco, Italy. The first limb lengthening case in the United States was performed in 1988. At first, there was much resistance and skepticism from the US orthopedic community, but limb lengthening has proven to be a very powerful and effective procedure.

Limb lengthening and reconstruction techniques can be used to replace missing bone and lengthen and/or straighten deformed bone segments. The procedures may be performed on both children and adults who have limb length discrepancies due to birth defects, diseases or injuries. The limb lengthening and deformity correction process works on the principle of distraction osteogenesis. This is a revolutionary concept that reverses the long-held belief that bone cannot be regenerated. In this process, a bone that has been cut during surgery can be gradually distracted (pulled apart), leading to new bone formation (osteogenesis) at the site of the lengthening. In this way, bone segments can be lengthened by 15 to 100 percent of their original length. We use a variety of techniques, including the use of monolateral (one-sided) and circular external fixation devices, to correct angular deformities as well as limb length discrepancies.

We provide opportunities for individuals who previously had no treatment alternatives.

Photo of a pediatric limb lengthening patientThe regenerated bone is normal and does not wear out. The muscles, nerves and blood vessels grow in response to the slow stretch like they do during a growth spurt or in pregnancy. The actual procedure is minimally invasive and requires only one or two nights in the hospital. Patients aren't in much pain since the distraction is so gradual and patients can continue to walk during the treatment.

Children and adults can be appropriate candidates for the procedure. Children with congenital deformities such as fibular hemimelia, congenital short femur and hemiatrophy will often have unequal leg length and this may be associated with deformity. Many adults have had this condition since childhood and have developed back pain and hip arthritis from the leg length discrepancy. Growth plate fractures and bone infections in children can cause stunting of growth that results in discrepancy.

Following trauma, bones can heal in a shortened and deformed position (malunion). Sometimes the bone can even remain unhealed (nonunion). Limb lengthening procedures address all of these issues. We have been able to successfully correct large deformities and equalize limbs with discrepancies of several inches. A segment of bone can be missing after a bone tumor, bone infection or severe fracture. We can transport new bone to fill in this defect.

Short stature can be very disabling in patients with dwarfism, for example. We can lengthen both legs simultaneously to increase stature. We have been able to lengthen achondroplastic dwarf patients 12 inches in the legs and five inches in the arms. This allows them to function more independently and be able to reach the telephone, toilet and gas pedal, for example.

Young adult patients with leg deformities are at risk for developing arthritis as a result of their malalignment. These same techniques can be used to correct severe deformities safely and avert the need for joint replacement.

Physicians

S. Robert Rozbruch, MD
Chief of Service
Orthopedic Surgery, Limb Lengthening
Dr. Rozbruch is an attending orthopedic surgeon specializing in treating leg length discrepancy, limb deformity, nonunions, osteomyelitis and bone defects in adults and children.

Austin T. Fragomen, MD
Fellowship Director
Orthopedic Surgery, Limb Lengthening
Dr. Fragomen is an associate attending orthopedic surgeon specializing in skeletal reconstruction, limb lengthening, nonunions and malunions, and other orthopedic conditions.

S. Robert Rozbruch, MD
Chief of Service
Orthopedic Surgery, Limb Lengthening
Dr. Rozbruch is an attending orthopedic surgeon specializing in treating leg length discrepancy, limb deformity, nonunions, osteomyelitis and bone defects in adults and children.
Austin T. Fragomen, MD
Fellowship Director
Orthopedic Surgery, Limb Lengthening
Dr. Fragomen is an associate attending orthopedic surgeon specializing in skeletal reconstruction, limb lengthening, nonunions and malunions, and other orthopedic conditions.

Staff

 
 
 
 

Specific techniques that we provide include: joint preservation, joint distraction, osteotomy, bone lengthening, bone transport, internal lengthening, integrated fixation, external fixation, limb reconstruction, foot and ankle deformity, Ilizarov reconstruction, knock-knee and bowleg realignment, knee and foot rotational correction, arthroscopy, and replacement. In addition, through our Limb Salvage and Amputation Reconstruction Center, we provide osseointegration limb replacement for certain patients who have amputated limbs and difficulty with socket prostheses. 

Patients come to HSS to receive the best care available, and it is our mission to ensure each patient we meet gets the best. To that end, we are dedicated to providing services that are within our expertise and referring patients to others master physicians for procedures we do not perform. This ensures the highest standard of patient care. See if you are a candidate for limb lengthening and deformity correction surgery.

PRECICE Internal Bone Lengthening

The PRECICE system is an adjustable intramedullary rod used for limb lengthening of the femur and tibia.

 

Knock Knee and Bowleg Deformities

Pain in the hip, knee, and ankle can often be caused by bowlegs (varus deformity) or knock knees (valgus deformity). This often leads to pain, cosmetic deformity, and premature knee arthritis.

 

Foot and Ankle Deformities

Complex foot and ankle deformity can be difficult to treat with conventional surgical approaches. External fixation with acute or gradual correction of deformities can be used to safely treat complex ankle deformity.

 

Trauma: Nonunion and Malunion

Problems with bone healing, alignment, or infection can occur after bone trauma. Nonunion is when the bone does not heal properly leaving the limb with pain and instability. When a fracture heals in a deformed position or with shortening of the limb, this is called a malunion.

 

Upper Extremity Lengthening and Deformity Correction

Infection or trauma can damage the shoulder growth plate and lead to shortening and deformity of the humerus (upper arm). Limb lengthening techniques are used to restore symmetry to the arms improving function and appearance.

 

Limb Lengthening for Kids and Teens

In children, limb length discrepancies and deformity commonly arise from birth defects (congenital) or after trauma. Drs. Rozbruch and Fragomen can perform advanced surgical techniques that reliably equalize limb length, correct deformities, and even increase stature in select conditions.

