Limb lengthening in achondroplasia by Ilizarov's method

Summary In achondroplasts limb lengthening can restore the normal proportion of the body. The Ilizarov method of limb lengthening has been used in 37 patients, 23 of whom have had an adequate follow-up after operation. In this technique the cortex of the bone is partially cut, leaving the medulla intact; the two bone segments are then subjected to distraction by means of a special apparatus. The bone tissue between the two segments starts regenerating and this allows a considerable increase in length. The results and complications are reported. It is considered that this method is based on sound principles and is free of major risks.

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Résumé Chez les achondroplases l'allongement des membres rétablit les proportions corporelles. La méthode d'Ilizarov a été utilisée avec succès dans une série de 37 cas, dont 23 ont été revus avec un recul de deux à quatre ans. Après corticotomie, respectant le canal médullaire, en exercant une distraction progressive des deux fragments on obtient dans la zone de section une régénération osseuse qui permet des allongements considérables. Les auteurs rapportent leurs résultats et leurs complications, ils pensent que cette méthode est valable et dépourvue de risques importants.

     

Clinical and biochemical indicators in patients undergoing limb lengthening using Ilizarov's method

The authors report that in 33 patients who underwent stretching of the extremity by the method of dosed distraction after G. A. Ilizarov following corticotomy there were no significant changes in a number of biochemical values (serum concentrations of general protein, albumin, urea, uric acid, glucose, cholesterol, triglycerides, magnesium, chlorides). The level of other values (alkaline phosphatase and lactate dehydrogenase enzymes, etc.) increased and sometimes exceeded the physiological limits of its age group, but did not exceed the normal limits in the population as a whole. A reliable change in the values was observed with their level being higher during the period of natural growth because of intensification of anabolic processes and growth of the mass of organs and tissues or increase in their function. A rise in serum concentrations of calcium, phosphate and hydroxyproline with the urine demonstrates in combination with the data of biphoton densimetry of the skeleton and distraction regenerate that at the same time with improved absorption of electrolytes in the intestines during distraction there was an activation of mobilization of the minerals from the intact skeleton. A problem of adequate consumption of mineral substances with the food is put forward.     

Knee arthrodesis with simultaneous lengthening using the Ilizarov method

OBJECTIVE: To determine whether knee arthrodesis with simultaneous lengthening using the Ilizarov method for a nonreconstructable knee joint with bone loss and infection is a successful salvage procedure. DESIGN: Retrospective review of patients. SETTING: University hospital-based orthopaedic practice. PATIENTS: From 1999 to 2001, 4 consecutive patients with a nonreconstructable knee joint, bone loss, and infection after trauma underwent knee arthrodesis with simultaneous lengthening. INTERVENTION: Arthrodesis of the knee with simultaneous limb lengthening through an osteotomy of the tibia and/or femur and the use of an Ilizarov frame. External bone stimulation was used at the knee arthrodesis site and the lengthening sites. Application of this device began during the early distraction phase and continued until frame removal. MAIN OUTCOME MEASURES: Bony union at the arthrodesis and bone lengthening sites, alignment of the lower extremity, limb length discrepancy, infection, pain, and outcome scales (SF-36 scores and American Academy of Orthopaedic Surgeons lower limb modules). RESULTS: Bony union of the knee arthrodesis and lengthening sites and good alignment were achieved in all 4 patients. Mean amount of lengthening was 5.4 cm (range 2.5-11.5 cm). Average time in frame was 11 months (range 6-17 months). Limb length discrepancy after treatment averaged 1.8 cm (range 0.6-3.7 cm). Mean duration of follow-up after frame removal was 35 months (range 28-48 months). At follow-up, infection had not recurred, pain was not present, and assistive devices were not needed for ambulation. Average SF-36 scores improved in all 8 categories, and the average American Academy of Orthopaedic Surgeons lower limb modules improved from a mean of 33 (range 11-37) to a mean of 68 (range 51-76). CONCLUSION: Knee arthrodesis with simultaneous lengthening can be performed successfully using the Ilizarov method. It enables surgeons to optimize limb length during knee arthrodesis. The use of external fixation and the avoidance of internal implants may be advantageous in the presence of or history of infection. The Ilizarov frame provides stability that allows weight bearing during treatment.     

Vascularization of the crus in defect substitution by lengthening of fractured fragment using Ilizarov's method (an experimental study)

Crus vascularization in case of substitution of diaphysial defect of tibia by means of proximal fractured fragment lengthening have been studied by anatomo-functional methods in the experiment with 16 dogs. The results of the experiment demonstrated unequal increase of crus blood-filling with localization of the maximum vascularization zone in the projection of a distraction regenerate, displaced fragment and adjoining bone ends. Increase of the operated segment vascularization was caused by dilatation of circulatory channel and formation of new vessels in tissues, subjected to distraction. Tissue hypervascularization in case of distraction of the osseous fragments in defect is a natural reaction, attending prolonged osteogenesis and is preserved till organ-like restructuring of newly formed bone.     

Consolidation of congenital tibial pseudoarthrosis using Ilizarov's compression-distraction method

Authors describe a case of consolidation of a congenital pseudarthrosis. The difficulties of the treatment of this disease are known. Very few procedures can secure the internal fixation and the induction of osteogenesis in the same time. Authors used beside internal fixation the distraction method that led to a surprisingly quick consolidation.     

Simultaneous ipsilateral femoral and tibial lengthening with the Ilizarov method.

