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PubMed1977

Tibial lengthening: a preliminary report.

A preliminary review of 9 tibial lengthenings has been made to assess the value of a modification of the Anderson operation. The procedure can be carried out in one stage and is applicable to the older child and young adult. This is important as it may be used in the late or neglected case where epiphyseal arrest has failed or was never done. Five out of 9 patients in this series were skeletally mature. Leg lengthening procedures will always entail certain hazards. Complications occurred in 7 of the 9 patients, but were recognized early and expeditiously managed, and in several instances resulted in only minor deformity. The satisfactory end results in this series are attributable to the principle of limiting tibial lengthening to no more than 10 per cent of the overall bone length, i.e. 5 cm or less. No neurovascular complications occurred. Although tibial lengthening is hazardous and can cause severe disability, the results reported here suggest that in selected cases, it is a valuable procedure for correction of leg length discrepancy.

Adolescent↗
PubMed2003

Lower limb deformities in children: two-stage correction using the Taylor spatial frame.

The Taylor spatial frame is a new external ring fixation system developed for correction of axial, sagittal, planar and rotational deformities of the extremities. Between August 1999 and October 2000 five children were treated by this system. Four had shortened and deformed femurs after fracture, osteomyelitis or a congenital short femur. One patient had a pseudoarthrosis of the tibia. Mean corrections were leg lengthening 5.9 cm (1.7-7.2), valgus correction 10.6 degrees (0-19), lateral translation 12.6 mm (0-33) and rotation 10 degrees. The mean healing index was 48.4 days/cm. In all patients the bones fused without major complications. We recommend the Taylor spatial frame for corrections of complex limb deformities.

Adolescent↗
PubMed1995

[Quantitative follow-up of callus distraction with dual-energy roentgen absorptiometry (DEXA)].

With dual-energy X-ray absorptiometry (DEXA), bone mineralization during and after limb-lengthening procedures with unilateral fixators can be monitored quantitatively and precisely with low radiation exposure. We measured prospectively the bone mineral density (BMD) in the newly formed callus, in the bone adjacent to the callus and in the proximal femur in 21 patients with leg lengthening of the femur and/or tibia with unilateral external fixators. Mineralization showed a typical course with a peak value of 0.365 +/- 0.196 g/cm2 (30.9% of the first value) at 6-8 weeks after the beginning of distraction and a minimum value at the time of maximum distraction. In the consolidation period BMD in the distraction gap increased to 1.020 +/- 0.234 g/cm2 (87%) at the time of fixation removal. BMD in the regenerated bone increased faster in regions of interest (ROIs) opposite the fixator compared to ROIs near it. Dynamization of the fixation device led to a 13% increase in mineralization velocity (VBMD). On the other hand, dynamization caused more homogeneous regeneration equalizing VBMD in the different ROIs as well. BMD in the proximal femur of the leg operated on decreased to 67% and in the contralateral leg to 87% of the preoperative value. We consider DEXA to provide a precise and quantitative assessment of callus and bone mineralization during limb lengthening with unilateral fixators. Since we are well aware of the limitation of the technique. DEXA helps to understand what is happening in limb-lengthening procedures by providing quantitative values.

Absorptiometry, Photon↗
PubMed1986

Congenital aplasia of the cruciate ligaments. A report of six cases.

Instability of the knee is frequently found in association with congenital leg-length discrepancy. We have studied six such patients clinically, radiologically and arthroscopically. Clinical signs of knee instability and significant radiological changes were present in all, and at arthroscopy the anterior cruciate ligament was completely absent in four patients and functionless in the other two. This deficiency appears to be a congenital condition which may predispose to meniscus injury or retropatellar pain; it may also lead to subluxation or dislocation of the knee during leg-lengthening procedures.

Adolescent↗
PubMed1996

Fibular hemimelia: a preliminary report on management of the severe abnormality.