 
Limb Salvage and Amputation Reconstruction Center

Limb Salvage and Amputation Reconstruction Center

The Limb Salvage and Amputation Reconstruction Center (LSARC) is a specialty center of excellence offering integrated care for patients who have a limb at risk or have already undergone amputation surgery.

 

Preparing Our Patients for Surgery with Preoperative Patient Education

Preoperative education about your procedure will aid in your recovery. We want you to understand the details of your procedure and the usual in hospital and post-operative routine. A better understanding of your procedure will empower you to participate in your care and know what to expect during the recovery.

Other Educational Materials

Before and After Photos

For additional patient videos, click the menu button YouTube menu button in the upper right corner of the video player.

Read more patient stories.

Videos

Video - Physical Therapy for the Femur
PT for the Femur
Video - Physical Therapy for the Tibia
PT for the Tibia
Video - Physical Therapy for the Ankle Distraction or Fusion
PT for Ankle Distraction or Fusion
Video - Physical Therapy for Upper Extremity
PT for Upper Extremity
 

Physical Therapy Guides

Postoperative Physical Therapy Guide
Covers exercises for the tibia, femur, hinged foot/ankle, and the fixed foot/ankle.

Phase II Strengthening Exercises
Covers exercises for limb lengthening phase II.

Tibial and Femoral Osteotomy
Contains rehabilitation exercises and challenges presented after surgery.

Femur Lengthening with the PRECICE Internal Lengthening Nail
Contains postsurgical rehabilitation exercises.

Fellowship

During the Limb Lengthening and Complex Reconstruction Fellowship, fellows become proficient in the diagnosis, management, decision-making, and surgical techniques associated with limb lengthening and reconstruction. The fellow will gain both clinical and research experience. The Ilizarov method is extensively used in addition to more conventional approaches. This will include preoperative, surgical, and postoperative care. There will also be opportunities for basic and clinical research.
 

Publications

Research is an integral part of the innovation and advancement of our specialty. These publications reflect the breadth of research from the Limb Lengthening and Complex Reconstruction Service at HSS.

2019

2018

2017

2016 and earlier

2016

2015

2014

2013

2012

2011

2010 and earlier

2010

2009

2008

2007 and earlier

Selected Books/Chapters

Rozbruch SR, Fragomen AT: Tibial/Femoral Osteotomy in Andrew Green, MD, and Roman Hayda, MD: Orthopaedic Postoperative Rehabilitation, American Academy of Orthopaedic Surgeons 2017.

Rozbruch SR, Hamdy R: Limb Lengthening and Reconstruction Surgery Case Atlas, Major Reference Work, Springer International Publishing 2015, On line reference and Textbook (3 volumes, 2500 pages)

Rozbruch SR, Fragomen AT: Hybrid Lengthening Techniques: Lengthening and then Nailing (LATN), Lengthening and then Plating (LAP) In: Tsuchiya, Kocaoglu, Eralp (Eds.): Advanced Techniques in Limb Reconstruction Surgery, Springer 2015

Fragomen AT, Rozbruch SR: Distraction Arthroplasty for Ankle Osteoarthritis. In: Tsuchiya, Kocaoglu, Eralp (Eds.): Advanced Techniques in Limb Reconstruction Surgery, Springer 2015

Fragomen AT, Rozbruch SR: Iatrogenic Deformities, In: Sabharwal S: Pediatric Lower Limb Deformities: Principles and Techniques of Management, Springer 2015.

Rozbruch SR: Percutaneous Supramalleolar Osteotomy Using the Ilizarov/ Taylor Spatial Frame. In: Scuderi GR, Tria AJ: Minimally Invasive Surgery in Orthopaedics, (second edition); Springer International Publishing 2015.

Fragomen AT, Rozbruch SR: External Fixation. In: edited by Simon Lee and Andrew Hsu: Synopsis of Foot and Ankle Surgery. Thieme Publishers, New York (in progress)

Academic Case Presentations

Image: Correction of Windswept Rotational Deformity
Correction of Windswept Rotational Deformity with Fixator Assisted Plating Technique

-S. Robert Rozbruch, MD

 
Distal Tibial Bone Defect Treated with Bone Transport Using Two Proximal Osteotomy Sites
Distal Tibial Bone Defect Treated with Bone Transport Using Two Proximal Osteotomy Sites

-Austin T. Fragomen, MD

 
Image: Tibia Lengthening with PRECICE Internal Lengthening Nail
Tibia Lengthening with PRECICE Internal Lengthening Nail

-S. Robert Rozbruch, MD

 
Ankle distraction arthroplasty and supramalleolar osteotomy
Ankle Distraction and Supramalleolar Osteotomy for Arthrosis and Deformity

-Austin T. Fragomen, MD

 
Femur Lengthening with Precice Internal Lengthening Nail
Femur Lengthening with Precice Internal Lengthening Nail

-S. Robert Rozbruch, MD

 
Image: Reconstruction of Bone Defects After Malignant Tumor Resection
Reconstruction of Bone Defects After Malignant Tumor Resection

-Austin T. Fragomen, MD

 
Proximal Tibial Growth Arrest with Varus, Recurvatum, and Shortening After ACL Reconstruction
Proximal Tibial Growth Arrest with Varus, Recurvatum, and Shortening After ACL Reconstruction

-S. Robert Rozbruch, MD

 
Correction of bilateral Genu Varum for a high level athlete
Correction of Bilateral Genu Varum for a High Level Athlete

-Austin T. Fragomen, MD

 
Correction of Varus Deformity of the Femur and Tibia in Patient with LCL Laxity
Correction of Varus Deformity of the Femur and Tibia in Patient with LCL Laxity

