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PubMed1993

[Leg lengthening using callotasis. I. History of lengthening of extremities and surgical technics].

In the first part of the article divided into two sections the authors describe the history of approaches to limb length discrepancy and they compare several methods and discuss their advantages and disadvantages. The surgical method proper used at the clinic is described incl. preoperative preparation and deliberations as used at the clinic up to the procedure used for removing the fixator after completion of the lengthening of long bones. The operation proper is described in detail from application of the apparatus to performance of osteotomy. The lengthening process is also described.

Bone Lengthening↗
PubMed1992

[Possible uses for callus distraction. Bridging bone defects and bone lengthening in leg length inequality].

AIMS: Representation of the possibilities of callus distraction for bridging bone defects on the basis of four typical cases successfully treated with this procedure. MAIN TOPICS: The filling of large diaphyseal bone defects through the use of callus distraction is reliable, relatively simple to carry out, and in most cases can be done on an outpatient basis. After prior osteotomy, a segment of the remaining bone is forced, millimeterwise, into the defect zone. As a result of continuous distraction of the callus forning in the osteotomy, tubular bone with weight-bearing capability is formed, and the patient is spared the defect resulting at the donor site when an autologous bone graft is taken, or the implantation of exogenous material. The same principle is employed for leg lengthening, and also permits simultaneous compensation of axis malalignment.

Adult↗
PubMed1994

[Foot deformities in longitudinal ectromelia of the lower limbs].

We have studied 204 feet in 181 children with congenital limb shortening. There were 17 short femurs in 11 children in whom it was impossible to lengthen the leg. Thirteen feet were abnormal. It was necessary to adapt the foot to fit the chosen prosthesis. In 34 children it was possible to correct the length of the short femur. In 21 the feet were normal. 13 had abnormal feet associated with fibular aplasia and deformities included equinovalgus, hind foot synostosis, and deficient rays. In 72 children with congenital hypoplasia or aplasia of the fibula, 76 feet were affected. The function of the foot depends on attaining a stable position beneath the tibia. In 34 children (35 feet), the feet were in a stable position. There were 22 ball and socket ankle joints. Before carrying out leg lengthening, operation was necessary on 9 feet, and a further 13 required operation after lengthening had been carried out. In 34 children (41 feet) there was fibular aplasia. The feet lay in equinovalgus and were often narrow. Only 5 did not have a degree of synostosis. Twenty-three feet in twenty two children were operated on with early soft tissue release, tendon transfer and tibiotalar arthrodesis. This is our treatment of choice. Twenty-seven children had tibial dysplasia which affected 37 feet. The feet lay in equinovarus and in 5 there was partial diplopodia. In the absence of a tibia (19 feet) disarticulation of the knee was carried out. In 12 there was proximal shortening of the tibia which in 9 cases was treated by tibiofibular union. It was possible to retain only 2 feet in a proper position in a lengthened leg. In 30 children (33 feet) both fibular and tibial hypoplasia was present. The feet functioned well. There were 22 ball and socket ankles, 28 narrow feet and numerous synostoses. In limbs with atypical dysplasia 7 abnormal feet were noted. If it is possible to preserve or lengthen the limb it is vital that the foot is retained in a stable position beneath the tibia in order that satisfactory function be obtained. If limb lengthening is impossible, the foot must be adapted to match the prosthesis.

Adolescent↗
PubMed2004

Internodes can nearly double in length with gradual elongation of the adult rat sciatic nerve.

Leg lengthening procedure is used increasingly to treat leg length discrepancy and some forms of dwarfism. We investigated adaptation in rat sciatic nerve to the gradual nerve elongation that occurs with leg lengthening. Indirect nerve elongation was produced by leg lengthening by a total of 15, 30, 45, or 70 mm at a rate of 1 mm/day. One day after leg lengthening completion, transverse semithin sections of sciatic nerve were prepared and examined; a teased-fiber study also was performed. Elongation decreased axon diameter, but not significantly. In teased-fiber preparations, internodal length was increased by 93%, and the longest internode measured 3000 microm after leg lengthening by 70 mm. Slopes of fiber diameter-internodal length regression lines increased with increasing elongation. Paranodal demyelination caused by nerve elongation worsened as elongation increased, stimulating remyelination (i.e., intercalation of a segment). Only 0.8% of axons showed degeneration in the group with 70 mm of elongation. We concluded that adult rat sciatic nerve can adapt itself to leg lengthening procedure with even doubling internodal length.

