Limb lengthening methods
Human active natural growth ends in majority of cases before 20 years and in some cases leaves disproportionately short limbs. Limb lengthening methods extend the length of bones (height); either growth stimulators administration or surgical operations (distraction osteogenesis). At this considerable results are possible only in artificial lengthening of lower extremities bones length by various construction devices.
All distraction methods may be divided into three main groups:
- external methods
- internal (intraosseal) methods
- combined (mixed) methods.
All methods generally feature:
- Bone dissection (actually – artificial fracture). This is the place where additional length will be received.
- Artificial regeneration process, prolonged by distraction (gradual bone parts separation with average speed 1 mm a day). The bone “young” regenerate is stretched to a planned length, and is totally formed (ossified) only after distraction termination.
- muscles and tendons stretching (various methods only change this stretching conditions).
General demands to all methods:
- Stiff solid bone fragments fixation until the moment of complete bone co-ossification («device-bone» complex).
- Gradual distraction (lengthening). In other words, creating favorable conditions for “young bone”, regeneration that takes place between stretching bone fragments.
- Sparing environment for muscles and joints during stretching and regeneration.
- 1 External methods
- 2 Combined methods
- 3 Internal methods (devices)
- 4 References
- 5 External links
Characteristic features of external methods are:
- external construction presence (outside the body)
- power clusters (for distraction activation) are situated on external construction
- bone fixation (creation of common «device-bone complex») due to spokes (rods) that run through leg segment. Spokes (rods) ends are fixated in the external device
- distraction due to separation of external device elements (increases distance between spokes, which fixate various bone zones)
Transosseous compression-distraction osteosynthesis in shin and hip lengthening
Starting in the 1960s, external compression-distraction devices gained maximal popularity. This was caused by device construction changes and more progressive surgical intervention methods.
Ilizarov method became widespread in many world countries. G.A.Ilizarov method is universal. Ilizarov device (see Fig. 1.3) – is external ring clamp, consisting of split rings with fixation possibility of bars, spikes and rods in it. The device construction foresees its composition in various variants (Fig. 1.4, Fig. 1.5) depending on exact clinical task.
Combined methods characteristics:
- during protraction period external device is used (fixation and distraction functions);
- after lengthening the external device is removed, and a rod is implanted into bone (that provides for more stable fixation comparing to external device)
"External device-bone" complex – is using of spikes (rods) that counteract closed regeneration process. Organism «perimeter» is not closed in spikes penetration zones. External construction (device) – is discomfort for a patient, negative conditions for muscles and joints, and infectious complications risk. This is because combined methods appeared, which task is shortening of external (open) fixation time. The lengthening is provided by external device, which is removed immediately (rods are taken off) after distraction completion. Fixation after external device removal is provided by intraosseous rod (osteosynthesis).
Wasserschtein method. Intraperiosteal osteotomy of shin-bone in medium one-third and of fibula in lower one-third was carried out; the fragments were fixated inside the bone by flat metal rod. As distraction device Gudushauri or Ilizarov device was used .After lengthening completion with distraction speed 2 mm per day, diastasis between bone fragments was substituted by homocylindrical transplant with longitudinal notch (Fig. 1.6 left).
Sanchis Olmos (see Fig. 1.6 right) proposed to insert inset-separator from patient shin-bone between bone fragments with the same lengthening method. J. Kepf proposed after lengthening completion in transosseous way to block the rod in order to exclude fragments rotation shifting. D. Paley used simultaneously external device (Ilizarov device, one-sided "Orthofix" device), and intramedullary rod for hip lengthening. Authors J. E. Herzenberg и D. Paley, carried out by the same way device shin lengthening (LON).
Internal methods (devices)
Internal methods characteristics:
- intraosseous device completes distraction and fixation functions without external constructions;
- soft tissues (skin, muscles, fascia) remain intact (do not contact with devices).