-S. Robert Rozbruch, MD

 
limb lengthening academic case
Periarticular Distal Tibial Infected Nonunion, Ankle Salvage With Bone Transport

-S. Robert Rozbruch, MD

 
Proximal Tibial Bone Defect Treated with Intentional Deformity and Bone Transport
Proximal Tibial Bone Defect Treated with Intentional Deformity and Bone Transport

-Austin T. Fragomen, MD

 
Lengthening of 20cm in the Femur and Tibia to Qualize Leg Lengths in a Growing Child
Lengthening of 20cm in the Femur and Tibia to Equalize Leg Lengths in a Growing Child

-S. Robert Rozbruch, MD

 
Salvage of Metatarsal Lengthening Nonunion with Structural Iliac Crest Autograft
Salvage of Metatarsal Lengthening Nonunion with Structural Iliac Crest Autograft

-Austin T. Fragomen, MD

 

Presentations

Quality Metrics

Quality Metrics are standards of measurement by which efficiency, performance, progress, or quality of a plan, process, or product can be assessed. We have measured our clinical outcomes for the conditions that we treat. Some of these outcomes have been published in the following peer-review journals.

2019

Sculco PK, Kahlenberg CA, Fragomen AT, Rozbruch SR. Management of Extra-articular Deformity in the Setting of Total Knee Arthroplasty. J Am Acad Orthop Surg. 2019 Jan 7. doi: 10.5435/JAAOS-D-18-00361. [Epub ahead of print], PMID: 30624304
Extra-articular deformities of the femur and tibia in conjunction with advanced knee osteoarthritis pose unique challenges for the arthroplasty surgeon. Careful preoperative planning is needed to evaluate both the intra- and extra-articular deformities and to determine the best route to total knee arthroplasty.

Steinhaus ME, Buksbaum J, Eisenman A1, Kohli M, Fragomen AT, Rozbruch SR. Tranexamic Acid Reduces Postoperative Blood Loss in Distal Femoral Osteotomy. J Knee Surg. 2019 Feb 12. doi: 10.1055/s-0039-1678540. [Epub ahead of print]
Blood loss remains a significant source of morbidity and mortality in orthopaedic surgery. Administration of tranexamic acid (TXA) resulted in less postoperative blood loss during distal femoral osteotomy (DFO), with the most pronounced effect in those who receive two doses.

Da Cunha RJ, Kraszewski AP, Hillstrom HJ, Fragomen AT, Rozbruch SR. Biomechanical and Functional Improvements Gained by Proximal Tibia Osteotomy Correction of Genu Varum in Patients with Knee Pain. HSS J, Open AccessOriginal Article, First Online: 19 March 2019
Bilateral proximal tibial osteotomy (PTO) may be effective in improving knee biomechanics during gait and correcting mechanical alignment in patients with bilateral genu varum. Patients also demonstrated improvement in functional outcome scores. Bilateral PTO should be considered in patients with varus knee osteoarthritis in the setting of genu varum to alleviate symptoms and potentially decrease further clinical deterioration.

Gruskay JA, Fragomen AT, Rozbruch SR. Idiopathic Rotational Abnormalities of the Lower Extremities in Children and Adults. JBJS Rev. 2019 Jan;7(1):e3. doi:10.2106/JBJS.RVW.18.00016. PMID: 30624306
Full text Rotational malalignment of the lower extremity is a potential cause of hip, knee, and ankle pain. Surgical correction of rotational malalignment of the femur and tibia is reserved for severe, symptomatic deformity.

Makhdom AM, Fragomen A, Rozbruch SR. Knee Arthrodesis After Failed Total Knee Arthroplasty. J Bone Joint Surg Am. 2019 Apr 3;101(7):650-660. doi: 10.2106/JBJS.18.00191
Full text Knee arthrodesis after failure of a total knee arthroplasty (TKA) because of periprosthetic joint infection (PJI) may provide superior functional outcome and ambulatory status compared with above-the-knee amputation.The use of an intramedullary nail (IMN) for knee arthrodesis following removal of TKA components because of a PJI may result in higher fusion rates compared with external fixation devices.

Morgan OJ, Hillstrom HJ, Ranawat A, Fragomen AT, Rozbruch SR, Hillstrom R. Effects of a medial knee unloading implant on tibiofemoral joint mechanics during walking. J Orthop Res. 2019 May 23. doi: 10.1002/jor.24379. [Epub ahead of print]
The Atlas™ unicompartmental knee system is a second-generation extra-articular unloading implant for patients with mild to moderate medial knee osteoarthritis. From a biomechanical perspective, extra-articular joint unloading may serve as a treatment option for patients recalcitrant to conservative care. Evaluation of mechanical changes in the tibiofemoral joint demonstrate the potential treatment mechanism of the Atlas™, in accordance with the available clinical data. 

Fragomen AT, Rozbruch SR. The PRECICE magnetic intramedullary compression nail for long bone nonunions; a preliminary report. Archives of Orthopaedic and Trauma Surgery, accepted
 

2018

Iobst CA, Rozbruch SR, Nelson S, Fragomen AT. Simultaneous Acute Femoral Deformity Correction and Gradual Limb Lengthening Using the Retrograde Precice Femoral Nail: Technique and Clinical Results. J Am Acad Orthop Surg. 2018 Apr 1;26(7):241-250. doi: 10.5435/JAAOS-D-16-00573.
The Precice nail was effectively used to correct both limb-length discrepancy and deformity, with excellent overall outcomes. This surgical technique may help avoid the complications that can occur with prolonged postoperative use of an external fixator.