Animals↗
PubMed1997

Prevention of deformity during limb lengthening.

Deformity occurs frequently at the site of distraction during leg lengthening and can add to disability. The elastic and nonelastic displacements have been measured in a model that simulates leg lengthening in the laboratory. Measurements have been made for different fixator systems. The angulation in the vertical plane that occurs during leg lengthening is minimized if the distance between the bone and the fixator bar is kept as small as possible, if three screws are inserted in the proximal and distal bone fragments, and if the peak loads on the fixator are reduced by adjusting the rhythm of distraction. However, even if these precautions are taken, the results show that some fixators designed for leg lengthening will fail and lead to deformity at the osteotomy site. This may occur under the repeated cycles of high loads associated with the rises in soft tissue tension that are known to occur in certain groups of patients. This study suggests that deformity can be prevented by the proper selection of a suitable frame and the adjustment of its configuration to meet the loading requirements.

Bone Lengthening↗
PubMed1976

Continuous trans-physeal traction: a simple method of bone lengthening.

Leg length increments utilizing continuous traction across the epiphyseal plate of growing puppies produces a cleavage fracture at the level of the primary metaphyseal trabeculae which neither anatomically nor physiologically alters the growth plate. These fractures heal readily and growth resumes following removal of the traction device. This method is relatively atraumatic to the extremity. It does not require an open operation and the controlled distraction rate has not caused neurological or vascular complications. The study was designed to determine the anatomic site of fracture; no attempt was made to achieve maximal leg length increments.

Bone Lengthening↗
PubMed1999

Tensile force in limb lengthening: histogenesis or only mechanical elongation.

Although bone response can be evaluated by radiography, there have been no reports in human confirming formation of new soft tissue in limb lengthening. This study evaluated the tensile force between pin clamps in 14 lower limb lengthenings. Legs were lengthened 0.5 mm every 12 hours and the tensile was measured continuously. The tensile force increased simultaneously with each lengthening and decreased gradually. However, the reduction rate of tensile force during the nighttime (120+/-22%) was significantly higher than that during the daytime (72+/-10%). This differed from the stress relaxation phenomenon shown by viscoelastic material and suggested the presence of other phenomena such as histogenesis.

Adolescent↗
PubMed1998

Progressive subtalar joint dislocation and limb-length inequality. An unusual case.

Subtalar joint dislocation is a rare entity, accounting for only 1% of all traumatic dislocations. The authors report a case of an adolescent with gradual lateral subluxation of an anatomically abnormal subtalar joint with no history of trauma, an extremely rare presentation. The patient also had a congenitally short limb. The patient underwent llizarov leg lengthening along with multiple surgeries of the subtalar joint. The choice of the Ilizarov technique to lengthen the leg and realign the subtalar joint in this case is discussed.

Abnormalities, Multiple↗
PubMed1999

[Bone lengthening. History of the development and field of applications].

Leg lengthening has been performed since early in this century. The first successful lengthening was reported in 1905. Leg lengthening evolved from forced lengthening of the bone during anaesthesia, through use of cortical bone grafts, plate and screws to callus distraction (callotasis). Development of external fixators and evolution of biological concepts of bone regeneration has been important. In 1951 Ilizarov developed his apparatus. Ilizarov pioneered the biology of bone and soft-tissue regeneration. He performs a percutaneous subperiosteal corticotomy and waits five to seven days prior to distraction with a rate of 0.25 mm of length four times each day. The method has increased the opportunities in reconstructive bone surgery. The technique is difficult with many problems and obstacles which can be overcome.

Bone Lengthening↗
PubMed2004

Pre-degenerated nerve shows enhanced regeneration after incremental elongation in rats.

