External Fixation vs. Internal Nails for Cosmetic Lengthening: A Meta-Analysis (2025)

Study Question

The authors pooled seven studies with 489 patients to compare reported complications and functional outcomes after cosmetic limb lengthening with external fixation or intramedullary nails. The article was published in the July 2025 volume of the Journal of Orthopaedics, with a 2024 online DOI. ^[1]

Main Reported Findings

The pooled data showed more Paley problems in external-fixator cohorts and reported high satisfaction in several studies. No procedure-related deaths were reported among the included cohorts. The paper also presented obstacle and complication categories, but definitions and reporting were not uniform across all source studies.

Important Limitations

• Only seven studies were included, totaling 489 patients.
• The evidence was observational and heterogeneous rather than randomized.
• External-fixator and internal-nail groups can differ by era, indication, selection, technique, and follow-up.
• Paley categories and denominators may not have been applied identically across studies.
• A sample of this size cannot reliably quantify rare outcomes such as mortality.

Responsible Interpretation

The analysis supports discussing different complication profiles for external and internal fixation. It does not prove that an internal nail is safer for every patient, that external fixation causes the observed differences, or that either method has zero mortality. Provider-specific outcomes for the proposed device, segment, indication, and follow-up remain necessary.