Fragomen AT, Rozbruch SR. Does the surgical correction of tibial torsion with genu varum produce outcomes similar to those in varus correction alone? J Knee Surg. 2018 Apr;31(4):359-369. doi: 10.1055/s-0037-1603797. Epub 2017 Jun 24.
The aim of this article is to study the relationship between tibia vara and external tibial torsion in adults. Based on the finding of this analysis, the incidence of rotational malalignment with genu varum is close to 50%. The recognition of this close association between external tibial torsion  and tibia vara may allow for further insight into the role of rotation in varus deformity-related knee pathology and treatment. Patients can expect nearly identical outcomes.

James E, Corpus K, Fragomen AT, Rozbruch SR. Opening Wedge High Tibial Osteotomy, Microfracture, and Bone Marrow Aspirate Concentrate for Treatment of Varus Deformity and Osteoarthritis of the Knee. Ann Sports Med Res 2017, 4(2):110.
This report presents two patients with varus deformity and extensive grade IV medial compartment osteoarthritis treated with medial opening wedge high tibial osteotomy (HTO) and microfracture augmented with bone marrow aspirate concentrate (BMAC). Results demonstrate restoration of a neutral mechanical axis, filling of the osteochondral defect, and improvement in subjective outcome scores.

Rozbruch SR. Adult Post-traumatic Reconstruction Using a Magnetic Internal Lengthening Nail. J Orthop Trauma. 2017 Jun; 31 Suppl 2:S14-S19. doi: 10.1097/BOT.0000000000000843.
A new generation of internal lengthening nail is now available that has reliable remote-controlled mechanisms. This allows accurate and well-controlled distraction rate and rhythm, and early clinical results have been very positive.

Kleeblad LJ, van der List JP, Pearle AD, Fragomen AT, Rozbruch SR. Feasibility of correcting the mechanical axis in large varus deformities with medial unicompartmental knee arthroplasty. J Arthroplasty. 2018 Feb;33(2):372-378. doi: 10.1016/j.arth.2017.09.052. Epub 2017 Oct 5.
Patients with large preoperative varus deformities (7°-18°) could be considered candidates for medial unicompartmental knee arthroplasty (UKA), as 98% were corrected to optimal or acceptable alignment, although cautious approach is needed in deformities >15°. Furthermore, it was noted that the feasibility of achieving optimal alignment could be predicted using the preoperative mechanical axis angle (MAA), joint line congruency angle (JLCA), and age

Hammouda AI, Standard S, Herzenberg JE, Rozbruch SR. Humeral Lengthening with the PRECICE magnetic lengthening nailHSS J. Accepted Sept 2017.
Intramedullary lengthening nails can provide successful and safe humeral lengthening. Specifically, the PRECICE nail has accurate control over the lengthening process.

Fragomen AT, Kurtz A, Barclay JR, Nguyen J, Rozbruch SR. A comparison of femoral lengthening methods favors the magnetic internal lengthening nail when compared with lengthening over a nail. HSS J. 2018 Jul;14(2):166-176. doi: 10.1007/s11420-017-9596-y. Epub 2018 Jan 5.
Femoral lengthening with magnetic internal lengthening nail (ILN) was more accurate than with lengthening over nail (LON). The magnetic ILN comports the additional advantage of greater precision with distraction rate control and fewer complications. Both techniques afford reliable healing and do not significantly affect knee motion at the final follow-up. The magnetic ILN method showed no superiority in regenerate quality and healing rate.

Harkin E, Rozbruch SR, Liskutin T, Hopkinson W, Bernstein M. Total Hip Arthroplasty And Femoral Nail Lengthening For Hip Dysplasia And Limb Length Discrepancy. Arthroplast Today. 2018 May 3;4(3):279-286. doi: 10.1016/j.artd.2018.03.001. eCollection 2018 Sep.
Staged ipsilateral total hip arthroplasty and retrograde intramedullary femoral nail lengthening allows for the correction of both deformity and limb-length discrepancy. Our results report leg-length equalization, independent ambulation without assistive devices, and excellent bone and functional outcomes without complications, demonstrating that this combined technique can be used to achieve targeted lengthening and deformity correction.

Buly RL, Sosa B, Poultsides L, Caldwell E, Rozbruch SR. Femoral Derotation Osteotomy in Adults with Version Abnormalities. J Am Acad Orthop Surg. 2018 Oct 1;26(19):e416-e425. doi: 10.5435/JAAOS-D-17-00623.
A closed, subtrochanteric derotation osteotomy of the femur is a safe and effective procedure to treat either femoral retroversion or excessive anteversion. Excellent or good results were obtained in 93%, despite the need for subsequent implant removal in more than two-thirds of the patients.

Fragomen AT, Kurtz AM, Wagner PJ, Nguyen J, Liu SS, Rozbruch SR. Anesthesia for removal of external fixation with hydroxyapatite-coated half pins. J Limb Lengthen Reconstr 2018;4:90-6.
IV sedation administered in the operating room provided adequate pain control to perform fixator removal and pin site debridement in most cases. Removal of external fixation used for foot and ankle reconstruction may be more painful.

Sheeha ED, Steinhaus ME, Kim HJ, Cunningham ME, Fragomen AT, Rozbruch SR. Leg-Length Discrepancy, Functional Scoliosis, and Low Back Pain. JBJS Rev. 2018 Aug;6(8):e6. doi: 10.2106/JBJS.RVW.17.00148
Patients with a limb length discrepancy (LLD), low back pain, and functional scoliosis should undergo radiographic evaluation with the pelvis leveled using blocks placed under the shorter limb. When the LLD or symptoms are minimal, patients may benefit from a shoe lift. Patients with an LLD of 20 mm may be considered for operative intervention.

Hamdy RC, Bernstein MA, Fragomen AT, Rozbruch SR. What's New in Limb Lengthening and Deformity Correction. J Bone Joint Surg Am. 2017 Aug 16;99(16):1408-1414. doi: 10.2106/JBJS.17.00464.
This specialty update provides a summary of the most impactful articles related to limb alignment, limb lengthening, and joint preservation that were published in 2017.

