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Discussion of Limb Lengthening

- See:
       - Limb Lengthening Fixators
       - Distraction Histiogenesis
       - Post Op Care in the Ilizarov Method: (by Dr. Mangal Parihar)

- Discussion:
    - growth deformities of the limbs
    - it is important to distinguish between limbs with good potential for lengthening (such as limbs prematurely shortened due to
           physeal injury) vs those w/ poor potential for lengthening (such as the congenitally short limb that was never
           "programmed" to be long);
           - some pediatric orthopaedists will be extremely reluctant to attempt lengthenings of the congentially short limb (such as PFFD)
                    due to the high complication rate;
    - in adults, obtaining more than a 15% increase in limb length is difficult;
           - bone density measurements can be helpful in determining whether it is safe to remove the fixator (during regenerative phase);

- Limb Lengthening in Children:
    - lengthening of the pediatric diaphysis:
         - when projected discrepancy  is > 5.1 cm, consider limb lengthening;
         - femur can be lengthened in a single stage, upto 3 to 4 cm, or lengthening can be performed gradually over several weeks;
         - references: Epiphyseal distraction. Chondrodiatasis.         
    - transphyseal lengthening
         - distraction device is placed across the growth plate & lengthens the limb by causing separation at plate;
         - procedure is generally performed just before skeletal maturity;
    - congenitally short leg:
         - limbs that were never "programmed" to achieve normal length will be at especially high risk for major complications from
                limb lengthening;
                - this is in contrast to limbs that are short as a consequence of growth plate trauma, in which case, limb lengthening is a more
                reasonable treatment option;
         - references:
                - Complications of limb lengthening in children who have an underlying bone disorder.         

- Limb Lengthening of the Femur

- Lengthening of the Tibia

- Specific Lengthening Methods:
    - Wagner Method:
         - distraction apparatus is applied following a mid-diaphyseal osteotomy;
         - following completion of lengthening, the lengthening apparatus is removed, & metal side plate is applied along w/ bone grafting
                  to diaphyseal defect;
    - Ilizarov Technique
         - bone is lengthened at a rate of 1.0 to 1.5 mm per day.
         - gradual distraction allows the neurovascular bundle and muscles to lengthen safely;
         - osteotomy is performed at lower metaphyseal level for enhanced bone healing;
    - Lengthening over an IM Nail:
         - in report by Simpson AS, et al (1999), authors followed 20 patients who underwent leg lengthening with a combination of ex fix
                and IM nailing;
                - mean gain in length was 4.7 cm (2 to 8.6);
                - mean time of external fixation was 20 days per cm gain in length;
                - all distracted segments healed spontaneously without refracture or malalignment;
                - there were 3 cases of deep infection, two of which occurred in patients who had had previous open frx of bone which was
                           being lengthened (all resolved with appropriate treatment)
                - authors noted the following advantages:
                           - early rehabilitation, early return of knee ROM, low rate of complications, shorter period for using external rotation;
         - Leg lengthening over an intramedullary nail
    - Immediate Lengthening:
         - references:
               - Limb Lengthening and Correction of Angulation Deformity: Immediate Correction by Using a Unilateral Fixator
               - One-stage lengthening for femoral shortening with associated deformity.
    - Complications:
         - adults will have a much higher complication rate than children;
         - avoid simultaneous femoral and tibial lengthenings;
         - contractures:
               - occur from stretk
         - neurovascular damage from stretching;
               - if neurological damage develops, then lengthening must be stopped or reversed;
               - consider decompression of the peroneal nerve over the fibular neck along with excision of the fascia lata and lateral
                         intermuscular septum;
         - fractures:
               - lengthening should never be attempted through a previous fracture site

Lengthening of congenital lower limb deficiencies.

One-stage lengthening for femoral shortening with associated deformity.

The effect of lengthening of the femur on the extensors of the knee. An electromyographic study.

Results of the Wagner and Ilizarov methods of limb-lengthening.

Limb Lengthening and Correction of Angulation Deformity: Immediate Correction by Using a Unilateral Fixator.

Distraction osteogenesis of the lower extremity with use of monolateral external fixation. A study of two hundred and sixty-one femora and tibiae.

Nerve Lesions Associated with Limb-Lengthening.

Complications Encountered During Lengthening Over an Intramedullary Nail.

Autologous Bone Marrow Grafting Combined with Demineralized Bone Matrix Improves Consolidation of Docking Site After Distraction Osteogenesis

Surgical Technique: Lower Limb-length Equalization by Periosteal Stripping and Periosteal Division