SUCCESS IS A JOURNEY NOT A DESTINATION HY ? HEN ? HERE ? of of lim limb b le lengthening ngthening
RASHTRAPATI NATIONAL AWARD WINNER FOR POLIO WORK BY GOVT. OF INDIA WITH THE AUSPIOUS HANDS OF PRESIDENT OF INDIA DR.A.P.J. ABDUL KALAM PROF. DR. J. J. PATWA M S (ORTHO.) Abstract no.- 1171 Contact no.- +919824036131 S.B.K.S.M.R.C. PIPARIA, WAGHODIA, VADODARA, GUJARAT, INDIA.
LIMB LENGTHENING PHYSEAL THROUGH DISTRACTION BONE CHONDRODIASTESIS ILIZAROV WASSERTAIN LON(Lengthening ANDERSON TECHNIQUE on Nail) WAGNER ILIZAROV + ILIZAROV / CORTICAL Threaded Tibular ALLOGRAFT fix.+ InterlockNail
LENGTHENING THROUGH BONE Anderson – Wagner – Wasserstein - LoN The biology of bone growth according to Ilizarov is maintained within the tissue stretches periosteal vessels, nerves, muscle and skin to induced growth. Bone growth depends upon the ability to regenerate tensile force within the limb. Distraction of the corticotomy by mecahnically applied tension force called “Distraction Osteogenesis” is the primary method of the limb lengthening.
LENGTHENING THROUGH BONE Anderson Method T.F. Syndesmosis Apparatus Lengthening Diaphyseal corti. L. Plate Final at the end
DISADVANTAGE OF ANDERSON METHOD • Diaphyseal corticotomy • During lengthening patient is bed ridden • To make patient ambulatory second surgery of lengthening plate + bone graft is necessary • Requirement of additional bone graft • Third surgery for removal of plate • Stress protection osteo-penia which is the weakest junction may lead to refracture
LENGTHENING THROUGH BONE Wagner Method [Uniplanner Fixator] Corti. Lengthening Apparatus T.F. Syndesmosis Plate + B.G. Post infective hypo plastic hip with coxa- vara treated by valgus osteotomy followed by Wagnor lengthening L Plate Final
DISADVANTAGE OF WAGNER METHOD • Canti- lever fixation with Schanz’s screw • Uni-planer fixator so three dimensional correction is not possible • During lengthening patient is on non weight bearing walking • Requires plating and bone grafting • Third surgery for removal of plate • Stress protection osteo-penia may lead to re-fracture
LENGTHENING THROUGH BONE Wasserstein Technique Distracted gap filled up with Allograft inside the periosteal tube
DISADVANTAGE OF WASSERSTEIN TECHNIQUE • At times allograft may not unite with original bone • May require massive bone grafting • Body rejection phenomena is to be kept in mind • Too much delay in weight bearing
LENGTHENING THROUGH BONE Lengthening on Nail (LoN) / Ilizarov or Tibular Fixator(rail fixator) Now telescopic lengthening inter lock nails of Italy & France are available
DISADVANTAGE OF LENGTHENING ON NAIL • Precise placement of wire’s / Schanz’s screw’s • Splinted and non-splinted bone junction is the weakest portion of bone which may lead to fracture during treatment • Additional external support is must till solid consolidation achieved on x-ray • Longer post protection phase
ADVANTAGE OF LENGTHENING ON NAIL • No possibility of translation and other deformity of regenerate • Cumbersome frame removed early after distal locking of the nail on achieving length • Early mobilization / Early weight bearing • Because of above reason early consolidation of regenerate • No need of bone grafting
PHYSEAL DISTRACTION A second method which may be used for obtaining longitudinal bone growth is epiphyseolysis or epiphyseal distraction. When the physis is well formed and sufficiently active, distraction can be applied without a corticotomy. The most common complication is early fusion of epiphysis.
FAILED HINTINGTON’S TECHNIQUE TREATED BY EPIPHYSEAL LENGTHENING
DISADVANTAGE OF EPIPHYSEAL LENGTHENING • At times it leads to early fusion if epiphyseal lengthening is perform before adolescent period • Epiphyseal wire infection may lead to pio-arthrosis • This infection may lead to early fusion and deformity at the joint level • May require second surgery for length discrepancy in future • Possible in only 4 % of lengthening • Unpredictable rate of growth after epiphysiolysis
INDICATION – Length Discrepancy Why L.L? SHORTENING Upto 2 cms. - No surgery 2 to 15 cms. - Surgery > 15 cms. - Leave Alone - Orthotics - Double bone lengthening - Double Procedure Lengthening of affected limb & shortening of normal limb
INDICATION – Length Discrepancy SHORTENING Upto 6 to 8 cms. - Tibial Lengthening 8 to 15 cms. - Lengthening of Tibia & Femur - Or lengthening of affected bone and shortening of normal bone TO KEEP LEVEL OF KNEE EQUAL
LIMB LENGTHENING HEN ? • Ideal Period – Adolescent growth spurt 10 to 14 yrs. • 65% growth around knee • 35% distal femur and 30% proximal tibia • 71% of distal metaphyseal femoral growth during 10 to 15 years • 57% proximal metaphyseal tibial growth during 10 to 15 years • Discrepancy is more in tall child than short child
HY ? Limb Lengthening by ILIZAROV METHOD Biology of Limb Lengthening Distraction Osteogenesis Distraction Histiogenesis (Soft Tissues) Avoid bone grafting Avoid release operation (in majority) Distraction Epiphysiolysis possible
HERE ? Types of Limb Lengthening • Distraction Epiphysiolysis • Metaphyseal Corticotomy • Diaphyseal Corticotomy
Why metaphyseal region is preferred? • Very high osteogenic potential • Growth plate located next to metaphysis • Soft tissues better adopted to lengthening
FACTORS AFFECTING CONSOLIDATION INDEX • Disphyseal osteotomies healed slower than metaphyseal • Tibia healed slower than femur • Pts. < 20 yrs. healed faster than > 20 yrs. • Aeitology of discrepancy
OW ? Formula J.B.J.S. VOL. 72 – B NO. 1 JAN 1990 A.T.HADLOW, R.O.NICOL S.A.P. – Length of shorter bone at present L.A.P. – Length of Longer bone at present L.A.M. – Length of Longer bone at Maturity P.L.N. – Predicted lengthening necessary
Formula P.L.N. = [1-X] L.A.M. + X L.A.P. – S.A.P. FOR FEMUR X = 0.9 P.L.N. = 0.1 L.A.M. + 0.9 (L.A.P. – S.A.P.) FOR TIBIA X = 0.64 P.L.N. = 0.36 L.A.M. + 0.64 (L.A.P. – S.A.P.)
“Healing Index” or “Lengthening Index” or “External fixation treatment index” Time in (months) external fixation = No. of centimeters lengthened
BONE RANGE OF UPPER LIMIT Femur 6 to 10 cms. Tibia 10 to 15 cms. Humerus 10 to 15 cms. Radius / Ulna 5 to 10 cms.
“Lengthening Index” for tibia Children Adult De Bastiani - 1.2 ms/cm Paley 0.97 ms/cm 1.7 ms/cm Index is higher for short distraction gap but lower for large distraction gap
PROF. DR. J. J. PATWA
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