Guichet® Nail

Although there are other nails which perform this function, none offer the weight-bearing ability, safety or control of the Guichet® nail, from memory:

  • the Judet’s nail
  • Bliskunov’s nail
  • ISKD nail
  • Fitbone nail
  • Betzbone nail
  • Precice nail

INVENTORS

From left to right, Drs : Paley (Baltimore), Baumgart (Munich), Shevskov (Kurgan), Cole (Orlando), Soubeiran (Paris), Guichet (Nancy), Herzenberg (Baltimore)

From left to right, Drs : Paley (Baltimore), Baumgart (Munich), Shevskov (Kurgan), Cole (Orlando), Soubeiran (Paris), Guichet (Nancy), Herzenberg (Baltimore)

Number of basic operations (complications are not counted) to get a 10 cm (4 inches) gain with various nails :

Number of basic operations (complications are not counted) to get a 10 cm (4 inches) gain with various nails :

ALBIZZIA® AND GUICHET® NAIL SPECIAL FEATURES

Patients using the Albizzia® nail need to perform a 20 degree leg rotation. For maximum recovery, a patient needs to learn how to complete this ratcheting maneuver, which may seem intimidating to begin with. This has been noted as a criticism of the Albizzia® nail, but with enough practice and preparation, a patient can perform this maneuver painlessly. Experience shows that patients notice the gain in length after mastering the ratcheting maneuver, which allows them to then manage the lengthening on their own.

The lengthening process can be altered as needed in order to avoid neurological complications or premature fusion. If required – in the case of nerve complication, for example – lengthening can be halted at any time, or may progress more quickly than originally planned, such as with good soft tissue tolerance. Counting the number of ratchets done, or ‘clicks’ heard, gives a clear indication of the increase in length, so it cannot be done arbitrarily. This method is also more beneficial than using x-rays, which may provide a distorted picture of a patient’s progress.

The mechanism of the Albizzia® nail allows for automatic ‘dynamization’, which prevents the need for further operations in order to insert new intramedullary nails. As the Albizzia® nail supports more weight through physical activities such as walking, bone formation becomes stimulated. Once the bone is strengthened, the force of the load is transferred from the nail to the bone, which removes the need to remove any screws to lessen the axial load.

The Albizzia® nail is inserted into the bone percutaneously – through stab incisions – which is a method that other competing devices are not designed for.
For a 10-cm increase in length, without complications, there are only two surgical operations necessary for the Albizzia® nail:

  • Insertion
  • Removal

Weight-bearing is allowed during the lengthening procedure (see relevant chapter on post-operative care), which allows patients to recover their bone functionality more quickly and efficiently. Some sports are authorized during this process.

To date, over 3000 Albizzia® nails have been used in 30 countries around the world.

THE JUDET NAIL

Professor Robert Judet had already designed the ‘Distractor.’ However, by using an adjustable screw to transfix the skin, also allowing a gradual increase in length, this led to a high rate of infections after the operation. This in turn led to the end of its general use. (Judet R. [Presentation of the distractor for limb bone lengthening] Chirurgie. 1971;Nov 10;97(11):777-8. In French)

THE BLISKUNOV NAIL

Professor Bliskunov, from Sinferopel, Russia, invented a gradual mechanical nail which was used by over 100 patients over the course of several years. The device ceased development following Bliskunov’s death, however a few surgeons in Russia continue to use it.

As well as a primary femoral part set within the bone cavity, the Bliskunov nail features a pelvic part which links the femoral part to the pelvis – which leaves a pelvic scar. The procedure of inserting the nail is not percutaneous, which causes longer scars. Lengthening takes place via rotatory motion between the femoral and pelvic parts, but can be stopped in the event of a complication through ceasing hip motion, though it is not always easy to enforce this. It is unknown whether a tibial nail is used, as it may be harder to set the mechanism.

For a 10-cm increase in length, without complications, there are 5 to 6 necessary surgical procedures:
the-bliskunov-nail

  • Insertion
  • Removal of the pelvic part
  • Removal of the pelvic part and locking of the nail
  • 1 to 2 exchanges of the nail (not more than 10-cm
    are permitted at one time)
  • Dynamization’ (removing of the upper or lower femoral screws, to allow loading through the newly-formed bone, rather than through the nail; ‘dynamization’ can lead to a 2-7mm reduction in the gain)
  • Removal of the nail.

