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Home >> Consumer/ Patient Info >> Limb Lengthening LIMB LENGTHENING AND RECONSTRUCTIONWritten by Click here to open a printable handout on Limb Lengthening & Reconstruction. Limb lengthening and reconstruction techniques can be used to
replace missing bone and WHO WAS ILIZAROV?In 1951, Professor Gavril Abramovich Ilizarov from Kurgan in the
Soviet Union developed |
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This is a non-union |
BONE LOSS FROM TUMOUR, TRAUMA OR INFECTION
Tumour, trauma, and infection can all lead to bone loss due to
either the injury or resection. Bone
loss
may be manifested as a bone defect or as limb length discrepancy or
both.
JOINT CONTRACTURES
Joints may be limited in their movement from tight muscles or capsule or from scarring in the joint.
BONE INFECTION (OSTEOMYELITIS)
Bone infection may be a result of fracture or blood borne infection (usually occur during childhood).
Usually the only way to effectively eradicate established bone
infection is to resect the abnormal
bone
and this can result in a bone defect that needs to be reconstructed
using the Ilizarov technique.
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THE PROCESS
PHASE 1:
CONSULTATION
The initial assessment involves detailed history examination and
review of previous x-rays.
Specialized x-rays are usually required to complete the assessment.
The initial assessment
and discussion often takes an hour.
If surgical treatment is considered appropriate, all aspects of the
procedure are discussed
with the patient. The patient is encouraged to consider the
information and a follow up
appointment is made to answer any further questions and make
definitive treatment plans.
It is extremely important that the patient and the surgeon have a
clear understanding of
the goals of surgery. It is important the patient understands
what can realistically be achieved
by the surgery and the potential complications both common and minor
and rare but serious.
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PHASE 2: SURGERY
The surgeon in preparation for each surgery preconstructs a customized apparatus. Using wires or pins, the apparatus is surgically attached to the affected limb. Surgery is usually performed percutaneously through small incisions. Special care is taken to minimize injury to the bone and surrounding soft tissue, nerves and blood vessels when making specialized bone cuts.
PHASE 3: POSTOPERATIVE TREATMENT AND REHABILITATION
ADJUSTMENT
PHASE
Generally, patients remain in the hospital for 3 to 7 days before
they are discharged home. A
more
complex procedure may require a longer inpatient stay.
The actual lengthening or straightening of the limb begins 1-2
weeks after surgery. At that
time,
adjustments are made to the apparatus usually four times a day.
Detailed instructions
are provided
to the patient to ensure they fully understand what is required.
The bone ends are separated at a rate of 1 mm per day.
Muscles do not lengthen as easily as bone and therefore
physiotherapy may be an important
part of the treatment to maintain
joint range of motion and prevent contractures. A joint at risk
may be
included in the frame to prevent contractures that would otherwise
occur.
Swimming and showering are allowed with the apparatus in place once initial wound healing has occurred at 5-7 days postoperatively.
During the adjustment phase the patient is
followed up in the rooms every two
weeks with clinical examination and x-rays. A close scrutiny is
maintained to identify any complications early.
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• Consolidation phase-
allows for intramembraneous ossification and recanalization of new bone |
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CONSOLIDATION PHASE (BONE HARDENING)
After the desired length has been achieved and the limb has been
straightened, no further
adjustments are made. The apparatus is left in place to allow the new
bone to harden and
mature. Once the new bone is judged to be sufficiently strong, the
frame is removed under
a short general anaesthetic. A cast or brace may be applied for an
additional month or two
for further protection. The new bone tissue assumes all the qualities
and strength of normal
bone with time.
During the adjustment phase the patient is seen every month.
FOLLOW-UP
With close follow up if a problem is arising then it can be picked
up early and can usually be
treated without affecting the final outcome.
All the necessary surgeries are anticipated and communicated to the patient before treatment commences but sometimes an unscheduled operation is required to correct a problem.
When the desired correction is achieved the frame is locked down
and the consolidation
phase begins. The patient is seen on a monthly basis with x-rays and
examination.