In distraction osteosynthesis by external devices the spikes overcome (cut) soft tissues resistance (skin, fascia, muscles) during lengthening. There is contact-conflict between multidirectional forces along the whole immersion depth of spike (spikes) into body: distraction force against resistance force. Therefore, methods without external constructions appeared.
At early 1980-s professor Bliskunov created method of completely closed distraction osteosynthesis. Prof. Bliskunov proposed intraosseous devices for hip. Afterwards, V. Dragan MD, DMSc invented intraosseous device for shin (tibia) lengthening (Fig. 1.8). The particular feature in these devices (Bliskunov method) is mechanical drive, which work initiates (activates) the device: 18 mechanism clicks – 1 mm (hip), 56 clicks – 1 mm for shin. (Fig. 1.7)
The devices are made of titanium alloy and are fixated to the lengthening bones. The nail lengthens on a ratcheting principle. The device works like a lever and considerably facilitates the process of lengthening. There are two designs for the clicker. One is for the tibia (shin) and the other is for the femur (hip).
With the Bliskinov nail the patient has an opportunity to independently lengthen by him/herself. In order to lengthen the hip a patient makes a side-movement by the leg (diversion) till mechanism action ("click" sound). To lengthen the shin a patient alternately presses on drive wings (the drive is situated under soft tissues and works as pendulum). The devices activation is painless. The devices provide a smooth lengthening process without harsh jerks and deleterious twisting along the bone. This approach is very important for gradual adaptation of muscles, nerves and tendons to the newly lengthened limb.
The method Albizzia J.-M.Guichet. was developed in 1986, patented in 1988. The Albizzia Telescopic tube device (Fig. 1.9, 1.10) consists of two tubes – external (1) and internal (2), connected by a ratchet mechanism that allows lengthening through rotation in one direction. Due to the ratchet mechanism, reverse rotation brings the system back into neutral position without lengthening loss. Rotation angle of inner rod part is 20°. 15 go-and-forth rotations correspond to 1 mm of lengthening. The nail is made of highly resistant stainless steel allowing full weight bearing and fast return to sports. A 10 cm maximal gain is possible.
The Guichet nail system is the latest evolution of the Albizzia nail. The Albizzia rotatory ratchet concept, validated on thousands of patients, has been maintained, but the system strength (nail and screws) has been strongly increased, with some part in Chrome-Cobalt. Small nails (down to a 12 cm length) allow lengthening with this device in dwarfism or in congenital short bones (PFFD, etc.). Specific devices exist for femur, tibia and humerus. The ‘Method’ itself is fully modified with a complete control of the patient initiated in the preoperative phase (evaluation of the bone and muscle quality, specific muscle and stretching training). The control of the surgery itself with minimal blood loss allows resuming biking on the first day after surgery, and even in some cases from 30 to 60 minutes after discharge from the operating room. The per- and post-operative care with intensive training allows a higher speed of gain (43 mm in one month) while maintaining full range of motion, and with higher speed of healing (Healing Index down to 15-20 days per cm of gain, to obtain bone fusion). Patients use standard crutches for walking, and perform gentle sports during lengthening, then weight training after bone fusion (e.g. minimum 4 months for 7 cm of gain). Gain can be stopped at any time.
ISKD device (skeletal kinetic distractor) was proposed by company Orthofix. Its work principle resembles that of Albizzia device. This is intramedullary rod with mechanical distraction, created for hip (Fig. 1.11) and shin (Fig. 1.12). Its proximal and distal parts are connected inside by thread and two one-sided clamps. In rotation from 3 to 9° these clamps are activated. 1 mm of distraction is achieved after 160 extremity rotation movements. Actual distraction length is controlled by external manual monitor, which assesses magnet orientation in distal part of internal threaded rod. Patients change day distraction minimum five times a day. If distraction length is not significant, the lower extremity is rotated under monitor control till the desirable length achievement.
