{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T14:51:37Z","timestamp":1787755897268,"version":"build-2784847793"},"reference-count":22,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","license":[{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"\n Background:<\/jats:title>\n \n Tibial lengthening with use of a motorized intramedullary lengthening nail (MILN) provides precise deformity correction and distraction osteogenesis without requiring external fixation\n 1<\/jats:sup>\n . A MILN can be utilized for many etiologies requiring lengthening, such as congenital (e.g., short stature, limb deficiency) or acquired (e.g., post-infectious, traumatic)\n 2<\/jats:sup>\n . The present video article describes the surgical technique for MILN use in the tibia in a skeletally mature patient with use of the Precice System (Globus Medical).\n <\/jats:p>\n <\/jats:sec>\n \n Description:<\/jats:title>\n \n The preoperative patient evaluation starts with a history to understand the primary reason(s) that the patient seeks lengthening, to identify potential care challenges (such as dormant infection for patients with a post-infectious etiology or joint instability for patients with limb deficiency). The physical examination should evaluate for joint contracture or instability, spasticity, prior surgery compromising the surgical approach, and patient psychological or physical capacity to comply with postoperative weight-bearing and lengthening instructions. Preoperative imaging includes calibrated orthogonal radiographs of the operative tibia to ensure suitable anatomy and bilateral hip-to-ankle radiographs, with blocks to level the pelvis as needed, to determine any limb-length discrepancy (LLD) or alignment deformity\n 3,4<\/jats:sup>\n . A gastrocnemius-soleus complex release may be considered; otherwise, the surgical procedure begins with exposure of the tibia and predrilling of the osteotomy site. The tibial canal is entered in either a suprapatellar or infrapatellar (as shown in this video) fashion and sequentially reamed over a centrally placed guidewire. Proximal and distal rotation marker pins are placed posterior to the expected path of the MILN\n 5<\/jats:sup>\n . Blocking screws can be placed to prevent or correct deformity\n 6<\/jats:sup>\n . Prophylactic fasciotomy may be appropriate when performing acute deformity correction\n 7<\/jats:sup>\n . Osteotomies of the fibula and tibia are performed with use of an osteotome. The nail is inserted and locked in position. Proximal and distal tibiofibular fixation minimizes undesired migration of the fibular segments\n 8<\/jats:sup>\n . Lengthening generally starts 7 days after surgery, using 4 lengthenings, totalling a maximum of 0.8 mm, per day.\n <\/jats:p>\n <\/jats:sec>\n \n Alternatives:<\/jats:title>\n \n Some LLD cases are suitably treated without surgical intervention\n 9<\/jats:sup>\n . Alternative lengthening techniques\n 10<\/jats:sup>\n include monolateral external fixators\n 11<\/jats:sup>\n and circular fixators, with or without computer guidance\n 12<\/jats:sup>\n and with or without subsequent internal fixation\n 13,14<\/jats:sup>\n , and other brands of MILN\n 15<\/jats:sup>\n . Hexapod fixators facilitate the most comprehensive deformity correction\n 16<\/jats:sup>\n , although indications are expanding for deformity correction via nailing\n 17<\/jats:sup>\n . Patients may feel that internal options are more convenient than external ones\n 18\u201320<\/jats:sup>\n . Few patients desire treatment of LLD by shortening the longer extremity\n 21<\/jats:sup>\n .\n <\/jats:p>\n <\/jats:sec>\n \n Rationale:<\/jats:title>\n \n LLD and associated deformities can alter natural gait patterns and lead to abnormal joint forces, which may cause a painful and altered gait. Although there are broad opinions regarding the minimum LLD indicating surgery, distraction osteogenesis is a well-established and proven mechanism for bone lengthening. Once lengthening has been indicated, many factors influence the decision to use external or internal fixation, such as the magnitude of lengthening, need and ability to correct other deformity, implant access, and non-medical patient factors. Regardless of the implant, tibial osteotomy should be performed utilizing safe planning, techniques, and medical adjuncts\n 7<\/jats:sup>\n .\n <\/jats:p>\n <\/jats:sec>\n \n Expected Outcomes:<\/jats:title>\n \n When an MILN procedure is performed safely, patients can expect up to 8 cm of lengthening with a minimal risk of implant problems, fracture, infection, or other adverse events\n 7,22<\/jats:sup>\n . Patients must adhere to weight-bearing limitations and perform stretching exercises to avoid joint stiffness. Most patients report high satisfaction after lengthening\n 23<\/jats:sup>\n .