Lam A, Fragomen AT, Rozbruch SR. Metacarpal Lengthening in Adults With Brachymetacarpia. Hand (N Y). 2017 Oct 1:1558944717736859. doi: 10.1177/1558944717736859. Epub ahead of print.
Progressive distraction osteogenesis can obtain functionally successful results and improvement in aesthetics and body image without severe complications in skeletally mature adults with brachymetacarpia.

Vulcano E, Markowitz JM, Ali S, Nguyen J, Fragomen AT, Rozbruch SR. Assessment of Bone Healing During Antegrade Intramedullary Rod Femur Lengthening Using Radiographic Pixel Density. JAAOS - Journal of the American Academy of Orthopaedic Surgeons. September 15, 2018 - Volume 26 - Issue 18 - p e388–e394 doi: 10.5435/JAAOS-D-16-00949.
This study suggests that there may be a correlation between pixel density ratio (PDR) and clinical bone healing, and should be followed by additional studies to understand the relationship between PDR and bony union.

Richardson SS, Schairer WW, Fragomen AT, Rozbruch SR. Cost Comparison of Femoral Distraction Osteogenesis With External Lengthening Over a Nail Versus Internal Magnetic Lengthening Nail. J Am Acad Orthop Surg. 2018 Oct 1. doi: 10.5435/JAAOS-D-17-00741. [Epub ahead of print]
Although implants are more expensive for magnetic lengthening nails (MLN) than lengthening over nail (LON), this appears to be offset by fewer procedures. Overall, the two procedures had similar total costs, but MLN was associated with a decreased number of procedures and shorter time to union.

Bernstein M, Fragomen A, Rozbruch SR. Tibial Bone Transport Over an Intramedullary Nail Using Cable and Pulleys. JBJS Essent Surg Tech. 2018 Mar 28;8(1):e9. doi: 10.2106/JBJS.ST.17.00035. eCollection 2018 Mar 28
Massive bone defects (>8 cm) will not unite without an additional intervention., and require a predictable, durable, and efficient method to regrow bone. Our technique of tibial bone transport over an intramedullary nail using cable and pulleys combines internal and external fixation, allowing the external fixator to be removed at the end of the distraction phase. This increases the efficiency of limb reconstruction and decreases complications associated with external-fixators.

Green SA, Fragomen AT, Herzenberg JE, Iobst C, McCarthy JJ, Nelson SC, Rozbruch SR, Standard S. A magnetically controlled lengthening nail: A prospective study of 31 individuals (The PRECICE™ intramedullary nail study). J Limb Lengthen Reconstr 2018;4:67-75.
The PRECICE™ IM nail is a well-tolerated, reliable, fully implantable limb lengthening device that accurately elongates the femur or tibia in a variety of causes of limb length inequality, with a low implant failure rate, and few complications.
 

2017

Fragomen AT. Transitioning to an Intramedullary Lengthening and Compression Nail. J Orthop Trauma Vol 31, Number 6 Supplement, June 2017.
The Intramedullary lengthening nail has allowed for treatment of tibia and femur problems without the use of an external device.

Adult Posttraumatic Reconstruction Using a Magnetic Internal Lengthening Nail. S. Robert Rozbruch, MD. J Orthop Trauma Vol 31, Number 6 Supplement, June 2017. DOI: 10.1097/BOT.0000000000000843.
Intramedullary lengthening  is effective in treating deformity and shortening of  tibial malunion and posttraumatic growth arrest of the femur.

Humerus Lengthening With the PRECICE Internal Lengthening Nail. Anton M. Kurtz, MD and S. Robert Rozbruch, MD. J Pediatr Orthop Vol 37, Number 4, June 2017. DOI: 10.1097/BPO.0000000000000941.
Intramedullary lengthening works well in the humerus.

Rozbruch SR. Why are we special? Limb deformity is more than an overlapping subspecialty. J Limb Lengthen Reconstr 2017;3:1-3.
Limb lengthening reconstruction is a specialization that is unique from the classical orthopedic specialties and is a practice that is proving to be more and more necessary.

Rozbruch SR, Fragomen AT. Tibial/Femoral Osteotomy. In Green A, and Hayda R: Orthopaedic Postoperative Rehabilitation. American Academy of Orthopaedic Surgeons; 2017
Prescribed exercises after surgery are effective in preventing joint stiffness.

2016 and earlier

2106

Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes.  Mitchell Bernstein, Jay Reidler, Austin Fragomen, S. Robert Rozbruch. J Am Acad Orthop Surg 2016;0:1-11. DOI: 10.5435/JAAOS-D-14-00077
Ankle distraction is a reliable alternative to ankle arthrodesis or total ankle arthroplasty in young patients with arthritis. Although the initial goal of ankle distraction is to ankle arthrodesis many patients achieve the lasting benefit of the eliminating the need for ankle arthroplasty or fusion completely.

Prophylactic Postoperative Antibiotics May Not Reduce Pin Site Infections After External Fixation. Austin T. Fragomen,  Andy O. Miller, Barry D. Brause, Vladimir Goldman, and S. Robert Rozbruch. The Musculoskeletal Journal of Hospital for Special Surgery. Vol. 12 No. 3; October 2016. DOI 10.1007/s11420-016-9539-z
Pin infection is a common problem at pin sites. Prophylactic antibiotics do not aid in the prevention of pin site infections in any way and should not be used on healthy patients.