The rod consists of two parts: external corpus (1), where special mechanism is situated – highly sensitive epicyclic drive (produced by Wittenstein Intens Company, which specializes on high accuracy drives), two holes for fixating screws (2), and telescopic rod (3) with two holes for screws (4). Special electric aggregate (5 on Fig. 1.14) sends electric impulses to antenna (receiver) (6) under patient skin, connected to epicyclic drive, which in its turn moves telescopic rod (3) with impulsive force up to 200 kg (600 microimpulses)/ By R. Baumgart and A. Betz  this is enough to counteract muscle resistance during distraction.
- Volkov M. V. Treatment of joints and bones damages by author devices/ М. V. Volkov, О. V. Oganesyan. – Tashkent : Medicine, (1978), P. 203
- Ryabzev S. L. Lower extremities lengthening in adults with simultaneous restoration of adjacent joints function by Volkov-Oganesyan devices / S. L. Ryabzev // Form and function restoration in damaged joints by Volkov-Oganesyan devices: CYTO Works Collection. – М. : CYTO Publishing House, (1982), P. 100–102
- Gudushauri О. N. Device for reposition and fixation of long tubular bones in fractures and bones lengthening/ О. N. Gudushauri // Orthopedics, traumatology and prosthetics– (1958). – # 3, P. 53–56
- Popova L. А. G/A/Ilizarov method evolution in traumatology and orthopaedics / L. А. Popova // Orthoped genius – (2006). # 4, P. 10–19
- Ilizarov G. А. Clinical possibilities of transosteous osteosynthesis method (basic practical directions)/ Ilizarov G. А., Popova L. А., Shevzov V. I. // Russian Federation Health Care. – (1986) # 9, P. 5–10
- Ilizarov G. А. Clinical and theoretical aspects of compression and distraction osteosynthesis/ G. А. Ilizarov // In the book: Theoretical and practical aspects of transosteous compression and distraction osteosynthesis. – Kurgan: Kurgan Publishers. NIIEKoT, (1976), P. 14–25
- Blachier D. Allongements progressifs du temur selon la technique de Wagner. A propos de 48 cas / D. Blachier, L. Trevonx // Rev. Chir. Orthop. – (1986),Vol. 72., P. 495–499
- Wagner H. Surgical lengthening or shortening of femur and tibia / H. Wagner // Progress in Orthopaedic Surg. (1977), Vol. 1., P. 71
- B. Vargas Barreto, J. Caton, Z. Merabet, J. C. Panisset and J. P. Pracros. Complications of Ilizarov leg lengthening: a comparative study between patients with leg length discrepancy and short stature, Int. Orthop. (2007) October; 31(5), P. 587–591 ON-LINE ACCESS
- B de Billy; J. Langlais; J.C. Pouliquen; J.M. Guichet and J.P. Damsin. COMPLICATIONS IN LENGTHENING OF THE FEMUR USING DIFFERENT METHODS, Journal of Bone and Joint Surgery - British Volume, Vol 87-B, Issue SUPP_I, 70., (2004) June ON-LINE ACCESS
- Wasserstein I. The Closed Distraction Epiphysiolysis. Methods and Recommendations / I. Wasserstein, T. Hawiko. – Riga, (1975), P. 1–24
- Wasserstein I. Twenty-five years experience with lengthening of shortened lower extremities using cylindrical allografs / I. Wasserstein // Clinic. Orhtoped. – (1990), Vol. 250, P. 150–154
- Sanchis Olmos Verlangerungosteotomien des Oberschenkelkels / Sanchis Olmos // Z. Orthop. – (1963) Bd. 97, № 3., P 289–296
- Kepf J. Locked intramedullary nailing. It’s application to femoral and tibial axial, rotational, lengthening, and shortening osteotomic / Kepf J., Corosse A., Abalo C. // Clin. Orthop. – (1986), Vol. 212, P. 165–173