The introduction of Ilizarov leg lengthening techniques has allowed a change in philosophy in treatment of fibular hemimelia. Between January 1990 and October 1993, eight patients with 10 involved extremities underwent correction of severe grades of fibular hemimelia by the Ilizarov technique. Mean follow-up from operation was 26.7 months. Because the lengthening desired was achieved in all cases, this form of treatment is an attractive alternative to the more traditional Syme's amputation. However, complications are common. Frequency and severity of complications apparently is less in younger patients who require less extensive, staged lengthening.

Abnormalities, Multiple↗
PubMed1996

Management of forme fruste fibular hemimelia.

Children with fibular hypoplasia and three-or four-ray feet have a forme fruste of congenital short tibia with absent or dysplastic fibula. We outline the criteria for management of this condition. Although fibular deficiency can be considered benign, two thirds of our patients underwent operation. Leg length inequality may require epiphysiodesis, leg lengthening, or simply a shoe raise. Only very occasionally, when the foot is nonfunctional, is amputation through the ankle undertaken.

Adolescent↗
PubMed1977

[Can bone growth be stimulated (author's transl)].

UNLABELLED: Stimulation of bone growth by heterologous (bovine) bone grafts may help in leg length discrepancies. Arrest of epiphyseal growth plates or leg lengthenning by osteotomy may be necessary to a lesser extent or be entirely unnecessory. MATERIAL: 72 cases, 88 stimulations in 16 years.

Adolescent↗
PubMed2000

Correction of complex lower limb deformities by the Ilizarov technique: An audit of complications.

This is an audit of complications resulting from correction of complex lower limb deformities by the Ilizarov technique. 33 patients (40 bone segments) were reviewed and divided into 4 groups according to the type of surgery carried out: limb lengthening and/or correction of deformity, bone or joint stabilisation, treatment of nonunion or bone defect, angular and/ or rotation correction. Most minor complications were fixator specific. Pin tract infections were almost universal but responded well to oral antibiotics and rarely resulted in osteomyelitis. Major complications were procedure specific and more common in those patients who underwent leg lengthening, treatment for nonunion and bone transport. There was also a high incidence of nerve injury as a result of acute angular deformity correction. Despite the high complication rate the Ilizarov technique remains an effective tool for complex lower limb reconstruction surgery.

Journal Article↗
PubMed1989

[Congenital pseudarthrosis of the legs and the Ilizarov method. Apropos of 4 cases].

Four cases of congenital pseudarthrosis were treated by the Ilizarov method and consolidation obtained by 3.5 months in three patients who had all undergone several previous surgical procedures. Although the length of follow up is short (maximum 3.5 years) consolidation occurred quicker than by traditional methods. This technique also permitted both simultaneous correction of axial malalignment and leg lengthening. We think that this method has a place as a salvage procedure except where the distal fragment is very thin or dystrophic.

Adolescent↗
PubMed1999

Treatment of achondroplasia with growth hormone: six years of experience.

We describe the effects of recombinant hGH (r-hGH) therapy for up to 6 y on stature and body proportions of 35 children with achondroplasia (Ach). Consecutive height (Ht) measurements were plotted on disease-specific Ach growth curves, but age and sex SD scores (SDS) of Ht, sitting Ht, subischial leg length, and Ht velocity were made with respect to Tanner normal standards. r-hGH was administered by daily subcutaneous injections at a median (range) dose of 30 (15.8-40) U/m2 per week [0.06 (0.04-0.08) mg.kg(-1).24 h(-1)]. Patients were treated for 3 (1-6) y from age 2.25 (1.2-9.3) y. Before treatment, Ht SDS was -4.6 (-6.5 to -3.24). Treatment caused a significant increase in Ht SDS year to year until y 4 (ANOVA F = 46.94; p < 0.01) that was subsequently sustained with no significant further change (y 5 and 6 versus y 4, p > 0.05). When the response to r-hGH was also expressed as a change in Ht velocity, there was a significant increase in the first year of therapy that was maintained over subsequent treatment years (ANOVA = 4.28, p = 0.001). Age was the most important variable accounting for the first-year response in Ht SDS (r2 = 0.41, p < 0.001), and dose of r-hGH did not influence this. Increments in sitting Ht SDS were greater than subischial leg length SDS (F = 26.25, p < 0.001; F = 9.04, p < 0.001, respectively). r-hGH treatment improved the Ht position of Ach children relative to their normal and Ach peers without obvious side effects. A young age at initiation of therapy prevented the characteristic Ht deficit from accumulating. The greater increase in spinal Ht accentuated the existing disproportion. The addition of later surgical leg lengthening could offer the possibility of proportionate adult stature just within the normal range.