Neglected Patellar Tendon Rupture with Massive Proximal Patellar Migration Treated with Patellar Transport and Staged Allograft Reconstruction. Osama Elattar, MD, Struan H. Coleman, MD, Russell F. Warren, MD,and S. Robert Rozbruch, MD. The Orthopaedic Journal of Sports Medicine. 4(11), 2325967116672175. DOI: 10.1177/2325967116672175
For patients with soft tissue contractures, adhesions, and fixed proximal patellar migration the use of pins and wires for external fixation is an effective way to treat and salvage neglected patellar tendon rupture.

Validation of a modified Scoliosis Research Society instrument for patients with limb deformity: The limb deformity—Scoliosis Research Society (LD-SRS) score. Peter D. Fabricant, Eugene W. Borst, Stuart A. Green, Robert G. Marx, Austin T. Fragomen, and S. Robert Rozbruch. Journal of Limb Lengthening & Reconstruction. Jul‑Dec 2016, Vol 2, Issue 2.
The new scale LD-SRS was shown to give a more accurate description of the quality of life in regards to people with nonarthritic lower extremity deformity than the global quality of life measurements.

Gradual correction of knee flexion contracture using external fixation. Ettore Vulcano, Jonathan S. Markowitz, Austin T. Fragomen, S. Robert Rozbruch. Journal of Limb Lengthening & Reconstruction. Jul‑Dec 2016, Vol 2, Issue 2.
Circular external fixation was found to be a reliable way of treating knee flexion contractures and concurrent ankle equinus as long as the correction with a brace continued on for 1-3 months following surgery.

Oxygen consumption testing and self-reported outcomes following limb salvage with tibiocalcaneal or tibio-talo-calcaneal fusion. S. Robert Rozbruch, Joshua R. Buksbaum, Austin T. Fragomen, Eugene W. Borst, Polly DeMille. Journal of Limb Lengthening & Reconstruction. Jul‑Dec 2016, Vol 2, Issue 2
Although our complex ankle fusion patients have elevated oxygen consumption levels compared to normal subjects, they have lower oxygen consumption levels than amputees, and thus are able to walk while consuming less energy.

Open Wedge Distal Femoral Osteotomy: Accuracy of Correction and Patient Outcomes. Osama Elattar, Ishaan Swarup, Aaron Lam, Joseph Nguyen, Austin Fragomen and S. Robert Rozbruch. The Musculoskeletal Journal of Hospital for Special Surgery. 5 July 2016. DOI 10.1007/s11420-016-9516-6
Distal femoral osteotomy was found to be a reliable procedure to treat valgus knee malalignment with accurate deformity correction and clinical improvement post surgery.

The use of blocking screws with internal lengthening nail and reverse rule of thumb for blocking screws in limb lengthening and deformity correction surgery. Muthusamy S, Rozbruch SR, Fragomen AT. Strat Traum Limb Recon. 11 September 2016. DOI 10.1007/s11751-016-0265-3
Common deformities that occur in femur and tibia osteotomies during the use of internal lengthening can be prevented with the use of blocking screws. The reverse rule of thumbs is useful for placing blocking screws.

What's New in Limb Lengthening and Deformity Correction. Hamdy RC, Bernstein MA, Fragomen AT, Rozbruch SR. The Journal of Bone and Joint Surgery. 17 August 2016. DOI 10.2106/JBJS.16.00460
Limb reconstruction is a fast growing practice with many new techniques appearing, this paper summarizes our most recent techniques.

Lengthening of the Femur with a Remote-Controlled Magnetic Intramedullary Nail: Retrograde Technique. Austin T. Fragomen, MD, S. Robert Rozbruch, MD, JB&JS Essential Surgical Techniques, Volume 6, Issue 2, May 11, 2016
When fixing a distal femoral deformity the retrograde technique is more effective than the antegrade technique and allows for corrections of distal deformities when the osteotomy is done at the time of the nail.

Prevention of pin site infection in external fixation: A review of the literature. Kazmers NH, Fragomen AT, Rozbruch SR. Strategies in Trauma and Limb Reconstruction. 3 May 2016. DOI 10.1007/s11751-016-0256-4.
There is no clear way to avoid infection in the pin sites of external fixators; however, many techniques are commonly used by surgeons to minimize the risk.

External fixation reconstruction of the residual problems of benign bone tumours. Levent Eralp, F. Erkal Bilen, S. Robert Rozbruch, Mehmet Kocaoglu, Ahmed I. Hammoudi. Strategies in Trauma and Limb Reconstruction, 26 January 2016.
The use of external fixators and distraction osteogenesis are effective in treating benign bone tumors and at minimizing the risk of recurrence of deformity.

Lengthening of the Femur with a Remote-Controlled Magnetic Intramedullary Nail: Antegrade Technique. S. Robert Rozbruch, Austin T. Fragomen. JB&JS Essential Surgical Techniques, Volume 6, Issue 1, January 13, 2016.
The intramedullary nail is good for lengthening of the femur as well as angular and deformity correction.

2015

Talar body fracture nonunion and osteonecrosis with adjacent arthritis can be successfully treated with tibiotalocalcaneal arthrodesis using circular external fixation. Eugene Wilson Borst, Scott J. Ellis, Austin Thomas Fragomen. Journal of Limb Lengthening & Reconstruction. Oct-Dec 2015, Vol 1, Issue 1.
Circular external fixation was used for the first time to simultaneously treat a complex talus nonunion as well as ankle and subtalar arthritis. Our patient has been pain free, in neutral alignment, and back to normal activity after this complex TTC fusion.

Distraction osteogenesis for brachymetatarsia: Clinical results and implications on the metatarsophalangeal joint, Amgad M. Haleem, Angela Balagadde, Eugene Wilson Borst, Huong T. Do, Austin Thomas Fragomen, S. Robert Rozbruch. Journal of Limb Lengthening & Reconstruction. Oct-Dec 2015, Vol 1, Issue 1.
DO is an effective method to treat brachymetatarsia, with high patient satisfaction. Larger studies are required to further investigate MTP joint complications and the optimal method of stabilization of the distraction.

