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From 1998 to 2001, 112 lengthening procedures with or without deformity correction were performed in 108 children by external fixation with the Ilizarov method. Of these cases, 16.9% did not lead to a solid bone consolidation. Two children were operated the second time, mainly because of the parent's decision. Seventeen delayed unions or nonunions in 13 children were treated with low-intensity pulsed ultrasound. All 17 cases healed within 3 to 12 months without any risk of surgical intervention.
STUDY DESIGN: Prospective longitudinal study. OBJECTIVE: To determine factors predictive of loss of movement in a cohort of patients undergoing femoral lengthening. BACKGROUND: Loss of joint movement due to poor adaptation of the muscle is a major problem during limb lengthening but remains poorly documented in the literature. METHODS AND MATERIALS: A validated technique using a modified goniometer was used to measure knee motion. Measurements were taken before surgery, prelengthening, during lengthening, and at 6 and 12 months post frame removal. The subjects were 35 patients with a mean age of 22 years (+/-12.8 years), 23 men and 12 women, undergoing femoral lengthening by the Ilizarov method. RESULTS: The pattern of recovery of knee range of movement that was observed showed that 88% of knee flexion was regained by 6 months, 92% of patients regained their knee flexion by 12 months, and 97% by 18 months. Significant loss of knee flexion occurred in the latent period prior to lengthening, mean loss 79 degrees (+/-22.8 degrees). All patients regained full knee extension by the end of lengthening, but 2 patients who had fixed flexion deformities of > 40 degrees developed posterior subluxation of the knee. CONCLUSIONS: The unexpected loss of movement observed in the prelengthening period indicates that physical therapy efforts must be directed to this phase in order to accelerate the recovery of joint range and reduce the muscle-related complications that can occur during limb lengthening.
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30 operative lengthenings of the lower limb had been performed during 1967 til 1981, all of them after the method described by Wagner. Indication of this treatment was given by a legshortening from minimum 4.0 and maximum 15.0 cm. Twelve lengtheningosteotomies occurred in the thigh, two in the thigh under simultaneous shortening of the opposite side and sixteen in the lower leg. In eight patients resulted a complete compensation, in 21 patients remained a length -- difference between 0.5 until 6.0 cm., in one patients resulted a further legshortening in account of a pseudarthrosis. The following severe complications occurred: necrosis of the skin (n = 3 and infected pseudarthrosis (n = 2). In one case we observed a fatigue fracture in the lower leg when taking away the metal plate. All of these complications could be cured under adequate surgical management.
Transiliac limb lengthening osteotomy is a modified Salter innominate osteotomy which uses a trapezoidal interposition bone graft instead of the usual triangular graft to achieve up to 3 cm of intrapelvic lengthening. It allows correction of certain forms of postural imbalance and pelvic obliquity, as well as allowing an optimal and variable amount of acetabular redirection. This review of 105 patients who have undergone the procedure at our institution revealed the following indications: decompensated scoliosis, 26 patients; acetabular dysplasia with ipsilateral femoral shortening, 34 patients; intrapelvic asymmetry, 7 patients; pure limb length inequality, 38 patients. Intrapelvic lengthening averaged 2.5 cm. Correction of decompensated scoliotic curves averaged 7 degrees reduction in Cobb angle. Improvement in center-edge angle in patients with hip dysplasia averaged 17 degrees. Reduction in size of shoe lift required to balance the trunk in all cases was correlated closely with the intrapelvic lengthening achieved. Complications included two transient neurapraxias (one femoral, one femoral and sciatic), two cases of sacroiliac subluxation (one patient with myelodysplasia, and one patient with polio), three cases of partial graft collapse, and six instances of broken fixation pins, and three deep wound infections. No patient had chondrolysis or avascular necrosis of the femoral head. After average follow-up of nearly 5 years (minimum follow-up 2 years), patients who underwent transiliac limb lengthening osteotomy for correction of postural imbalance for various causes retained satisfactory correction.
Spinal dysraphism may lead to limb inequality and foot deformities. Fears have been expressed regarding limb lengthening in such patients because of potential sequelae in relation to their peripheral neurologic abnormalities. We performed Ilizarov lengthening of the lower limb on seven community walkers with spinal dysraphism. The procedure was well tolerated with no increase in sepsis, soft-tissue, or bony complications compared with patients undergoing lengthening for reduction anomalies. All the patients mobilised rapidly after frame application and returned to their previous functional level within 3 months of plaster removal.