- Paley D. Femoral lengthening by simultaneous external fixation and intramedullary rodding / Paley D., Maar D., Tetsworth K. // Montaggi speciali in traumatologia e ortopedia. – Genova : (1993), P. 91–92
- Herzenberg J. E. Tibial lengthening over nails (LON) / J. E. Herzenberg, D. Paley // Tech. Orthop. – (1997), Vol. 12., P. 250–259
- V. Klimovitskiy, V. Dragan, L.Goncharova, А. Danylyk, Abu Nemer Jamal A. M., S. Lysunov, A. Kuznetsov DISTRACTIOUS OSTEOSYNTHESIS EXTERNAL VS INTERNAL, Bulletin of Orthopaedics, Traumatology and Prosthetics, (2010), No. 3; P.59-61 ON-LINE ACCESS
- V. V. Dragan, COMPARATIVE ANALYSIS OF MODERN METHODS OF LONG BONES LENGTHENING BY INTRAMEDULLARY DEVICES. PRIORITIES OF DISTRACTION ORTHOPAEDICS. Bulletin of Orthopaedics, Traumatology and Prosthetics, (2008), No. 3; P.81-87 ON-LINE ACCESS
- V. Klimovitskiy, V. Dragan, L. Goncharova, Abu Nemer Jamal A.M., S. Lysunov, A. Kuznetsov MULTI-PAIR ELONGATION OF THE LOWER EXTREMITIES WITH THE INTRAOSTEAL DRIVE DEVICES Bulletin of Orthopaedics, Traumatology and Prosthetics, (2009), No. 3; P.44-47 ON-LINE ACCESS
- Vladimir Dragan M.D. A Short Height is as Social-Conditioned Indication for Orthopedic Correction of the Length of Lower Limbs // Таврический медико-биологический вестник.- В кн.: Труды Крымского государственного медицинского университета им. С.И.Георгиевского, - Симферополь. - (2006).- т.9.- № 1., С. 34-37. (2002) ON-LINE ACCESS
- D.A.Popkov, J.-M.Guichet, Elongation of the femur using the Albizzia intramedullary rod P.Lascombes, Genij Ortopedii 1, (2001) ON-LINE ACCESS
- Guichet J.-M., Deromendis B., Donnan L. T. Gradual femoral lengthening with the Albizzia intramedullary nail / [et al.] // J. Bone Jt Surg. – (2003) Vol. 85-A, № 5. P. 838–848
- Stefan Hankemeier, Hans-Christoph Pape, Thomas Gosling, Tobias Hufner, Martinus Richter, Christian Krettek Improved comfort in lower limb lengthening with the intramedullary skeletal kinetic distractor. Principles and preliminary clinical experiences, Arch Orthop Trauma Surg (2004) 124 : P.129–133 ON-LINE ACCESS
- Cole J. Dean The intramedullary skeletal kinetic distraction (ISKD): first clinical results of a new intramedull ary nail for lengthening of the femur and tibia / Cole Dean J., Justin Daniel, Tagus Hasparis // Injury. – (2001), Vol. 32 (Suppl. 4)., P. 129–139
- Andreas H. Krieg, MD, Bernhard M. Speth, MD, and Bruce K. Foster, MBBS, MD Leg Lengthening With a Motorized Nail in Adolescents. An Alternative to External Fixators?, Clin Orthop Relat Res. (2008), January; 466(1), P. 189–197. ON-LINE ACCESS
- Baumgart R. A fully implantable motorized intramedullary nail for limb lengthening and bone transport / Baumgart R., Betz A., Schweinberer L. // Clin. Orthop. – (1997), Vol. 343., P. 135–143
- Betz A. A fully implantable intramedullary system for callus distraction – intramedullary nail with programmable drive for leg lengthening and segment displacement. Principles and initial clinical results / Betz A., Baumgart R., Schweiberer L. // Chirurgie. – (1990), Vol. 61., P. 605–609
- Guichet procedure
- Information on Bliskunov procedure
- Betz Intitute
- Introduction to Distraction Osteogenesis by Dr. Martin Chin, D.D.S.
- Cosmetic Leg Lengthening
- Cosmetic and Congenital Short Stature Lengthening
- Limb Lengthening - ISKD Documents by Dr. Cole
- Vardaan Hospital describes the Ilizarov's technique