Following nerve degeneration, we investigated effects of linear elongation on subsequent nerve regeneration in a total of 92 Wistar rats (weight 380-430 g). The nerve was ligated at the midthigh and then elongated incrementally by a total of 15 mm by leg lengthening at a rate of 3 or 5 mm/day. Seven days after initiation of nerve elongation, the external fixator was removed and normal leg length was restored with internal fixation. Then a 10 mm nerve segment at the ligature site was excised, and the nerve was repaired with sutures (group D). At 2, 4, 6, and 8 weeks after nerve suturing, we examined transverse semi-thin nerve sections compared with group I (severed and repaired after leg lengthening without a nerve ligature) and control group (severed and repaired without leg lengthening). After lengthening at 3 mm/day, nerve regeneration in group D was enhanced at 4 weeks. After lengthening at 5 mm/day, nerve regeneration in group D also was enhanced at 6 and 8 weeks. Pre-degenerated nerve showed better regeneration after suturing than intact nerve. Elongation holds promise as an alternative to nerve grafting in treatment of nerve injury.

Animals↗
PubMed2005

Distribution of sodium channels during nerve elongation in rat peripheral nerve.

A number of studies have investigated electrophysiological and morphological changes of peripheral nerves during gradual elongation. There has been, however, no report on the distribution of sodium channels at Ranvier's nodes during peripheral nerve elongation. We investigated peripheral nerve injury after the gradual elongation of rat sciatic nerves. Indirect nerve elongation was induced by leg lengthening at a rate of 3 mm/day by 15 or 30 mm. At 7 days after the leg lengthening, the electrophysiological properties of sciatic nerves, the ultrastructures of the Ranvier's nodes and axons, and the distribution of voltage-dependent sodium channels were examined. In the control nerves, most sodium channels were localized at Ranvier's nodes in myelinated axons, providing the physiological basis of saltatory conduction. In the elongated nerves, both the amplitude and conduction velocity of compound nerve action potential decreased following leg lengthening. The elongated nerves also showed paranodal demyelination in Ranvier's nodes longer than those in the control group. In addition, the distribution of sodium channels became diffuse or disappeared at Ranvier's nodes of elongated nerves. The diffuse distribution and/or disappearance of sodium channels may underlie the electrophysiological changes in compound nerve action potential induced by nerve elongation.

Animals↗
PubMed1985

[Circulatory status and architectonics of the vascular bed of the leg after lengthening it following double-distraction epiphysiolysis].

In 6-7-month-old puppies of mongrel dogs under anesthesia by means of G. A. Ilizarov apparatus double epiphysiolysis of the tibia has been performed. The activity of metabolic processes, the state of blood and lymphatic circulation have been studied in the shin at its lengthening by radioisotopic, angiographic and histological methods. Beginning from the first postoperative days, an essential increase of metabolic processes is observed in the osseous tissue, in the blood circulation at the areas of distraction and in the shin as a whole. Blood supply of the regenerates, when the magistral and intraosseous blood stream is remained intact, is performed via the nutritional, metaphysial and epiphyseal arteries. The preservation of the magistral blood stream ensures formation of a normal blood bed in the red bone marrow (arterioles, closed system of the sinuses).

Animals↗
PubMed2002

Paranodal demyelination by gradual nerve stretch can be repaired by elongation of internodes.

Nerve elongation resulting from leg-lengthening surgery can be injurious. We investigated peripheral nerve injury and recovery after gradual elongation of the rat sciatic nerve by progressive stretching. Indirect nerve elongation was produced by leg lengthening by 15 mm, at a rate of 3 mm/day (group I) or 5 mm/day (group II). The elongated length was then maintained. At 0 weeks, representing the 7th day after starting leg lengthening, and at weeks 2, 4, and 6, transverse semithin sections of sciatic nerve were examined. At the same time a teased fiber study was performed. As a result of nerve elongation axon diameter was decreased, although it later recovered. Axon diameter recovered more slowly in group II than I. Myelin thickness did not change compared with controls. In the teased fiber study, internodal length was increased by about 10% after nerve elongation in each group. Almost all nerve fibers showed demyelination at 0 weeks; myelination recovered with time, more slowly in group II than I. More obvious demyelination, axonal degeneration, and remyelination were observed in group II. We conclude that mild demyelination was repaired by elongation of internodes, while more severe demyelination was repaired by intercalation of segments.