Complex Ankle Arthrodesis: Review of the literature, Remy V Rabinovich, Amgad M Haleem, S Robert Rozbr. World Journal of Orthopedics, 2015 September 18; 6(8): 602-613 ISSN 2218-5836.
This article discusses the literature surrounding complex ankle arthrodesis, namely the risk factors, surgical techniques (internal vs. external fixation), and various methods to accelerate healing at the fusion site.

Skeletal Repair in Distraction Osteogenesis: Mechanisms and Enhancements, Jocelyn Compton, Austin Fragomen, S. Robert Rozbruch. JBJS Reviews, Volume 3, Issue 8, August 2015, DOI 10.2106/JBJS.RVW.N.00107.
This article explores what distinguishes Distraction osteogenesis bone healing from typical fracture healing, and explains the numerous adjuncts to accelerate osteogenesis and risk factors associated with the procedure.

Limb Lengthening and Reconstruction Surgery Case Atlas, Springer International Publishing, Editors: Rozbruch, S. Robert, Hamdy, Reggie (Eds.) Copyright: 2015.
3 book set,  2500 pages. The atlas features six sections all pertaining to limb deformity correction: Pediatric Deformity, Trauma, Foot & Ankle (edited by Dr. Fragomen), Adult Deformity (edited by Dr. Rozbruch), Tumor, and Upper Extremity.

What is the Utility of a Limb Lengthening and Reconstruction Service in an Academic Department of Orthopaedic Surgery?; S. Robert Rozbruch, Elizabeth S. Rozbruch, Samuel Zonshayn, Eugene W. Borst & Austin T. Fragomen. Clinical Orthopaedics and Related Research. Volume 473, Number 4; DOI 10.1007/s11999-015-4267-0.
Based on referral data, surgical diversity, and academic productivity, our practice highlights the utility of a Limb Deformity Service to an academic hospital.

2014

Does Integrated Fixation Provide Benefit in the Reconstruction of Post-Traumatic Tibial Bone Defects?; Symposium: 2014 Annual Meeting of the Limb Lengthening and Reconstruction Society; Mitchell Bernstein MD, Austin T. Fragomen MD, Samir Sabharwal BA, Jonathan Barclay BA, S. Robert Rozbruch MD. Clin Orthop Relat Res DOI 10.1007/s11999-015-4326-6.
Integrated fixation reduces time in external fixation while increasing surgical efficiency of tibial reconstruction as compared to exclusive use of external fixation.

Metatarsophalangeal Arthritis Following Fourth Metatarsal Lengthening Treated With Distraction Arthroplasty: Case Report, Amgad M. Haleem, Douglas N. Mintz and S. Robert Rozbruch. Foot Ankle Int 2014 35: 1075 originally published online 18 July 2014 DOI: 10.1177/1071100714543648.
Iliac Crest Bone Marrow Aspirate injections and distraction arthroplasty of the Metatarsophalangeal joint can effectively combat arthritis and stiffness in the joint after distraction osteogenesis of the metatarsal due to brachymetatarsia.

Knee Arthrodesis as Limb Salvage for Complex Failures of Total Knee Arthroplasty, Raul Kuchinad, MD, FRCSC, Mitchell S. Fourman, MD M.Phil, Raul Kuchinad, MD, FRCSC, Mitchell S. Fourman, MD M.Phil. The Journal of Arthroplasty 29 (2014) 2150–2155.
Bone loss, soft tissue envelope, and overall bone health determine the best method of knee arthrodesis for limb salvage after a complex failed Total Knee Replacement. Knee arthrodesis is an effective technique for limb salvage after complex failure and infection following knee replacement.

Neglected rotatory knee dislocation: A case report, Saker Khamaisy, Amgad M. Haleem, Riley J. Williams, S. Robert Rozbruch, S. Khamaisy et al. / The Knee 21 (2014) 975–978.
A unique rotary knee dislocation, in addition to a lateral patellofemoral dislocation was effectively treated after 3 years of neglect with a Taylor Spatial frame and multiple surgeries.

What Risk Factors Predict Usage of Gastrocsoleus Recession During Tibial Lengthening? S. Robert Rozbruch MD, Samuel Zonshayn BA, Saravanaraja Muthusamy MBBS, MS, Ortho, Eugene W. Borst BA, Austin T. Fragomen MD, Joseph T. Nguyen MPH. Clin Orthop Relat Res DOI 10.1007/s11999-014-3526-9.
Patients with tibial lengthening greater than 42 mm or 13% of the overall segment lengths, as well as those with a congenital LLD are more likely to undergo a gastroc-soleus Recession during Tibia lengthening.

Motorized Intramedullary Nail for Management of Limb-length Discrepancy and Deformity. S. Robert Rozbruch, MD; John G. Birch, MD; Mark T. Dahl, MD; John E. Herzenberg, MD. J Am Acad Orthop Surg 2014;22:403-409, July 2014, Vol 22, No 7.
Motorized Intramedullary Nails can lengthen both Femurs and Tibias internally, obviating the need for external fixation while providing stable fixation and lengthening.

Development and validation of a computational model of the knee joint for the evaluation of surgical treatments for osteoarthritis. R. Mootanah, C.W. Imhauser, F. Reisse, D. Carpanen, R.W. Walker, M.F. Koff, M.W. Lenhoff, S.R. Rozbruch, A.T. Fragomen, Z. Dewan, Y.M. Kirane, K. Cheah, J.K. Dowella and H.J. Hillstrom. Computer Methods in Biomechanics and Biomedical Engineering, 2014 Vol. 17, No. 13, 1502–1517.
The computational knee model can accurately predict normalized intra-articular pressures and forces for different loading conditions, and could be further tuned to account for different surgical procedures.