I am very conservative regarding when to remove the frame. This is
to minimize the risk
of deformation of the regenerate or fracture after frame removal,
which can be a devastating complication. When it is thought that it is
time to remove the frame then it is completely
loosened so that it is not assisting in weight bearing and the patient
is encouraged to fully
weight bear for two weeks. If this can be achieved without any loss of
correction then the
frame removal is scheduled. If there is loss of position then usually
this can be corrected by
frame adjustment on an outpatient basis thereby avoiding needing
further surgery.
Pain Relief
The adjustment phase is painful because of the constantly changing
conditions for the bone
and soft tissue. Standard pain medications often are not all that
effective especially at night
when sleep can be significantly disturbed. If a patient is not getting
much sleep it does affect
his/her ability to cope- as well as his/her carer. I often get
patients to see a pain management
specialist- Dr Henry Lam who can assist with appropriate medication.
He is aware of all the
side effects, interactions and appropriate dosages and therefore is
best qualified to handle
this aspect of your care.
COMPLICATIONS
All surgery has the potential for complications
and Ilizarov surgery is no exception.
With careful preoperative planning and close co-operation between
surgeon and patient and
realistic treatment goals most complications can be avoided and a
successful outcome achieved.
When a surgeon discusses a possible procedure with a patient he has
to be a pessimist and
talk about the worst-case scenario. That relates to the anaesthetic
and the surgery itself.
Anaesthetic Complications
In the worst-case situation you can die under an anaesthetic or
have a major stroke or heart
attack that can be life threatening or have permanent consequences.
Fortunately these events
are very rare these days but the chances are increased if a patient
has intercurrent illnesses
such as diabetes or heart, lung problems.
The treatment of any intercurrent illnesses should be optimized
prior to surgery and this may
involve delaying the surgery until appropriate medical assessment has
been performed usually
with the assistance of your local doctor. It is important that you
have a regular local doctor
prior to commencing Ilizarov surgery because they can be an important
resource to assist
in the treatment phase in consultation with the surgeon.
Anaphylaxis
Very rarely a patient can be allergic to a medication that we are
unaware of. That reaction
can vary from a rash to a severe life threatening reaction called
anaphylaxis.
Surgical Complications
These can vary from minor to severe and limb
threatening.
Infection
Infection is a potential problem with any surgery. Deep infection
in Ilizarov surgery is rare
because most of the surgery is percutaneous . Pin
tract infections however are
common and most can be treated with careful pin tract cleaning
and oral antibiotics.
Rarely someone would require admission to hospital for debridement of
a pin site and IV
antibiotics or removal/ exchange of a pin or wire.
You are provided with information on pin site care in hospital and
encouraged to shower using
antimicrobial soap that you can obtain from your chemist.
DVT/Pulmonary Embolus
A DVT is a Deep Vein Thrombosis and this is a clot in the leg that
can complicate any surgery.
It can enlarge inside the leg and break off and travel to the lung
where it is called a Pulmonary Embolus. It can make you very sick and
if it is big enough you can die from it.
A number of precautions are taken in hospital to minimize the risk
including a subcutaneous
injection of a blood thinner called Clexane. Usually you are sent home
with Clexane injections
for two weeks and present to the first follow-up review with a Doppler
Ultrasound test to ensure
there is no evidence of a DVT. If this is clear then the Clexane is
discontinued. If there is evidence
of a DVT then the Clexane is continued until you are warfarinized
which is a tablet that thins out
your blood. This requires regular blood test and needs to be
supervised by your local doctor in
conjunction with a vascular physician.
Nerve/Blood Vessel Injury
Great care is taken to prevent injury to nerves or blood vessels
during the surgery. All the
structures at risk are kept in mind throughout the surgery. Despite
this it is still possible to
injure one of these structures. A nerve injury can vary from a
temporary injury that recovers
in days to weeks to normal function to a permanent partial or total
loss of function of the nerve.
This can cause permanent numbness and loss of joint movement and
muscle power with wasting.
The nerve most at risk is the sciatic nerve and its branches.
Particularly the Peroneal nerve
just below the knee.
Blood vessel injuries can cause significant blood loss or lead to
ischaemia (loss of blood supply)
to a limb that if not corrected will lead to loss of that limb.
Fortunately both of these complications
are extremely rare.
