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Limb lengthening

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Limb lengthening


While lengthening or correcting a deformed limb, the principle that is based on is distraction osteogenesis. During this process, a bone that has been cut surgically is gradually distracted (pulled apart), leading to a new bone formation (osteogenesis) at the spot that has been lengthened. This technique is most frequently used to correct limb length discrepancies (LLDs) in both adults and children which may arise either due to birth defects, diseases or injuries. This method is also used to correct deformities in other joints, hip correction and treating complex problems concerning scar tissue that limits normal limb function and movement. Highly trained orthopaedic surgeons have an extensive knowledge and experience in correcting LLDs by utilizing the full range of techniques that include the Ilizarov and Taylor Spatial Frames and intramedullary nailing techniques.

How it Works

Limb lengthening techniques utilise the body's ability to heal itself through the regeneration of bone and soft tissues (example: blood vessels, muscles, nerves, skin, etc.) The method of distraction osteogenesis involves gradually pulling apart (distraction) of a surgically cut bone, enabling for the growth of a new bone (osteogenesis) in the gap created. The new bone hardens or merges and is as strong as any other bone in your body.

Step 1: The bone to be lengthened is cracked through a small incision made by your surgeon.
Step 2: The limb is then stabilized using (one of a variety), of either an external or internal fixation device.
Step 3: Most patients stay in the hospital for a day or two after surgery with physical therapy starting the day after surgery. Maintaining joint mobility is an essential requirement during the distraction and lengthening of the bone that usually starts five or ten days after surgery.
Step 4: During the distraction phase, the cut in the bone is slowly pulled apart with daily adjustments being made to the fixator. As the space between the bones increases, the body will produce new bone in the gap until the required amount of bone is generated.
Step 5: During the lengthening phase of treatment, patients are X-rayed and examined every week or fortnight to evaluate bone growth, nerve and muscle function and to also have pin sites examined for any infection.
Step 6: After the desired length of bone has grown and the limb has been straightened, adjustments to the fixator will be stopped. During this consolidation phase, the fixator is not removed while the new bone hardens and matures.
Step 7: Once the new bone is completely healed, as confirmed with X-rays, the fixation device is removed. This is done as a same day procedure under general anaesthesia. To protect the bone a cast or brace is placed on the limb after the fixator has been removed, It will have to be worn for a few weeks.

Note: The amount of time that the fixator has to be present in the limb depends upon the length of bone growth that is needed. In general, the average time in the fixator is one month per centimetre of bone lengthened in children and twice that period for adults. The time includes both the distraction and consolidation phases.

Conditions Treated

External fixation can be used to correct limb length discrepancies and deformities with different causes such as:

  • Trauma: Growth plate fractures, malunion (where the bones heal crooked), nonunion (where bone heals incompletely), shortening and deformity due to bone loss.
  • Congenital limb length discrepancies: These conditions are associated with many birth defects and deformities including short femur, fibular hemimela, pseudoarthrosis and hemiatrophy.
  • Short stature: This could include achondroplasia and other skeletal dysplasias and constitutional short stature. External fixators are effective in treating limb length discrepancies linked to dwarfism. Treatment may be appropriate in some cases in order to allow the patient to function more independently.
  • Infection: This could involve the bone (osteomylelitis) and joint (septic arthritis). Treatment of bone infection often requires removal of bone segments which may result in angular deformities and limb length discrepancies.
  • Developmental causes: These are related to the slowing of growth and limb deformities caused by illness such as Blount's Disease, which typically affects the bone development of overweight toddlers and adolescents.
  • Pediatric hip disorders: External fixators are also used in the treatment of pediatric hip disorders such as Developmental Coxa Vara (DCV), Perthes disease and Slipped Capital Femoral Epiphyses (SCFE).
  • Joint stiffness: This could occur following injury or infection, Other causes can sometimes be addressed by controlled joint distraction (arthrodiatasis), with the use of external fixators.
  • Soft tissue scarring: Burns and multiple surgeries for club foot correction can be addressed with gradual distraction techniques.

Techniques

There are a variety of devices that are available to accomplish the controlled distraction of the bone. Basically, they fall into two categories: external and internal fixators. External fixators are attached to the bone from outside of the body with a series of rings, pins and wires while internal devices are implanted inside the body and lie on the bone or in the marrow cavity of the bone. Additionally, other approaches that do not utilize the distraction concept may be more appropriate for specific cases. Sometimes a combination of external and internal fixators, such as "Lengthening over Nail" is used.

Limb Lengthening FAQs

What are the cases we treat at Ortho One?

Ortho One helps patients with bow legs, knock knees, leg or arm length differences, congenital short femur, growth plate fractures and traumatic orthopedic problems. We also perform cosmetic limb lengthening and shortening. Bone defects & infection, dwarfism, constitutional short stature and other such cases are also treated.

What is leg lengthening procedure?

In most cases this is cosmetic leg lengthening that works by taking advantage of the body's ability to heal itself. Cosmetic leg lengthening increases a patient's height. The procedure includes minimally invasive methods of accessing and cutting shin bones and femurs, which automatically begins to generate a new bone. As the bones heal, they are pulled apart by the Ilizarov-Veklich device to make them longer.

