Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Limb Lengthening (Ilizarov Method)
Limb Lengthening (Ilizarov Method)
Paul D. Sponseller MD
BasicsDescription
-
The process of forming new bone by slow, gentle stretching is called “distraction osteogenesis.”
-
1 method of lengthening was developed in
Kurgan, Russia, by G. I. Ilizarov as a means of slowly and completely
correcting many congenital and acquired abnormalities.-
The Ilizarov method uses a versatile external fixator to produce gradual changes in the length and alignment of an extremity.
-
The fixator consists of circular rings attached to bone with wires.
-
These rings are distracted (spread apart) by threaded rods.
-
Each fixator is custom assembled for the given patient and indication.
-
-
-
Fixators other than the Ilizarov (versatile but tend to be bulky) may be used:
-
Monolateral fixators and spatial frames
-
If complex rotation and angular
correction are not needed, fixators with PINS in a straight line may be
used (many different models are available).
-
-
Nevertheless, the principles described here are general and apply not to the device but, rather, to the concept and procedure.
-
The Ilizarov method is applicable to all
extremities, but it is used most commonly in the lower extremities
where alignment is more critical than in the upper extremities. -
The ideal age for performing the Ilizarov method is in the preteen and teen years.
-
At this time, the skeleton is almost
finished growing, so its final shape can be determined, yet the
potential for healing and remodeling is that of a child. -
In addition, the patient has the maturity to undergo an arduous treatment process.
-
Bone healing, however, is slower with advancing age.
-
-
For certain indications, this procedure
can be performed in younger patients (with severe congenital
abnormalities) or in adults (with nonunions and acquired deformities). -
Classification for types of procedures performed using with Ilizarov method:
-
Extremity lengthening
-
Angular correction
-
Repair of nonunion
-
Restoration of lost bone
-
Correction of contracture
-
Fracture treatment
-
-
Synonyms: Limb lengthening; Callotasis
DiagnosisSigns and Symptoms
History
In deciding whether this treatment method is appropriate
for a given individual, the physician should determine the degree of
functional impairment, degree of patient adaptation, and degree of
patient understanding and motivation to undergo a treatment that lasts
for many months.
for a given individual, the physician should determine the degree of
functional impairment, degree of patient adaptation, and degree of
patient understanding and motivation to undergo a treatment that lasts
for many months.
Physical Exam
The patient should be checked for pin-tract problems, nerve function, and joint ROM at each visit (1,2).
TreatmentSpecial Therapy
Physical Therapy
-
Patients may benefit from:
-
Instruction on appropriate weightbearing and transfers
-
Maintaining joint ROM
-
Strengthening
-
Monitoring the correction process daily
-
Medication
First Line
NSAIDs should not be taken for a long period because they may suppress bone healing.
Surgery
-
Surgery (to create the osteotomy and
attach the fixator) is performed with the patient under general
anesthesia (bone elongation usually is performed later). -
The external fixator frame is assembled on the patient’s limb according to its shape and the goal of treatment.
-
Several PINS or rings are needed above and below the site of bone correction.
-
Threaded distraction rods are positioned to provide the needed correction over time (Fig. 1).
-
-
The osteotomy is performed once the bone is stabilized.
-
Use a small incision.
-
Try to limit as much as possible the disruption of the blood supply.
-
Often, the fixator is extended to an adjacent bone for stability.
-
-
If the needed correction is minor, it can
be performed while the patient is under anesthesia, but usually no
distraction or lengthening is performed at the time of the surgery.
Fig. 1. The Ilizarov method may be used to lengthen a limb. Bone regenerates to fill in the gap. -
Distraction:
-
Started 7–10 days postsurgery (approximately the time the healing callus is 1st seen radiographically)
-
Continued at a rate of 1 mm per day:
-
Usually divided into at least 4 segments so the tissues are not stretched too suddenly
-
In this way, the callus is stretched slowly (distraction osteogenesis).
-
-
-
Once the desired length is achieved, the new bone is allowed to strengthen, which occurs with time and weightbearing.
-
The fixator is removed when the bone appears strong enough.
-
The total time spent in the fixator can be estimated by the lengthening index:
-
Time (per centimeter of length gained) needed for the process of lengthening and consolidation
-
Averages 1–1.6 months/cm
-
P.229
Follow-upPrognosis
-
The results usually are good, although problems and complications may require additional procedures before completion.
-
An 80–90% success rate may be expected (1–4), although the healing time often is prolonged.
Complications
-
Nonunion
-
Joint stiffness or subluxation
-
Fracture
-
Nerve injury
Patient Monitoring
-
Patients must be seen periodically during
the procedure to monitor the correction process and to check on the
status of the pin sites. -
Radiographs usually are necessary.
References
1. Paley
D, Lamm BM, Katsenis D, et al. Treatment of malunion and nonunion at
the site of an ankle fusion with the Ilizarov apparatus. Surgical
technique. J Bone Joint Surg 2006;88A:119–134.
D, Lamm BM, Katsenis D, et al. Treatment of malunion and nonunion at
the site of an ankle fusion with the Ilizarov apparatus. Surgical
technique. J Bone Joint Surg 2006;88A:119–134.
2. Patil
S, Montgomery R. Management of complex tibial and femoral nonunion
using the Ilizarov technique, and its cost implications. J Bone Joint Surg 2006;88B:928–932.
S, Montgomery R. Management of complex tibial and femoral nonunion
using the Ilizarov technique, and its cost implications. J Bone Joint Surg 2006;88B:928–932.
3. Cho TJ, Choi IH, Chung CY, et al. Isolated congenital pseudarthrosis of the fibula: Clinical course and optimal treatment. J Pediatr Orthop 2006;26:449–454.
4. McGarvey WC, Burris MW, Clanton TO, et al. Calcaneal fractures: Indirect reduction and external fixation. Foot Ankle Int 2006;27:494–499.
MiscellaneousPatient Teaching
-
Patients should be told of the duration of treatment (usually many months).
-
They should be helped to make arrangements for school or work and for care after the procedure.
-
Admission to a rehabilitation hospital sometimes is indicated.
-
-
Patients should be assessed to determine whether they have the level of maturity needed for the treatment.
-
Patients may be allowed to bear weight and to swim with the device, if the surgeon allows.
FAQ
Q: Can young children undergo this process?
A: Yes, if the deformity or discrepancy is severe and is limiting them.
Q: How do I decide whether to undergo limb lengthening versus shortening of the other side?
A:
The decision depends on the patient’s expected stature at adulthood and
on the condition of the joints and muscles in each limb.
The decision depends on the patient’s expected stature at adulthood and
on the condition of the joints and muscles in each limb.
Q: Can the Ilizarov procedure be used to make me taller?
A: In certain circumstances, yes. However, the treatment time is long and must be applied to both limbs.