Achondroplasia↗
PubMed1980

[Elongation of the leg with the Kawamura-method (author's transl)].

Results of leg lengthening with the Kawamura method are reported here. This procedure was in 8 cases, where a 2,8--4,0 cm (i.e. 10%) lengthening was achieved. There were 2 transient peroneal palsies and in one case bony union was achieved with autologous bone transplantation for delayed healing. In correctly selected cases even 3--8 cm shortening can be safely managed with this method.

Adolescent↗
PubMed2006

Optimum loading mode for axial stiffness testing in limb lengthening.

The axial stiffness of the regenerate is an indicator of bone healing after fracture or distraction osteogenesis. The axial stiffness may be assessed clinically by measuring the sharing of load between fixator and limb during loading. The aim of this study was to find out how to perform the stiffness test in order to minimize the influence of confounding factors to the test result. We investigated whether the test score was influenced by two factors: 1) the magnitude of the external load applied to the limb during the test; and 2) the patient's position during the test. The problem was approached by both a clinical study and by theoretical calculations. Thirty-three patients undergoing leg lengthening were tested regularly during the consolidation period. The stiffness test was executed with both high and low load, and in a standing and sitting position. There were significant differences in results between both the tests with high and low load, and between the standing and sitting tests. This indicated that both the magnitude of force and patient position during the test influenced the test result. Accordingly, these factors represent sources of error and must be taken into consideration when performing an axial stiffness test. The result of the theoretical calculations confirmed the result. We recommend performing the test while the patient is sitting, and to apply no more than 20% of the individual's body weight. It is also recommended that the same load be used in every test, when testing a patient several times during the treatment period.

Adolescent↗
PubMed2000

The effect of anatomical positional relationships on kinetic parameters after total hip replacement.

The purpose of this study was to evaluate the significance of positional relationships of the components on gait after total hip replacement (THR). Gait was analysed using multicomponent force platforms integrated into a treadmill, in conjunction with an optoelectric measuring system. 26 patients, after undergoing total hip replacement, were classified according to the vertical and horizontal positions of the centre of rotation, the vertical position of the femur and the functional leg length, and compared with a control group. Deterioration in parameters of gait was observed following cranialisation of the centre of rotation or of the femur, whereas neither medial movement of the centre of rotation nor leg lengthening by up to 1 cm had any effect. This study emphasises the importance of considering, at the time of preoperative planning, the effect of the position of the prosthesis on the functional parameters of gait.

Adult↗
PubMed1995

A graphic method for timing the correction of leg-length discrepancy.

We have developed a clinical method for the graphic recording, analysis and planning of treatment of leg-length discrepancy during growth. Initially, the clinically determined discrepancy is plotted against the chronological age yearly, and then in late childhood at six-monthly intervals. CT and measurements of skeletal age are made in middle and late childhood to confirm the clinical findings. In a prospective study in 20 children, we observed that only eight had a linear increase in discrepancy. The observed pattern of increase was therefore used to estimate the mature discrepancy. Epiphyseodesis reference slopes were used to determine the most appropriate time and type of epiphyseodesis. In all children, the leg-length discrepancy at maturity was within 1 cm of the predicted amount. Changes in discrepancy due to leg lengthening or correction of deformity were also plotted graphically. We conclude that the clinical graphic method is simple to use, takes into account the varying patterns of discrepancy, and minimises radiation dosage.

