Femoral length restoration via osteotomy and gradual distraction withIlizarov fixator and conversion to intramedullary nail in malunion: A case report

Abstract

Introduction
The management of femoral malunions with severe shortening due to fragment overlap represents a complex reconstructive challenge. In these cases, the combination of osteotomy, gradual distraction with a circular Ilizarov fixator, and subsequent conversion to intramedullary nailing offers unique biomechanical advantages. This approach enables millimeter-precise restoration of anatomical length through progressive repositioning, minimizing neurovascular risks associated with aggressive corrections. Furthermore, the dynamic stability of the system promotes bone tissue formation at the distraction site, facilitating early transition to definitive internal fixation.

Case Report
A 26-year-old male patient suffered a motorcycle accident resulting in a left femoral diaphyseal fracture and severe traumatic brain injury, requiring six weeks of intensive care management. During this period, the femoral fracture healed vicariously with bony fragment overlap, causing 9.5 cm of shortening. After neurological recovery and systemic stabilization, the patient was discharged, gradually resuming daily activities. However, the lower limb length discrepancy significantly compromised his mobility and functional independence, prompting orthopedic consultation.

A two-stage surgical approach was implemented: During the first phase, a diaphyseal osteotomy was performed at the site of fragment overlap using a periosteum-preserving approach. A circular Ilizarov external fixator was installed, followed by a gradual distraction protocol at 1 mm/day (divided into four 0.25 mm adjustments every 6 hours) with regular radiographic monitoring. Upon achieving the target femoral length, the second surgical phase involved fixator removal and antegrade blocked intramedullary nailing with prior canal reaming, achieving definitive femoral stabilization.

Results
The protocol successfully restored the full 9.5 cm shortening, achieving symmetrical lower limb length. Radiographic follow-up demonstrated satisfactory bone consolidation. No complications occurred during the distraction phase. At the 4-month functional assessment, the patient regained independent ambulation capacity with initial partial weight-bearing.

Discussion
This case demonstrates the efficacy of gradual repositioning through controlled distraction in complex femoral malunions. Unlike classical distraction osteogenesis (focused on longitudinal bone regeneration), this strategy prioritizes three-dimensional correction through progressive traction of overlapped fragments, avoiding traumatic intraoperative forces. Early conversion to intramedullary nailing - performed upon detecting initial mineralization signs - significantly reduced complication rates associated with prolonged external fixation.

Conclusions
The combination of gradual Ilizarov distraction and conversion to intramedullary nailing proved effective for length restoration in femoral malunion with fragment overlap. This approach leverages the mechanical precision of external fixation for progressive anatomical repositioning, while nail stability facilitates early rehabilitation. The technique is particularly valuable for young, high-demand patients where biomechanical restoration is paramount.