Long-term results of lower limb lengthening by physeal distraction

Of the many methods of limb elongation, lengthening by physeal distraction is among the newest. The goal of this study was to estimate the long-term results of femoral and tibial lengthening by epiphyseal distraction. The authors examined 40 patients who underwent 24 femoral and 16 tibial lengthenings. The average follow-up period was 9.6 years. An average of 4.6 cm of femoral lengthening and 4.7 cm of tibial lengthening was achieved. The femoral healing index was 38.1 days/cm and the tibial healing index was 35.7 days/cm. After lengthening the epiphyseal cartilage started to function in all patients, and premature growth cartilage fusion was not observed during follow-up. Complications occurred in eight patients during femoral lengthening and in four during tibial lengthening. The authors suggest that physeal distraction is a good method for moderate and simple limb lengthening. Particular care should be applied to knee joint function, especially during femoral lengthening.     

The value of selected imaging techniques in evaluation of bone regeneration during limb lengthening]

The paper presents the value of different imaging techniques, including X-rays, ultrasonography, computed tomography and densitometry in the evaluation of bone regenerates during limb lengthening. Material consisted of 60 children, age ranging from 4 to 18 years who underwent surgery using the Ilizarov technique because of limb inequality. During of limb lengthening different imaging techniques were employed for monitoring regenerate growth and remodeling. The study showed that all the employed imaging techniques play an important role in monitoring bone regenerate remodeling at different stages of limb lengthening.     

Attempted limb lengthening by physeal distraction. Continuous monitoring of an applied force in immature rabbits

The effectiveness of physeal distraction in stimulating bone growth in animals was investigated by force applied to the distal femoral growth plate of immature rabbits. The system was continuously monitored to detect physeal separation. A distraction of 0.25 mm every 12 hours led to physeal separation in five animals. One animal given a 6-kg force and two of seven given a 4-kg force showed physeal separation. All four rabbits given a 2-kg force and five of seven given a 4-kg force did not show a greater increase in length than the control femurs. Bone growth was not stimulated by physeal distraction. Any increase in length of more than the normal growth is attributable to physeal separation.     

Protocol of lower limb lengthening with the Ilizarov method]

The aim of this study is simplification of treatment monitoring, along with assessment of the passed and present state of the therapeutic process. Strategy of treatment with Ilizarov technique is presented. It is based on a short stay on the ward after performing the Ilizarov procedure (about 2 weeks), with most of the therapeutic process realised at home with support from the outpatient clinic. During the distraction phase patients are checked up at the outpatient clinic once a week, while during the consolidation phase once every 3-6 weeks. An original patient monitoring technique is presented. The protocol allows collecting the most important information in a comprehensive way for fast clinical evaluation and research.     

Problems, obstacles, and complications of limb lengthening by the Ilizarov technique

Difficulties that occur during limb lengthening were subclassified into problems, obstacles, and complications. Problems represented difficulties that required no operative intervention to resolve, while obstacles represented difficulties that required an operative intervention. All intraoperative injuries were considered true complications, and all problems during limb lengthening that were not resolved before the end of treatment were considered true complications. The difficulties that occurred during limb lengthening include muscle contractures, joint luxation, axial deviation, neurologic injury, vascular injury, premature consolidation, delayed consolidation, nonunion, pin site problems, and hardware failure. Late complications are those of loss of length, late bowing, and refracture. Joint stiffness may also be a permanent residual complication. Pain and difficulty sleeping are other problems that arise during limb lengthening, especially in the more extensive cases. Forty-six patients had 60 limb segments lengthened between 1.0 and 16.0 cm, with a mean of 5.6 cm. The average treatment time was approximately one month per centimeter for single-level lengthenings with no deformity and 1.2 months per centimeter with deformity correction. The lengthening index for double-level lengthening was 0.57 month per centimeter with no deformity and 0.90 month per centimeter with correction of deformity. In adults, the lengthening index was 1.7 months per centimeter for single-level and 1.1 months per centimeter for double-level lengthening. There were 35 problems that had to be resolved in the outpatient clinic. There were 11 obstacles that required additional operative intervention to resolve. There were 27 true complications, of which 17 were considered minor and ten were considered major complications. Of the major complications, three interfered with achieving the original goals of treatment. All three required further operative intervention to achieve the original goal. These were nonunion in one and late bowing in two. Despite these problems, obstacles, and complications, the original goals of surgery were achieved in 57 of the 60 limb segments treated. Patient satisfaction was achieved in 94% of 46 cases.     