\n <\/jats:p>\n <\/jats:sec>\n \n Important Tips:<\/jats:title>\n \n \n \n Establish the LLD before surgery, then rely on the machine to determine the length achieved; do not second-guess the machine during lengthening.<\/jats:p>\n <\/jats:list-item>\n \n Correct or prevent rotational, coronal, and sagittal deformity at the time of the MILN insertion surgery.<\/jats:p>\n <\/jats:list-item>\n \n Prioritize safety (i.e., with a percutaneous technique, fasciotomy, and tranexamic acid) to optimize outcomes (i.e., avoidance of complications and achievement of the desired length).<\/jats:p>\n <\/jats:list-item>\n \n Ensure patient compliance with weight-bearing limitations and stretching exercises.<\/jats:p>\n <\/jats:list-item>\n \n Limit weight-bearing until at least 3 cortices have full bridging.<\/jats:p>\n <\/jats:list-item>\n \n MILN removal is recommended after full union is achieved, typically approximately 1 year postoperatively.<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>\n \n Acronyms and Abbreviations:<\/jats:title>\n \n \n \n LLD = limb-length discrepancy<\/jats:p>\n <\/jats:list-item>\n \n MILN = motorized internal lengthening nail<\/jats:p>\n <\/jats:list-item>\n \n PT = physical therapy<\/jats:p>\n <\/jats:list-item>\n \n IM = intramedullary<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.2106\/jbjs.st.24.00028","type":"journal-article","created":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T18:10:14Z","timestamp":1774548614000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Tibial Lengthening with a Motorized Intramedullary Lengthening Nail"],"prefix":"10.2106","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7065-0656","authenticated-orcid":false,"given":"Jason S.","family":"Hoellwarth","sequence":"first","affiliation":[{"name":"Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-7786-6949","authenticated-orcid":false,"given":"Jason D.","family":"Gross","sequence":"additional","affiliation":[{"name":"New York Medical College School of Medicine, Valhalla, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9031-9079","authenticated-orcid":false,"given":"Austin T.","family":"Fragomen","sequence":"additional","affiliation":[{"name":"Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5220-8071","authenticated-orcid":false,"given":"Taylor J.","family":"Reif","sequence":"additional","affiliation":[{"name":"Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1632-4600","authenticated-orcid":false,"given":"S. Robert","family":"Rozbruch","sequence":"additional","affiliation":[{"name":"Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,1]]},"reference":[{"issue":"12","key":"bib1-20260326","doi-asserted-by":"crossref","first-page":"3869","DOI":"10.1007\/s11999-014-3575-0","article-title":"Precision of the PRECICE internal bone lengthening nail","volume":"472","author":"Kirane","year":"2014","journal-title":"Clin Orthop Relat Res."},{"issue":"7","key":"bib2-20260326","doi-asserted-by":"crossref","first-page":"403","DOI":"10.5435\/JAAOS-22-07-403","article-title":"Motorized intramedullary nail for management of limb-length discrepancy and deformity","volume":"22","author":"Rozbruch","year":"2014","journal-title":"J Am Acad Orthop Surg."},{"issue":"10","key":"bib3-20260326","first-page":"2243","article-title":"Computed radiographic measurement of limb-length discrepancy. Full-length standing anteroposterior radiograph compared with scanogram","volume":"88","author":"Sabharwal","year":"2006","journal-title":"J Bone Joint Surg Am."},{"issue":"3","key":"bib4-20260326","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1097\/BTO.0000000000000459","article-title":"Tibial Lengthening Technique","volume":"35","author":"Rozbruch","year":"2020","journal-title":"Tech Orthop."},{"issue":"3","key":"bib5-20260326","doi-asserted-by":"crossref","first-page":"00003","DOI":"10.2106\/JBJS.ST.22.00003","article-title":"Percutaneous Femoral Derotational Osteotomy in the Skeletally Immature Patient","volume":"12","author":"Ellsworth","year":"2022","journal-title":"JBJS Essent Surg Tech."},{"issue":"2","key":"bib6-20260326","doi-asserted-by":"crossref","first-page":"77","DOI":"10.5005\/jp-journals-10080-1430","article-title":"Blocking Screw-assisted Intramedullary Nailing Using the Reverse-rule-of-thumbs for Limb Lengthening and Deformity Correction","volume":"14","author":"Dabash","year":"2019","journal-title":"Strategies Trauma Limb Reconstr."},{"issue":"11","key":"bib7-20260326","first-page":"e23.00075","article-title":"Avoiding Compartment Syndrome, Vascular Injury, and Neurologic Deficit in Tibial Osteotomy: An Observational Study of 108 Limbs","volume":"7","author":"Hoellwarth","year":"2023","journal-title":"J Am Acad Orthop Surg Glob Res Rev."},{"issue":"1","key":"bib8-20260326","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1186\/s13018-023-03771-z","article-title":"Comparative fixation devices for preventing migration of the proximal tibiofibular joint during tibial lengthening: a tether versus screw fixation","volume":"18","author":"Wongcharoenwatana","year":"2023","journal-title":"J Orthop Surg Res."