Premature
Consolidation
The aim is to let the surgically induced fracture (osteotomy) to
start to heal but then stretch
(distract) it to lengthen and/or straighten the bone. Some people and
some bones heal faster
than others and it can get stuck which is called premature
consolidation. If this occurs we can sometimes get it unstuck by
continuing turns but other times it requires another short operation
to recut the bone.
Nonunion
Poor new bone formation can occur and sometimes this can develop
into a nonunion where the
bone fails to heal. In this situation modification of the frame may be
necessary and a bone graft
may have to be taken from the pelvis to achieve bone union.
Malunion
Malunion is where the bone heals but in an unsatisfactory position.
This is extremely rare in
Ilizarov Surgery because we can adjust the frame and take x-rays until
we are totally satisfied
with the position and then lock down the frame. With a stable frame
the position will not be lost. Sometimes late deformity can occur
after removal of the frame.
Joint Contracture
Muscles and tendons don't lengthen as well as bone does and the
limiting factor in how much
we can lengthen a limb is muscle tightening and joint contracture.
Sometimes a frame is
extended across a joint to correct or prevent a contracture occurring.
The joints most at risk a
re the knee and the ankle.
Physiotherapy and stretching performed by the patient and sometimes
formal physiotherapy
are critical to a successful result. The soft tissues and joint range
of motion are often the
difference between a “good” result and a “great” result.
Fracture/ Late
Deformity
The decision about when to remove a frame is a difficult one. We
don't want to keep it on
longer than necessary but if you remove it too early then the new bone
can fracture or deform.
This can undo all the good work and is extremely frustrating for the
surgeon and devastatingly
disappointing to the patient.
When I judge that the frame is ready for removal then I loosen the
frame right off and allow
the patient to fully weight bear for two weeks and then review with
repeat x-rays. If there is
no pain and no loss of correction then the frame can be removed under
a general anaesthetic
and usually no post- removal cast of brace is necessary.
Overlengthening or Underlengthening
This is possible but rare because with the Ilizarov method you can
gradually correct the deformity
until it is perfect and then lock down. For a week to two weeks you
can make further fine
adjustments except it is difficult to recommence lengthening after
more than a few days of
consolidation.
Scarring
Some scars are inevitable. They usually fade largely with time and
do not create a significant
cosmetic problem
Reflex Sympathetic Dystrophy(Complex Regional Pain
Syndrome)
This is where the nerves react adversely to an operation or injury
and become hypersensitive
and hyper-reactive. It is characterized by excessively severe pain
swelling and stiffness and
hypersensitivity. The pain is usually not amenable to standard
analgesics and pain management
specialist review is necessary. Treatment usually consists of
medication, nerve blocks and
physiotherapy. The earlier it is picked up and treated the better it
does. It is not possible to
predict who this will happen to unless there is a previous history and
despite treatment it can
lead to permanent disability.
Loss of Function
Everything that limb deformity surgery is aiming to do is to
relieve pain and restore function. Sometimes this is not achieved
despite the best intentions because of complications that are
an inherent risk with the surgery. It is possible for someone to be
functionally worse off after
surgery than they were before. This can occur with any surgery and is
not restricted to limb
lengthening and deformity correction.
Unplanned Return to Theatre
If a problem is identified then sometimes surgery is necessary to
correct this problem so that
is does not compromise the final result. The earlier and more
aggressively a complication is
treated then the better the outcome usually.
Amputation
One of the most devastating complications that can complicate limb
deformity surgery is
amputation. This can complicate any operation- even very simple
surgery. Major nerve or
blood vessel injury can necessitate amputation as can limb threatening
infections such as
gangrene. These complications are extremely rare but have been
reported.
Conclusion
Correction of deformity with the Ilizarov Fixateur is a time
consuming and challenging
process for both the patient and the surgeon. It is also an extremely
worthwhile process
because it can make a tremendous improvement in a patient's pain,
function, appearance
and quality of life.
With clear realistic goals shared by both the surgeon and patient
combined with patience
and co-operation then the goals can be reliably achieved with the
minimum of complications.
Dr Tim O'Carrigan MBBS FRACS
Sydney Bone and Joint Clinic