The value of ultrasonography in monitoring limb lengthening]

The authors attempted to assess the value of ultrasound for monitoring of the new bone formation at the site of distraction in patients undergoing limb lengthening after Bastiani. Twenty patients were assessed; 12 cases of femur lengthening and 8 cases of tibia lengthening. It was found, that ultrasound allowed to detect the new bone formation visible as hyperechogenic foci as soon as 4 to 14 days postoperatively, while regular radiology showed this only 4 to 8 weeks after operation. Detection of the new bone formation at the site of lengthening permits, in authors opinion, to choose an optimal onset of distraction and its pace according to the speed of bone formation. Regular ultrasound monitoring prevents premature bone union or disintegration of the newly generated bone in case of to slow or to fast distraction respectively. In two cases sonography early demonstrated cystic changes at the location of distraction. It also permits detection of an axial displacement of the fragments of bone in every case.     

Long-term results of lower limb lengthening by the Wagner method

Methods of limb lengthening have been continuously modified. The construction of an apparatus for gradual bone distraction was a great improvement. The aim of this study was to evaluate the long-term results of lower limb elongation using the Wagner technique. Between 1983 and 1989, 45 patients underwent surgery in the authors' institution. There were 31 femoral and 15 tibial lengthenings. The operation and lengthening procedure were performed according to the rules published by the method's author. The intended amount of lengthening was achieved in 80% of patients during tibial elongation and in only 52% during femoral elongation because of many problems, obstacles, and complications during treatment. A significant percentage of improper (deficient or irregular) new bone formation led to femoral malunion in three patients and to tibial and femoral delayed bone consolidation in six patients. Fast distraction produced great forces on the surrounding joint surfaces, resulting in a limited range of motion and joint stiffness. The Wagner technique does not seem to be effective and is associated with a long duration of treatment and some complications impairing the function of the limb.     

Benefits of Ilizarov automated bone distraction for nerves and articular cartilage in experimental leg lengthening

AIM To determine peculiarities of tissue responses to manual and automated Ilizarov bone distraction in nerves and articular cartilage.METHODS Twenty-nine dogs were divided in two experimental groups: Group M-leg lengthening with manual distraction(1 mm/d in 4 steps), Group A-automated distraction(1 mm/d in 60 steps) and intact group. Animals were euthanized at the end of distraction, at 30 th day of fixation in apparatus and 30 d after the fixator removal. M-responses in gastrocnemius and tibialis anterior muscles were recorded, numerical histology of peronealand tibialis nerves and knee cartilage semi-thin sections, scanning electron microscopy and X-ray electron probe microanalysis were performed.RESULTS Better restoration of M-response amplitudes in leg muscles was noted in A-group. Fibrosis of epineurium with adipocytes loss in peroneal nerve, subperineurial edema and fibrosis of endoneurium in some fascicles of both nerves were noted only in M-group, shares of nerve fibers with atrophic and degenerative changes were bigger in M-group than in A-group. At the end of experiment morphometric parameters of nerve fibers in peroneal nerve were comparable with intact nerve only in A-group. Quantitative parameters of articular cartilage(thickness, volumetric densities of chondrocytes, percentages of isogenic clusters and empty cellular lacunas, contents of sulfur and calcium) were badly changed in M-group and less changed in A-group.CONCLUSION Automated Ilizarov distraction is more safe method of orthopedic leg lengthening than manual distraction in points of nervous fibers survival and articular cartilage arthrotic changes.     

Denervation impairs bone regeneration during distraction osteogenesis in rabbit tibia lengthening

Background and purposes The nervous system plays an important role in bone metabolism. However, the effect of denervation on bone formation during distraction osteogenesis (DO) remains unclear. We studied neural influence on bone regeneration during DO in a rabbit model. Methods 24 New Zealand male white rabbits underwent left tibial osteodistraction. Before distraction, the animals were randomly divided into group R (resected left sciatic nerve) and group I (intact left sciatic nerve). 8 weeks after completion of distraction, the animals were killed and the lengthened tibias were harvested for radiography, micro-CT, histological evaluation, and mechanical testing. Results New regenerated bone was present in the distraction gaps of all animals at the end of the study, as revealed by radiography, micro-CT, and histology. However, less new bone formation and a lower degree of mineralization were observed in group R. The mechanical strength of the distraction gap in group I was 1.3-fold greater than that in group R when measured using the 3-point bending test. Interpretation The results suggest that the nervous system plays an essential role during DO: the denervation appears to have an inhibitory effect on bone formation.     