Weight-bearing is generally not encouraged before the bone is healed, which both delays recovery and weakens the surrounding muscles

To date, around 200-300 nails have been set in Russia. Site web du clou Bliskunov : www.lengthening.ukrpack.net/method-e.htm

THE NAIL FROM BAUMGART AND BETZ
(FITBONE®)

German scientists Betz and Baumgart designed an electronic nail, however its use is not currently widespread. This is due to concerns over its reliability, as well as financial constraints, which also limit its use outside of Germany.

The lengthening process involves connection to an electrical supply via an antenna, which allows energy to be generated for the motor. This technology raises the cost of manufacturing the nail.

A patient’s ability to recover from the surgery would be similar to other nails. Lengthening takes place at night, and can be stopped in the event of complication; within the constraints of the gain of the nail (6cm), additional lengthening of the bone can be performed.
For a 10-cm gain with no complications, 5 to 6 surgical operations are required:

  • Insertion
  • Resetting of the nail and screws, to allow extra gain over 4 to 6 cm
  • Locking of the nail at the end of procedure to permit weight-bearing
  • ‘Dynamization’
  • Removal

In the case of the Albizzia® nail, weight-bearing is generally not permitted before the end of the procedure, and full weight-bearing and sports are not encouraged until much later on. This postpones a fuller, quicker, more functional recovery.

Around 100 to 300 nails have been set, primarily in Germany and Asia.

THE NAIL FROM DEAN COLE
(ISKD®, ORTHOFIX®)

Despite having been designed over two decades ago, this nail has only been used in around 300-500 cases.

Figure showing a section of the ISKD (Orthofix®) nail alongside its verification device, which controls the polar position of a marker within the nail during the procedure.

Figure showing a section of the ISKD (Orthofix®) nail alongside its verification device, which controls the polar position of a marker within the nail during the procedure.

 

With the Orthofix® nail, lengthening takes place through an alternate rotatory motion, which is performed randomly, and is limited to 9 degrees (according to the manufacturer). An electronic device estimates daily length gain via positioning of a rotatory marker, which can be moved during lengthening. However, this cannot control the lengthening, and therefore does not explain how many turns have been performed, nor give a precise count of gain. Therefore, a patient may gain 5 mm in 1 day. Security is provided by presetting the gain required, as the nail stops once the gain is fully achieved, regardless of the distraction rate.

Length gain in mm per day is not modified precisely, such as in the case of voluntary gain to prevent premature bone fusion, or delaying the process to accommodate weak ossification management of a nerve lesion. In case of emergency, the only way to neutralize the implant and to stop it from gaining length is to perform additional procedures: setting an external fixator around the nail to lock its rotation. Ratcheting maneuvers are easier and more comfortable than ones with the Albizzia® nail, as they are not really noticed by the patient. Since the length gain of the nail needs to be pre-set, length can only be increased beyond this through surgery to insert a new nail.

For a 10-cm gain with no complications, 4 to 5 surgical procedures are required:

  • Insertion
  • Exchange of the nail for additional gain (maximal gain 6 cm with one nail)
  • ‘Dynamization’
  • Removal

Weight-bearing is not encouraged before the end of the procedure; correct bone formation, full weight-bearing, and sports can only begin again much later, delaying a fully-functional recovery.

THE BETZBONE® NAIL

betzbone-nail
The BetzBone is a modified copy of the first version of the Albizzia Nail. Its system of fixation can leave bones fragile, and at risk of fractures, which often necessitates a replacement with a static intramedullary nail. This leads to more surgical procedures for each patient, and has therefore not been used by other surgeons yet.

Please note on the x-rays the hypotrophic healing 11 months after the surgery.

THE PRECICE®NAIL

The Precice® nail uses magnetic induction, but its limited to only 25% of a patient’s body weight. This lowers muscle force for the lengthy recovery time, and stops patients from being able to perform physical activity for much longer. Those who want to regain full strength and functionality soon after surgery – in bilateral cosmetic patients, or non-cosmetic cases – prefer the Guichet nail.

OTHER NAILS

er lengthening nails are currently in experimental stages, with none yet passing the mechanical, preclinical, or clinical investigations required. Therefore none of these have been tested by many patients.

The nails of the future will certainly be different from those currently available.