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The albizzia femoral nail allows for lengthenings up to 10 cm. It can be used in achondroplastic patients. Multiplane corrections can be addressed with a special nail (3D-Albizzia) if multiple osteotomies are performed (e.g. for proximal and distal femoral varus). A derotation and a flexion/extension osteotomy can also be associated. IM nailing is suitable for patient with previous external fixators. Surgical planning should be careful. The operation is currently performed percutaneously, with a 1 to 2 cm skin incision for nail insertion, and a 6 mm incision for distal femoral dome osteotomies. CPM machine is applied in recovery room and rehabilitation resumes on day 1, allowing more than 120 degrees of knee flexion by day 1. Ratcheting for gradual lengthening is begun on day 5 at a rate of 1 mm/day. Muscle stretching and strengthening are maintained for one year. In bilateral cases, a preoperative strengthening program is set. A 120 degrees knee range of motion can be maintained all during lengthening. Intramedullary lengthening allows for maintaining muscle and soft tissue suppleness which protects from hyperpressure over joints and from long-term muscle waisting. The Albizzia is currently a good tool once the surgeon get used to its physiotherapy aspect. Previously reported general anaeshtesia for getting the ratcheting is barely needed, when the technique has been done percutaneously and when the full range of knee motion is recovered on day 1 and maintained thereafter.
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We performed a comparison of the effects of two bisphosphonates, pamidronate and zoledronic acid, on regenerate bone mineral content in distraction osteogenesis in an immature rabbit model. Single dose zoledronic acid was found to be 18 times more potent at producing an increase in bone mineral content than pamidronate per mg/kg of drug infused at surgery. Histological examination of all rabbit kidneys was performed at trial completion. Nephrocalcinosis was identified in 14 of 20 kidneys of rabbits infused with pamidronate, but was not detected in the 20 kidneys of those rabbits infused with zoledronic acid. A further 20 kidneys from rabbits given a second dose of zoledronic acid were also found to be free of signs of nephrocalcinosis. Three of 40 control kidneys exhibited signs of nephrocalcinosis. The increased potency of zoledronic acid allowed us to give one-tenth the dose of pamidronate, with increased therapeutic efficacy and no evidence of nephrocalcinosis.
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Osteotomy and gradual distraction of the distal radius was performed on 12 sheep. After 3-6 weeks of daily distraction by external fixation, lengthening of 0.5-1.8 cm was achieved. Three weeks after distraction was begun, striae of new bone, organized in the direction of the distraction, were noted radiologically. The bony consolidation developed from the osteotomized bone ends to the center of the distraction area. Medullary structures also contributed to bone formation in the distraction area. Collagen bundles, organized in the direction of distraction, formed a template for the developing bone. The medullary canal remodeled 16 weeks after the operation. Solid bone formed after the distraction procedure with no additional bone transplantation.
Limb lengthening by means of distraction through the callus of a knee arthrodesis was performed in a 14-year-old boy with congenital hypoplasia of one lower limb. Knee arthrodesis was indicated because of destruction of the distal femoral epiphysis caused by a previous bone lengthening procedure.
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The effect of lengthening the tibia, by callotasis on the articular cartilage in the knee, was investigated histologically in 18 rabbits. The distraction rate was 1 mm per day. On the right tibia, the distraction frequency was in 2 steps (0.5mm/12 hours), while on the left it was in 120 steps (0.0083 mm/12 minutes). The 18 animals were divided into 3 subgroups based on length gain. Cartilage and subchondral bone samples were examined by light and fluorescent microscopy. The incidence of cartilage degeneration on the 2-step side was 2/5, 5/6, and 6/7 at 10, 20, and 30 percent length increases. On the 120-step side it was 0/5, 1/6, and 1/7 at the same length increases. The intensity of tetracycline fluorescence of the subchondral plate on the 2-step side was higher than that on the 120-step side, showing 1.7, 2.0, and 2.3-fold increases at 10, 20, and 30 percent length increases. Our study suggests that increasing the frequency of distraction in callotasis can help to prevent damage to articular cartilage in adjacent joints.