Age Determination by Skeleton↗
PubMed1990

Response of the growth plate to distraction close to skeletal maturity. Is fracture necessary?

Axial force applied during epiphyseal distraction has been measured close to skeletal maturity in patients having leg lengthening, in a rabbit model, and in vitro from an amputation specimen. In the patient study, both slow distraction rates and low constant distraction loads were applied. For all the distraction regimens, it was not possible to lengthen the limb significantly without evidence of fracture as demonstrated by a sudden decrease in distraction force. Growth plate failure was observed from 600 to 800 N, these levels being lower than those recorded from the in vitro tests. In the animal study, three distraction regimens (0.13, 0.26, and 0.53 mm/day) were applied across the upper tibial growth plate of New Zealand white rabbits close to skeletal maturity. Distraction was applied and force measured using a strain-gauge dual-frame external fixator. The force-time results revealed two distinct patterns. One pattern, in which the forces rapidly increased to maximum values of approximately 25 N and then suddenly decreased, indicated fracture of the growth plate, which was confirmed histologically. In the other pattern, forces increased steadily throughout distraction, reaching maximum values at the end of distraction of approximately 16 N. Histologic observations indicated hyperplasia of the growth plate without fracture, however, only a small increase in limb length was detectable. Hence, if a significant increase in leg length is required close to skeletal maturity, then fracture of the growth plate must occur.

Adolescent↗
PubMedDate not supplied

Limb lengthening and correction of angulation deformity: immediate correction by using a unilateral fixator.

We performed limb lengthening (callus distraction) with immediate correction of the angulation deformity in 11 patients (16 long-bone segments) in Chiba Children's Hospital. The operated segments were 14 tibias and two femurs. The average age at operation was 12.0 years (range, 4.8-15.3). All had varus deformities and limb shortening. We used the Orthofix unilateral fixator in all cases. The following two types of osteotomy were selected, depending on the degree of the varus deformity: opening wedge osteotomy if it was < 20 degrees or dome osteotomy if > 20 degrees. The average amounts of the leg lengthening and the correction angle were 32.4 mm (range, 20-50) and 23.8 degrees (range, 15-40 degrees). The average of the healing index was 32.6 days/cm (range, 28.5-36.8 days/cm). There was also no difference in healing index between the two osteotomies groups, despite the greater angular correction in the dome osteotomy group. We concluded that our method of lengthening with immediate correction of deformity was a very simple and effective method.

Bone Diseases, Developmental↗
PubMed1988

Limb lengthening by low rate epiphyseal distraction. An experimental study in the caprine tibia.

Low-rate epiphyseal distraction of the left proximal tibia using a modified bilateral Hoffmann external fixation device, was accomplished in 14 goats (age 6-7 months). Daily distraction at a rate of 0.5 mm was continued for 5.5 weeks. Epiphysiolysis occurred after 5-9 days. After distraction had been discontinued, the external device was left in situ for fixation for 4 weeks. The animals in group 1 (n = 6), group 2 (n = 3), and group 3 (n = 5) were killed at 4, 16, and 32 weeks, respectively, from the end of the distraction period. The proximal growth plate of the elongated tibia appeared radiolucent at the conclusion of the study but was less distinct and reduced in height as compared with the control leg. The gained length at the end of the distraction period was on the average 2.2 cm (11.9%). This gain in length was reduced with further growth. In group 3, the final gain in length was reduced to half. A reduced cortical thickness of the bone within the area subjected to distractional force was observed. This finding is attributable to stress protection. An interesting observation comparing control and operated tibia was an increase of the cross-sectional diameter of the elongated bone. Both tibiae of all animals were tested mechanically. The torsional strength of the elongated tibiae as compared with controls was on the average 29% in group 1, 79% in group 2, and 95% in group 3. We conclude that leg lengthening by low-rate epiphyseal distraction in the proximal tibia is a justifiable alternative to other lengthening procedures in individuals approaching adolescence. In juveniles, lengthening by epiphyseal distraction may result in reduction in the longitudinal growth.

Animals↗