Precision of the PRECISE® Internal Bone Lengthening Nail, Yatin M. Kirane, Austin T. Fragomen, and S. Robert Rozbruch. Clin Orthop Relat Res. ISSN 0009-921X, DOI 10.1007/s11999-014-3575-0, 2014.
The PRECICE Internal Lengthening nail accurately and precisely lengthens bone, with minimal impact on knee and ankle range of motion and complications.

Recombinant Human BMP-2 Increases the Incidence and Rate of Healing in Complex Ankle Arthrodesis, Fourman MS, Borst EW, Bogner E, Rozbruch SR, Fragomen AT. Clin Orthop Rel Res. 2014 Feb, 472:732-9, Epub 2013 Aug 29.
Recombinant Human BMP-2 were significantly more likely to obtain fusion after initial surgery and spend less time in external fixation, while showing significantly more bone bridging on radiographic analysis.

Minimum Distraction Gap: How Much Ankle Joint Space Is Enough in Ankle Distraction Arthroplasty? Fragomen AT, McCoy TH, Meyers K, Rozbruch SR. HSS J 2014, 10:6-12.
Six mm of minimum tibiotalar joint distraction is sufficient to prevent contact between the tibia and talus during ankle distraction arthroplasty.

2013

Circular External Fixator Assisted Ankle Arthrodesis Following Failed Total Ankle Arthroplasty. McCoy TH, Goldman V, Fragomen AT, Rozbruch SR: Foot Ankle Int. 2012, 33(11):947-955.
External Fixation and possible tibia lengthening, provides an excellent method with a high fusion rate to combat bone loss and possible infection after failed total ankle arthroplasty.

Limb Lengthening and Reconstruction Society AIM Index Reliably Assesses Lower Limb Deformity. McCarthy JJ, Iobst CA, Rozbruch SR, Sabharwal S, Eisman E: Epub ahead of print Oct 2, 2012. Clin Ortho Rel Res. 2013, 471:621-7.

Growth Arrest of the Tibia after ACL Reconstruction: Lengthening and Deformity Correction with the Taylor Spatial Frame. Rozbruch SR, Schachter L, Bigman D, Marx R: Published online before print April 25, 2013, doi: 10.1177/0363546510369318; Am. J Sports Med, 2013, 41(7):1636-1641.
Tibia lengthening using TSF can counter acute deformity in the tibia stemming from a growth arrest after ACL reconstruction in skeletally immature patients.

Distal Tibial Periarticular Nonunions: Ankle Salvage with Bone Transport. Schottel P, Muthusamy S, Rozbruch SR. J Orthop Trauma. Epub 2013 Sep 26.
Nonunions in the distal tibia can be challenging due to the lack of bone stock in the area. However, a three ring, double osteotomy frame can be used to excise the infected bone and transporte proximal tibial bone to overcome the nonunion.

Femoral Deformity Planning: Intentional Placement of the Apex of Deformity, Peter D. Fabricant, MD, MPH, James M. Camara, PhD, S. Robert Rozbruch, MD. Healio.com/orthopedics, Search: 20130426-11, Volume 36, Number 5, May 2013.
Intentional placement of a single osteotomy can be used to correct a multiapical deformity in the distal femur to minimize translation.

Limb Lengthening in children with Russell-Silver syndrome: a comparison to other etiologies; V. Goldman, TH McCoy, MD Harbison, AT Fragomen, SR Rozbruch. Journal of Children's Orthopaedics ISSN 1863-2521, Volume 7, Number 2 (2013).
Patients with Russell-Silver syndrome treated for Limb Length discrepancies healed faster than other patients treated for LLDs.

Antibiotic-Coated Nail for Fusion of Infected Charcot Ankles, Abhijit Pawar, MD, Goksel Dikmen, MD, Austin Fragomen, MD, and S. Robert Rozbruch, MD. Foot & Ankle International 34(1) 80-84, American Orthopedic Foot & Ankle Society, 2013.
Antibiotic-coated retrograde nails were successfully used to achieve bony union, fusion of the ankle joint, and elimination of infection in our patients with infected Charcot ankles.

2012

Limb Lengthening and Reconstruction Society AIM Index Reliably Assesses Lower Limb Deformity, James McCarthy MD, Christopher A. Iobst MD, S. Robert Rozbruch MD, Sanjeev Sabharwal MD, Emily A. Eismann MS, Clin Orthop Relat Res, DOI 10.1007/s11999-012-2609-8, March 2012.
The LLRS’s AIM rating reliably classifies the complexity of a lower limb deformity.

Osteotomy, Arthrodesis and Arthroplasty for Complex Multiapical Deformity of the Leg, Alex C. Lesiak, MD, J. Turner Vosseller, MD, S. Rozbruch, MD, HSS Journal, The Musculoskeletal Journal of Hospital for Special Surgery, ISSN 1556-3316, Volume 8 Number 3 (2012).
Post-traumatic multiapical tibia deformities can be effectively treated with ankle fusion, tibial osteotomy, and total knee replacement. Techniques from less complex deformities are used in conjunction to attain pain relief and deformity correction in more complex cases.

Evidence-Based Indications for Distraction Ankle Arthroplasty, Nichoas C. Smith, MD, BA, Douglas Beaman, MD, S. Robert Rozbruch, MD, Mark A. Glazebrook, PhD, MD, Foot & Ankle International, 2012, by the American Orthopaedic Foot & Ankle Society.
There is inadequate evidence in the literature to refute or support the currently accepted indications for Ankle distraction-osteogenesis.

For general questions, please contact a staff member of Dr. Rozbruch's or Dr. Fragomen's office.

 

Why choose HSS? Our patients say it best.