Animals↗
PubMed1990

Radiographic features of bone lengthening procedures.

The successful treatment of leg length discrepancy depends not only on an accurate assessment of the pattern of growth of the femur and tibia but also on thorough understanding of the various treatment methods. The radiographic features of 43 leg lengthening surgeries were studied retrospectively, and their significance in the treatment of children with leg length discrepancies was evaluated. The morbidities seen in our study include leg deformities resulting from misalignment of bone segments and excessive stretching of soft tissues, and fractures, nonunions, and delayed unions at the lengthened sites, leading to prolonged application of traction devices. The overall frequency of morbidity was 148.8%. In the orthopedic literature, morbidity rates vary with the underlying reasons for leg length discrepancy, the type of bone lengthening procedure, and the type of complications included. Timely detection of radiographic abnormalities in the lengthened leg can contribute significantly to the successful treatment of leg length discrepancy.

Adolescent↗
PubMed1998

A simple technique for correction of complicated tibial deformity including rotational deformity.

Although the simplest way to correct bone deformity is one-stage correction, the problem associated with that method is overstretching of the soft tissues, which limits the correction and leads to complications such as compartment syndrome or peripheral nerve palsy. If an adequate amount of tissue necessary for correction is formed in advance, the deformity can be corrected safely at one stage without overstretching of the tissues. A leg lengthening technique was employed to form the necessary tissues. After leg lengthening with an unilateral external fixator (Hifixator), deformities were corrected manually at one stage without anesthesia, and the corrected positions were again secured with the fixator. To correct rotational deformity, two sets of pins were inserted into the proximal bone fragment of the tibia at the time of the operation, and after lengthening the proximal pin clamp of the fixator was disconnected from one pin set and reconnected to the other set. We applied this method to four tibias of three patients without any complications. The tension of the tissues was monitored using a pressure sensor built into a Hifixator to prevent the tissues from overstretching. During and after the correction, the tension of the tissue was maintained at less than before the correction.

Bone Lengthening↗
PubMed1990

[Early results of leg bone lengthening using epiphysis-metaphysis distraction].

The methods and results of elongation of the lower extremity by epiphysis-metaphysis distraction obtained at treatment of 13 children aged from 4 to 15 years, with abbreviation of 30-80 mm have been presented. In 11 children full elongation of the abbreviation of 30-57 mm was obtained. In two children full elongation was not obtained.

Adolescent↗
PubMed1988

Results of 21 Wagner limb lengthenings in 20 patients.

Roentgenograms and charts were reviewed on 20 patients (average age: 13.2 years) who had 21 Wagner limb lengthenings since 1975. Lengthenings included 15 femora (six acquired, eight congenital, and one fibrous dysplasia), four tibiae, and two humeri (one acquired and one congenital). Average femoral lengthening was 6.6 cm; tibial, 5.9 cm; and humeral, 9.7 cm. Lengthening of femora with congenital shortening (6.5 cm) was nearly the same as femora with acquired shortening (6.8 cm), and 85% of all lengthenings were greater than 5 cm. Humeri were lengthened more than 50%. Seventy-two percent of patients were in the 50th percentile or less of stature; 61% were in the 15th percentile or less of stature. Seventy-five percent had complications, with 65% having more than one major complication: pin tract and superficial infections in 40%; deep infections in 20%. All infections were in femoral lengthenings. Nonunion occurred in two patients (10%), and fracture after plate removal in two patients (10%). Five patients (25%) had nerve palsies, and four of these resolved without treatment. Malunion rate was 20%. Five patients developed joint contractures. Complications did not correlate with amount of lengthening but congenital deformities had a higher incidence of complication. Eleven patients required 19 additional procedures necessitated by the lengthening procedure. Wagner leg lengthening is generally recommended when amputation is only other surgical alternative and a full, complete informed consent is given to the parents and patient.

Adolescent↗