Who should AVOID cosmetic limb lengthening?

We don't recommend cosmetic limb lengthening to people who are looking for immediate results, who are impatient or those who have psychological problems. We perform limb lengthening with smallest trauma possible, with micro-intrusive technology, but it still requires surgery; a patient needs ample time for leg lengthening and full recovery. We also do not perform surgery on those with poor health and other conditions that are not optimum for surgery.

What type of tests does the doctor perform to learn about my problems before the surgery?

All tests are done in our clinic before the surgery. This starts with an X-ray of the legs and full analysis (blood pressure, urine analysis, EKG). At times the surgeon will assign a psychiatrist to assess whether a patient is capable of undergoing the procedure.

What are the risks of surgery?

The surgeries done at Ortho One Orthopaedic Speciality Centre, involving the Ilizarov – Verklich devices, are done with minimal risks.

What is the percentage of unplanned (additional) surgeries needed?

In less than 3% of cases, patients require additional surgery but this is due to ignoring the doctors' advice.

When can I remove the Ilizarov-Veklich device after my surgery?

The Ilizarov-Veklich Device can be removed when your bone has a good regeneration (a good clavus).

What is Lifestyle Management?

This addresses various aspects of a patient's lifestyle that may have an impact on his or her health. This includes smoking, alcohol consumption, drug abuse, diet, and exercise. Your doctor will try to identify any such issues and then counsel a patient on steps to reduce health risks. Lifestyle modification can lessen risks and prevent complications after surgery.

When can I go walking?

You should not try to walk until you have followed up with your surgeons and they have given you the go ahead to do so.

How much time will I have to stay away from work?

Your surgeons will be able to give you a better idea once you meet with them. Keep in mind that each individual heals differently. Recovery time also depends on the type of surgery you undergo.

I know that there are pins in the Ilizarov fixator that need to be removed from the leg. Is this painful?

The Ilizarov-Veklich device does not have multiple pins in comparison with the classic Ilizarov fixator. It has screws and removing them does not require general anesthesia. Compared to removing pins or other fixators and devices used for lengthening or correction, the Ilizarov-Veklich device is easy to take off and the procedure is not painful.

I am afraid the operation will leave large scars?

Whatever treatment you undergo, we care for minimal side-effects such as scarring. This is achieved with the help of minimally invasive operation and treatment with Ilizarov-Veklich devices. Small punctures like micro-wounds (2mm max. spots) on the skin disappear after some time.

When can I shower after my surgery?

You may shower as early as 24 hours after surgery, but you will not be allowed to wet the legs/hands that contain the device.

Is there a special diet that should be followed?

There might be a change in the everyday meals you’re used to at home, because of the need to provide you with vitamins and a balance of micro-elements for a better recovery process. You need to have a balanced diet while undergoing treatment, but if you want something special - it is not a problem in most cases.

What type of anesthesia will be used? What are the risks?

You will discuss anesthesia with the anesthesiologist and suggest your preferences. Epidural anesthesia can be used for the surgery. It has minimum side-effects compared to other kinds of anesthesia. As a rule, the more complex the procedure, the more risk associated with it. As all of our procedures are less than 1.5 hours, the risks are quite minimal.

What should I expect from the cosmetic leg lengthening?

Cosmetic limb lengthening procedures involve complex, painful, and considerably costly treatments with prolonged recovery periods of almost a year. If you are considering cosmetic limb lengthening, you must prepare yourself for the pain, discomfort and long recovery time associated with it. At the same time you can get the results you require - to become taller and increase the length of your legs.

What is minimally invasive surgery?

It is an approach to surgery whereby operations are performed with specialized instruments designed to be inserted through small incisions or natural body openings. This avoids the need for large incisions, minimizing bleeding and trauma to the body. This approach is used whenever possible.

How long is the device left on the leg for limb lengthening?

You will need to wear it for 3-4 months during distraction and then the device remains on the leg until the bones fully consolidate. This generally takes 6-7.5 months after surgery, depending on how much you want to increase your height. If you are away from the hospital this means we will need to see you in person or see your X-rays to make sure everything is going as planned.

How fast will the lengthening occur?

The duration of the lengthening procedure depends on how much length the patient needs to achieve, how fast they produce bone, and how accurately they are able to carry out the lengthening activities. The average desired rate is 1 mm per day, although this may vary from person to person. A 2.5 cm (approximately 1 inch) length discrepancy should be corrected in 3 - 4 weeks if the patient is able to average 1 mm per day of lengthening. The maximum length that can be achieved with a given procedure is 8 cm (or about 3 inches). At that point, the soft tissues stretch tight and need some time to adapt before additional length can be achieved. If additional length is required, another procedure may be done after approximately one year.

What are the possible complications arising from this surgery?

As with any limb lengthening surgery, there is a possibility of premature consolidation, where the soft regenerate becomes hard and the bone stops lengthening. Other possible concerns are contracture, tight soft tissues causing pain, infection, and breakage of the device or the screws. With careful attention to the rehabilitation program and regular, frequent monitoring of the patient’s leg by the surgeon every two weeks, most of these problems can be avoided.

Authored By : DR. DAVID V RAJAN

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