Limb Length Discrepancy Complications,Lengthening Devices Applications

4th Pediatric Infectious Diseases Conference

ISSN 0973 - 0958

Pediatric Orthopedics in Children

Limb Length Inequality

Pediatrics Orthopedics

Limb length inequality

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LIMB LENGTH INEQUALITY AND RELATED PROBLEMS IN CHILDREN

Related Topics

Limb Length Inequality Introduction and Causes

Increase Patterns and Evaluation Of Limb Length Discrepancy

Management and Surgery For Equalization Of Limb Lengths

Dr A.Johari.
Consulting Pediatric Orthopedic
Consultant at Bombay Hospital ,
B.J.Wadia Children's Hospital ,
Children's Orthopedic Centre.

COMPLICATIONS:

Inspite of all recent advances, limb-lengthening surgery is fraught with complications relating to the bone and joint, muscles, vessels and nerves. The commonest problems are:

Pin track infection, which is prevented by proper pin track care. If this is not controlled pin loosening is inevitable.
Joint deformities and loss of range of motion because of the pull on the muscles during lengthening. This requires sustained physiotherapy.
Malpositioning of the bone fragments and consequent deformity because of selective muscle pull, the stronger muscles pulling the bone in their direction. This requires correction during lengthening or after it but before the bone consolidates.
Vessel and nerve damage by improperly placed 'k' wires - a complication peculiar to the ring devices, which employ 'k' wires. These can be prevented by proper study of limb cross sectional anatomy.

OTHER APPLICATIONS OF LIMB LENGTHENING DEVICES:

Correction of bone and joint deformity:

Simultaneously with limb lengthening or even otherwise, fixation devices can be used for correction of bone and joint deformities. In such instances the bone is divided and fractionally distracted in the direction of correction. This corrects the deformity and preserves the length of the bone in comparison to open surgery, which in the usual form is closed wedge osteotomy, which shortens the bone. The lengthening device is used here to create an 'open wedge' of new bone. Further lengthening if required can be carried out either with or after the correction. Such correction would be useful in deformities due to rickets and allied situations, post traumatic malunions etc.

Joint deformities can be corrected by distracting the joint. This is especially useful where the muscles around the joint are weak. By open lengthening, this muscle power could be diminished and this may reduce a muscle which barely pulls against gravity to one which can not. Joint deformity correction would be helpful in cases of arthrogryposis, congenital problems and acquired conditions like poliomyelitis, joint sepsis etc.

Deformity near the epiphyseal ends can be corrected by distracting the epiphysis through the growth plate. Lengthening can be also be carried out in this way. At present this epiphyseal distraction is recommended only in the period near to skeletal maturity as it is possible that the physis can be damaged.
Bone transportation:

A bone fragment can be transported in any direction to fill in a bone gap. Bone continuity can still be maintained by the new bone regeneration-taking place in the area from which the bone fragment is being removed.

The applications of this technique are many. Unhealthy bone can now be radically resected e.g. in osteomyelitis, bone tumours and pseudarthrosis. In this situation or in bone loss following trauma or in gap non-unions the resulting gap can be filled in by bone transportation without resort to bone grafting.
Non- unions

Healing of recalcitrant non-unions is possible using the fixation devices by providing stability and vascular stimulus. Stability is provided by the fixator devices and this allows healing of many non-unions of the hypertrophic variety. Vascular stimulus can be provided by distraction, by repeated cycles of compression and distraction or by corticotomy which increases the vascularity of the bone segment.
Double lengthening:

To reduce the time spent in lengthening, a bone can be divided at two levels and lengthening carried out from each level. This saves time in long lengthenings. Also the muscles elongation is provided at two sites rather than at one site. This distributes the stresses more uniformly throughout the muscle.
Enhancement of stature:

An interesting offshoot of lengthening technology is the possibility of enhancement of stature in dwarfed patients. The process is lengthy and may involve different strategies like simultaneous ipsilateral lengthening of a femur and tibia followed by the same procedure on the opposite side. Lengthening of both legs can be carried out followed by the thighs or of one leg and opposite thigh followed by the other. Each has its own advantages and disadvantages.

Changes in lower limb length change the body proportions and this limits the length that can be gained. This situation is best where the extremities are short in relation to the trunk i.e. in achondroplasia. Another problem posed by the procedure is that after lengthening of the lower limbs, the upper limbs appear short and these may have to be lengthened too.

Because of the complexities of the procedure, this is not one to be lightly recommended to any patient. All the pros and cons have to be gone into and special consideration has to be given to the motivation of the patient and his psychological stability to withstand a long treatment which may be in the range of a year or so.

References:

Shapiro F- Developmental patterns in lower extremity length discrepancies. J Bone Joint Surg 1982, 64 A: 639-650.
Anderson M, Green WT & Messner MB. Growth and Prediction of growth in the lower extremities. J Bone joint Surg 1963, 45 A: 1 - 14.
Moseley C. A straight line graph for leg length discrepancies. J Bone Joint Surg 1977, 59 A: 174 - 179.
Greulich W, Pyle S. Radiographic atlas of the skeletal development of the hand and wrist. Stanford CA - Stanford University Press, 1959.
Westh R, Menelaus M. A simple calculation for the timing of epiphyseal arrest: A further report. J Bone Joint Surg 1981, 63 B: 117 - 119.
Ilizarov GA. The tension stress effect on the genesis and growth of tissues I. The influence of stability of fixation and soft tissue preservation. Clin Orthop 1989, 238: 249- 281.
Ilizarov GA. The tension stress effect on the genesis and growth of tissues II. The influence of rate and frequency of distraction. Clin Orthop 1989, 239: 263 - 285.
Ilizarov GA. Clinical application of tension stress effect for limb lengthening. Clin Orthop 1990, 250: 8 - 26
Saleh Michael, Burton Maria. Leg Lengthening. Patient selection and management in achondroplasia. Orthop Clin N Am 1991, 22: 589 - 599.
Villariubias JM, Ginebreda I, Jimeno E. Lengthening of the lower limbs and correction of lumbar hyperlordosis in achondroplasia. Clin Orthop 1990, 250: 143 - 149.