},{"issue":"1","key":"bib9-20260326","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/s10195-019-0541-3","article-title":"Limb lengthening history, evolution, complications and current concepts","volume":"21","author":"Hosny","year":"2020","journal-title":"J Orthop Traumatol."},{"issue":"1","key":"bib10-20260326","doi-asserted-by":"crossref","first-page":"13","DOI":"10.4103\/jllr.jllr_3_20","article-title":"Tibial Lengthening Evolution: Classic Ilizarov, Lengthening and Then Nailing, Motorized Internal Lengthening Nail","volume":"6","author":"Fragomen","year":"2020","journal-title":"J Limb Lengthening Reconstr."},{"issue":"5","key":"bib11-20260326","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1055\/s-0031-1299659","article-title":"Correction of proximal tibia varus with external fixation","volume":"25","author":"Ashfaq","year":"2012","journal-title":"J Knee Surg."},{"issue":"Suppl 4","key":"bib12-20260326","first-page":"156","article-title":"Correction of tibial deformity with use of the Ilizarov-Taylor Spatial Frame","volume":"88","author":"Rozbruch","year":"2006","journal-title":"J Bone Joint Surg Am."},{"issue":"12","key":"bib13-20260326","doi-asserted-by":"crossref","first-page":"2923","DOI":"10.1007\/s11999-008-0509-8","article-title":"Limb lengthening and then insertion of an intramedullary nail: a case-matched comparison","volume":"466","author":"Rozbruch","year":"2008","journal-title":"Clin Orthop Relat Res."},{"issue":"6","key":"bib14-20260326","doi-asserted-by":"crossref","first-page":"1771","DOI":"10.1007\/s11999-011-2178-2","article-title":"Does lengthening and then plating (LAP) shorten duration of external fixation?","volume":"470","author":"Harbacheuski","year":"2012","journal-title":"Clin Orthop Relat Res."},{"issue":"5","key":"bib16-20260326","doi-asserted-by":"crossref","first-page":"1352","DOI":"10.1007\/s11999-009-1161-7","article-title":"Does the Taylor Spatial Frame accurately correct tibial deformities?","volume":"468","author":"Rozbruch","year":"2010","journal-title":"Clin Orthop Relat Res."},{"issue":"3","key":"bib17-20260326","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1097\/BTO.0000000000000074","article-title":"Surgical Techniques for Lengthening and Deformity Correction of the Tibia With Lengthening Nails","volume":"29","author":"Thaller","year":"2014","journal-title":"Tech Orthop."},{"issue":"1","key":"bib18-20260326","doi-asserted-by":"crossref","first-page":"27","DOI":"10.5005\/jp-journals-10080-1519","article-title":"Patient-reported Outcome and Quality of Life after Treatment with External Fixation: A Questionnaire-based Survey","volume":"16","author":"Ugaji","year":"2021","journal-title":"Strategies Trauma Limb Reconstr."},{"issue":"1","key":"bib19-20260326","doi-asserted-by":"crossref","first-page":"28","DOI":"10.4103\/jllr.jllr_4_20","article-title":"Psychological and Orthopedic Outcomes after Stature Lengthening Surgery Using Intramedullary Nails","volume":"6","author":"Assayag","year":"2020","journal-title":"J Limb Lengthening Reconstr."},{"issue":"17","key":"bib20-20260326","doi-asserted-by":"crossref","first-page":"1432","DOI":"10.2106\/JBJS.N.00932","article-title":"Lengthening in Congenital Femoral Deficiency: A Comparison of Circular External Fixation and a Motorized Intramedullary Nail","volume":"97","author":"Black","year":"2015","journal-title":"J Bone Joint Surg Am."},{"issue":"1","key":"bib21-20260326","doi-asserted-by":"crossref","first-page":"8","DOI":"10.4103\/jllr.jllr_18_21","article-title":"Patient Perspectives in the Choice of Management of Leg Length Discrepancy","volume":"7","author":"Iobst","year":"2021","journal-title":"J Limb Lengthening Reconstr."},{"key":"bib22-20260326","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1051\/sicotj\/2017014","article-title":"Lengthening and deformity correction about the knee using a magnetic internal lengthening nail","volume":"3","author":"Fragomen","year":"2017","journal-title":"SICOT J."},{"issue":"3","key":"bib23-20260326","first-page":"174","article-title":"Patient Satisfaction After Limb Lengthening With Internal and External Devices","volume":"24","author":"Landge","year":"2015","journal-title":"J Surg Orthop Adv."}],"container-title":["JBJS Essential Surgical Techniques"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.ST.24.00028","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T13:53:47Z","timestamp":1787752427000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.ST.24.00028"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1]]},"references-count":22,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.2106\/jbjs.st.24.00028","relation":{},"ISSN":["2160-2204"],"issn-type":[{"value":"2160-2204","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1]]}}}