Biochemical and anatomic changes in the muscles after leg bone lengthening by the Ilizarov method]

In process of crus lengthening, following the method, given by Ilizarov G. A., with 22 adult patients have been studied the peculiarities of metabolic processes of muscle tissue of the lengthened segment as well as the muscle tissue structural changes. As the tests were used; determination of lactate dehydrogenase content and its isoenzymatic spectrum in the blood serum, the residual products of lactic and pyruvic acids glycolysis, relating to the higher indications of the internal medium of an organism; carboxylase activity detection. Energy provision of an organism was estimated according to the ATP content; anatomical state of muscles of the lengthened extremity segment and muscle tissue structure were estimated by means of contrast myography. Dynamics of biochemical indexes suggests that the sparing character of an operation, patient mobility from the first days, preservation of locomotive and supporting function contribute to prevention of metabolic disease and ensure earlier transformation of catabolic reaction to anabolic one. Carboxylase and lactate-dehydrogenase activity increase indicates the biochemical adaptation of an organism. Metabolic changes well correlate with the detected structural changes in the lengthened crus muscles.     

Biomechanical studies of forces occurring in the Ilizarov and Orthofix apparatuses during limb lengthening by distractive osteogenesis]

The magnitude of the distractive forces occurring in the Ilizarov and Orthofix apparatuses during limb lengthening by distractive osteogenesis has been investigated. Eighteen patients treated between 1995 and 1998 were included in the study. The data obtained were computerized and related to clinical, radiographic and sonographic findings. Typical and repeatable graphs of forces were found during the process of lengthening as well as typical relationships between the callus and the values of distractive forces.     

The changes in bone mineral content in experimental limb lengthening]

The results of bone mineral content measurement in experimental limb lengthening are reported. The results demonstrated that in the restoring process, both the strength and the stiffness of the lengthened bone are positively correlated to the relative bone mineral content with coefficients of correlation 0.59 (P < 0.001) and 0.85 (P < 0.001) respectively. Analyses of curve fitting showed that the strength is directly proportional to the 1.7479 th power of bone mineral content and the stiffness to its 2.05842 th power Hence, the authors consider that bone mineral content measurement could be used as a noninvasive index for monitoring the changes of bone strength and stiffness during recovering process of bone lengthening.     

Bilateral simultaneous limb lengthening of patients with short stature using the Ilizarov method]

Limb lengthening of patients with short stature is a complex orthopaedic problem. In these cases treatment is a long-term, multistage procedure. This paper presents the results of lower limb lengthening using the Ilizarov technique. The material consists of 5 cases, in which 10 stages of bilateral simultaneous lengthening of the femur and opposite tibia were performed. Follow-up was on average 3.1 years. Problems, obstacles and complications were typical for limb lengthening procedures and did not differ from the results presented by other authors. Success of treatment depends on the patient's full co-operation, adequate motivation and knowledge of the principles of therapy.     

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.     

Limb lengthening in children and osteogenesis using the technics of Wagner and Ilizarov and their modifications

Different methods of lower limb lengthening are reviewed, related to delays in strengthening and type of callus: Wagner's technique (5 cases), decortication 3 weeks before osteotomy (1 case), and Ilizarov's technique (10 cases on 8 tibiae and 6 femurs). In 5 cases, decortication with osteotomy-closure and waiting 2 weeks before beginning lengthening, was performed. This was carried out at 1 mm/day. The type of fixator is unimportant. This technique allows a restitution of the tubular bone structure in 3 or 4 months in a periosteo-cortico-medullary callus.     

Humeral lengthening and bone transport using the Ilizarov technique.

The authors present their results of Ilizarov treatment of eight humeral length deficits and bone defects in seven consecutive patients treated at the Hospital for Joint Diseases. The mean humeral lengthening achieved was 9.8 cm. The lengthening goal was completely achieved in six cases, while two cases achieved over 80% of the desired length. No permanent neurovascular or infectious complication occurred. The authors suggest that the Ilizarov technique is a viable method in treating severe humeral length deficits or bone defects.