Eight pediatric patients who underwent nine simultaneous ipsilateral femoral and tibial lengthenings with the Ilizarov external fixator were reviewed. The patient's demographics, diagnoses, corticotomy levels, mechanical axes, healing indices, amounts of lengthening, and complications were recorded. The patients' average age was 8 years 10 months (5 years 4 months-15 years 10 months) with an average follow-up of 49 months (30-88 months). The percentage of femoral lengthening averaged 16.7% (8-23%) with an average healing index of 28 days/cm (20-38 days/cm). The percentage of tibial lengthening averaged 18% (9.6-23.6%) with an average healing index of 29 days/cm (1940 days/cm). Four complications in three patients occurred as a direct result of the lengthening process. Three of the complications involved soft-tissue contractures, which were each successfully treated with one additional surgical procedure, whereas the fourth complication involved poor bone regeneration and required bone grafting and additional immobilization.     

One stage femoral lengthening.

Femoral lengthening can be obtained by a technique using a Z osteotomy and a distraction device separate from the operative field. The expected gain in length is 3-3.5 cm in children, 4-4.5 cm in adults. Sustained flexion of the knee during the procedure prevents vascular and nervous complications. One peroneal nerve and 2 femoral nerve palsies were nevertheless observed in 180 cases of the whole series. These were caused by a failure to comply with technical details. Bony union occurs promptly in young children. Pseudarthrosis occurred 11 times in patients more than 16-years-old, and once in an 8-year-old child. Avascular necrosis of the bone fragments after total separation of the soft tissue from the femoral shaft explains the frequency of non-union after the age of skeletal maturity. Faster and sound union in adolescents and adults is obtainable by the use of decortication to exposure the femur and strong internal fixation. The best indication for this method is a moderate discrepancy allowing a safe and complete equalization of limb length.     

The femoral neck lengthening osteotomy

Surgical Principles Premature closure of the epiphyseal plate can be a complication of hip dysplasia, Perthes disease, trauma or septic arthritis of the hip. As a result, the proximal femur may show a typical deformity with shortening of the neck of the femur and relative overgrowth of the greater trochanter. The femoral neck lengthening osteotomy aims at restoring the normal anatomy with restitution of the length of the femoral neck and leg length, and improving the lever arm of the abductors. The procedure includes three osteotomies parallel to the blade of a 130° or 120° blade plate. Lateralization of the shaft effectively lengthens the femoral neck. A part of the overgrown greater trochanter is used to fill the gap proximally to the lateralized shaft. The remaining trochanter is pulled distally and fixed to the femur. Revised Version from: Operat. Orthop. Traumatol. 1 (1989), 170–178 (German Edition).     

Fibula lengthening using a modified Ilizarov method

A combination of external and internal fixation techniques for a fibular lengthening procedure using the Ilizarov method is described. The technique is minimally invasive, allows precise deformity correction, enables early weight bearing, and minimizes the time that the patient wears the external fixator.     

Sagittal plane deformity during femoral lengthening

The purpose of this study was to determine the incidence and degree of sagittal plane deformity that occurs during limb lengthening of the femur. Twenty-one patients (25 limbs) were identified who underwent femoral lengthening. The limbs were lengthened a mean of 6.1 cm, and mean follow-up was 1.5 years. The immediate postoperative deformity in the sagittal plane was 8.3°; this deformity did not progress during lengthening (P<.05). Mean displacement in the sagittal plane was 3.1 mm.Angular deformities, although typically small, can occur in the sagittal plane and may be accompanied by displacement. These deformities are usually present immediately postoperatively and typically do not worsen significantly with lengthening.     

Influence of femoral lengthening on hip joint space in posttraumatic femoral shortening

We performed femoral lengthening for post-traumatic femoral shortening in 14 patients (10 men). The mean age was 26 (17-33) years. The callotasis method was employed using an Orthofix or a Hifixator monolateral external fixator. The average length gained was 6 (3-13) cm, equal to 16 (7-36)%.

The mean narrowing ratio of the hip joint space during lengthening was 9 (0-26)% and the narrowing persisted at the final follow-up. Cases with narrowing greater than 5% had a longer time between the development of the shortening and the lengthening than the others (p = 0.03).

Our findings indicate that femoral lengthening for posttraumatic femoral shortening should be done as early as possible to prevent the development of joint space narrowing during the lengthening procedure.     

The intramedullary elongation nail for femoral lengthening

We have analysed the results of 24 femoral lengthenings in 23 patients operated on between 1993 and 2000, using a gradual elongation intramedullary nail (Albizzia). Of the 23 patients, 22 had femoral deficiency and one was of short stature. Their mean age was 16.9 years. Technical difficulties encountered during the procedure were mild or moderate in 18 femora and severe in six femora. Distraction was obtained by 15 ratchetings per day (1 mm/day). There were 18 excellent results although in two patients this was achieved after the development of a pseudarthrosis which required further surgery. There were four good and two fair results in which the lengthening obtained was at least 3 cm less than had been projected. The consolidation index was 35.2 days/cm. No patient had associated long-term stiffness of the knee. Femoral lengthening using an elongation nail gives good results and is a comfortable procedure.     

Shortening of the calcaneus treated with Ilizarov's method

The author reports the case of a sixteen year old young lady with heel shortening, due to a growth arrest of the calcaneal epiphysis, secondary to its septic involvement by a heel puncture. At the age of sixteen a lengthening according to Ilizarov's method was performed, using progressive distraction of an osteotomy of the calcaneal tuberosity. The result was satisfying with a cosmetical improvement, a painless function and a more comfortable shoe fitting.     

Arthrodesis of the elbow using Ilizarov's external fixator

Arthrodesis of the elbow was achieved without major surgery on the joint itself, while maintaining satisfactory pronation, supination, and function of the arm. To this end, the external fixator of Ilizarov was used in a compression set-up which interfered only moderately with daily life activities. Solid fusion was achieved after 4 1/2 months. To our knowledge this is the first time that this technique has been used for such an indication. The operative technique is described and its advantages emphasized.