Limb Lengthening Procedures

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Limb Lengthening Procedures:

Limb Lengthening Procedures Aishourya Pradhan

Introduction::

Introduction: Limb lengthening procedures (LLP) are used to replace missing bones and/or to straighten deformed bones. Can be performed on both children and adults with limb length discrepancies (< 6cms) and angular deformities due to birth defects, injuries or diseases. Ilizarov Technique and its variations are commonly used.

Principle::

Principle: It is based on the principle of distraction osteogenesis . A bone that has been cut during surgery are gradually pulled apart ( distraction ) Leads to new bone formation ( osteogenesis ) at the site of lengthening

Candidates for the procedure::

Candidates for the procedure: Congenital deformities: Fibular hemimelia Congenital short femur Infantile Hemiatrophy Malunion or non- union of fractures leading to limb length discrepancies Achondroplasia

Four phases of LLP::

Four phases of LLP: Preparation : Consultation, X- rays of the limbs to build a custom- build external fixator , psychological evaluation Surgery : External fixator is attached to the bones Lengthening : Fixator is lengthened about 1 mm every day for new bone growth. Strengthening : For proper alignment and consolidation of new bone, removal of external fixator , PT rehabilitation.

Ilizarov External Fixator::

Ilizarov External Fixator : Metal rings Threaded rods Kirschner wires (1.5- 1.8 mm in diameter) Miscellaneous hardware for connecting the basic components

Surgical Procedure::

Surgical Procedure: Wire Insertion: Passing wire through skin and soft tissues Drill through near and far cortices of bone Tapping through the soft tissue and skin Attachment of the wires to the metal rings Increase in tension to enhance stability

Contd..:

Contd.. Connection of rings with rods: co-linear alignment- straight lengthening angular alignment with hinges- angular deformity Corticotomy - metaphyseal section of the bone. Performed through1 cm incision under fluoroscopy guidance Only cortex of the bone is cut.

Contd..:

Contd.. After 5- 10 days: Distraction is begun by turning the nuts on the rods- 0.25 mm 4 times/day Osteogenesis starts between the gaps Distraction continued till desired limb length achieved Fixator not removed until consolidation of the bone has taken place (2-3 months)

Contd..:

Contd.. Patient remains ambulatory and can bear weight on the operated leg. Lengthening up to 20 to 30% of the original bone length can be achieved.

Advantages::

Advantages: Osteogenesis occurs Regenerating bone resembles the existing bone External Fixator can be custom- made The basic parts- the wires, small pins and metal rings favors osteogenesis

Complications::

Complications: Muscle contractures Joint subluxations Axial deviations Neurological or vascular insult Premature or delayed consolidation Re- fracture Pin- site infections Psychological stress

Physical Therapy Intervention::

Physical Therapy Intervention: To help patients attain maximal functional recovery To prevent complications The protocols for PT depends on the diagnostic and healing phase Education of the patient and family Carefully consider patient’s needs, plan and execute therapy

Pre- operative phase::

Pre- operative phase: Manual Muscle Testing- to determine what areas need to be emphasized after the surgery. For UE- shoulder, elbow and wrist For LE- hip, knee and ankle Passive ROM- both UE and LE for post- operative comparison Sensory examination for post- operative comparison

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Girth measurements (bilaterally)- to determine edema post surgically Measurement of limb length discrepancy and shoe- lift Joint stability assessment- especially at the knee Valgus and varus stress test Lachman test, anterior and posterior drawer tests

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Identification of bony deformities- to monitor the changes post- operatively Evaluation of posture and gait: Identify possible deviations for post- operative rehabilitation Assessment of Functional Mobility- for reference of areas to concentrate or improve in the post- operative phase

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Crutch fitting and training- for better carryover Post- operative positioning and splinting instructions Stretching and strengthening exercises of the extremities to prepare for surgery and better carryover Home Program instructions- isometric, passive and active exercises

Post- operative phase::

Post- operative phase: Phase 1: Immediate post- operative phase First 1- 3 days Correct positioning of the limb- splinting if required for edema control Isometric and active- assisted exercises Walking using a walker or crutch (wt. bearing till tolerance/ full wt. bearing) In case of pain- modalities in conjunction with medications Bed mobility and transfers taught

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Phase II: Distraction Phase (4 th day onwards) Focus on maintaining the ROM in the joints to avoid joint stiffness and muscle contractures Pain management if pain present Strengthening exercises for the limbs Stationary bicycle Monitoring of edema and splinting Monitoring of shoe- lift height Gradual walking on a treadmill Balance exercises- weight shifting and propioception PT 5 days a week

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Phase III: The Consolidation phase Maintaining the ROM- active- assisted to active Continuation of strengthening exercises Balance exercises Maximize independent walking Home exercises as taught pre- operatively PT 3 days a week

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Phase IV: Post Removal Phase Limb is usually put in a cast to avoid fractures Exercises like SLR and Quadriceps isometrics to maintain the tone of the muscles Postural and gait training ROM and strengthening exercises continued Training in functional activities

Conclusion::

Conclusion: Steady gain of strength and function for up to 2 years after lengthening Rule of thumb- 10 degrees to return in a month per joint High impact activities like running, jumping and plyometric activities- only ten weeks after fixator removal

References::

References: Hassler CC, Krieg AH. Current concepts of leg lengthening. J Child Orthop . 2012; 6:89–104. Simard S, Marchant M, Mencio G. The Ilizarov Procedure: Limb Lengthening and Its Implications. Phys Ther . 1992; 72: 25-34. Physical Therapy. Paley Advanced Limb Lengthening Institute Website. http://www.paleyinstitute.org/?q=physical-therapy . Accessed July 8, 2013.

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