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An overview of lengthening is presented from the scarlet cloth through skeletal traction, screw distraction, and patient mobility. Unquestionably, significant advances have been made in the technology and techniques of lengthening legs, but more are yet to be made.
Leg lengthening techniques, imported from Russia and Europe, have developed during the past 10 years in North America and have matured to become an accepted method of treating leg length discrepancy. The use of these techniques for stature lengthening in dwarfism is somewhat less widespread. A review of published reports indicates a maturation in the field of leg lengthening, with more focused studies on larger cohorts of patients having the same pathology. Long-term follow-up studies are forthcoming, and there is still extensive room for basic research. Precise indications and limits for lengthening in femoral hypoplasia and fibular hemimelia are unclear, and await additional reporting. Future research needs to include outcome studies, hardware improvements, implantable lengthening devices, and a better understanding of the basic science behind lengthening of both bone and soft tissues.
The technique of lengthening the tibia with the Ilisarov device is explained. Different variations (bifocal or simultaneous) of the method are demonstrated, as well as the results of 53 cases of tibia lengthening in 37 patients of our hospital between 1986 and 1989. In 14 patients, a second operative procedure was necessary during treatment. In no case was internal fixation or grafting necessary. The Ilisarov ring fixator is very efficient, especially in major lengthening procedures and for simultaneous correction of deformities.
The distraction-epiphyseolysis is a method of leg-lengthening and allows to correct leg-deformities. A daily lengthening of 1 mm enhances ossification and enables a maximum lengthening of 8-10 cm. The indications, contra-indications and the method are described.
The leg lengthening distraction procedure was analyzed with objectives of understanding complications which arise due to overstretching, establishing guidelines to the optimum distraction rates and the frequency of distraction, and, determining the final amount of leg lengthening. An electronic recording system was devised to provide continuous monitoring of the tractive load resulting from distraction of the leg during the elongation procedure. The mechanical behavior patterns of the involved stretched tissues domonstrate time-dependent viscoelastic effects during distraction. During a leg lenthening procedure it is desirable to establish, if possible, a regular pattern of distraction early in the process. If it is necessary in the course of treatment to reduce the distraction rate for clinical reasons, then it is preferable to keep the same number of distraction events but reduce the distraction amount. Distract at equally spaced time intervals to obtain repetitive load cycles and thereby reduce peak values of load and maintain similar stress relaxation patterns for each instantaneous load increase. The total amount of lengthening depends on the characteristics of each individual leg length discrepancy and the physical properties of each distracted tissue.
Twenty-two dogs were provided with a circular fixator. Lengthening of the right lower leg by 2.5 cm was performed on 18 dogs 5 days after tibial osteotomy using a distraction rate of 0.5 mm, twice per day. Nine dogs with leg lengthening and two dogs of the control group without leg lengthening were sacrificed at the end of the distraction phase of 25 days and the remaining dogs after another 25 days. Post mortem, the tendons of the tibialis anterior, extensor digitorum longus, peroneus longus, and the Achilles tendon were taken from the operated-on right side and the left nonoperated-on control side and were analyzed histologically. The control group showed no histologic changes in the tendons of either side nor in those of the unlengthened left side of the operated-on dogs. Thirty-three tendons (41%) of dogs with leg lengthening were seen to have undergone histomorphological changes. An increase of the peritendinous connective tissue was seen, combined with chronic inflammatory cell infiltration in the tendons and/or the epitendinous tissues, edema, tendon fragmentation, necrosis, scarring of the tendons with dystrophic calcification and/or ossification, and broadening of the tenosynovial sheath. Furthermore, signs of histoneogenesis with growth in the tendons were found. Degenerative changes occurred far more often in the tendons of the ventral side of the lower leg and a slight pes equinus was regularly observed in the lengthened extremity. Therefore, pes equinus prevention and physiotherapy are important in the therapeutic use of lower-leg lengthening to minimize possible stress-induced damage of the ventral tendons.
Leg lengthening procedures have developed rapidly in the last 20 years, especially distraction epiphyseolysis and corticotomy. We have used both methods since 1977 and carried out 22 distraction epiphyseolyses (20 patients) and 33 corticotomies (28 patients). The average lengthening distance was 8.25 cm and 7.8 cm respectively (minimum 4 cm, maximum 18 cm). The time per cm lengthening (lengthening index) was 45.8 days/cm for epiphyseolysis and 52.2 days/cm for corticotomy. The complication rates were similar in both methods (1.18 and 1.21 pro lengthening procedure). Both techniques are preferably performed by a well trained team of physicians, nurses and physiotherapists for correction of leg length discrepancies.
Two hundred eleven leg lengthening operations have been carried out at the Royal National Orthopaedic Hospital, London, in 192 patients between 1966 and 1977. The results were analyzed in the 143 patients who had reached skeletal maturity. A 5 cm gain in length using Anderson's modification of Abbott's lengthening machine was achieved in 21 femora and 122 tibiae. There was no significant difference in the sexes, 98 boys and 94 girls. Average difference in leg length before operation was 5.75 cm (11.7--3.0 cm). Average reduction in difference 3.06 cm (7.5--4.5 cm). Average difference at maturity 2.48 cm (9.5--0.5 cm). Fractures occurred in 30 patients all of which united, but some lost part of the length gained. Most serious was a decision to amputate in 2 patients due to severe discrepancy in one patient and foot deformity in another. There were no failures of union, no long-term sepsis and no deaths.
Leg lengthening has been a procedure of last resort because of its high complication rate and significant morbidity with a relatively long period of disability during the process even when no complications occur. The new techniques of lengthening hold promise that orthopedists will be able to achieve more length with fewer complications. It is interesting to note, however, that, while it is the technology of these techniques that has stimulated the greatest enthusiasm, it is the biologic principles that are likely to offer the greatest ultimate benefit. The modern era of leg lengthening has therefore brought two things: new technical versatility to correct complex and coexisting deformities and new concepts of the biology of lengthening that are not device specific and can be applied with most lengthening devices.
Twenty patients with an average posttraumatic leg length shortening of 4.6 cm (range 2.5-9) underwent direct leg lengthening. The operation time averaged 210 min and the peroperative blood loss was 1,800 ml. Angular and rotational malalignment, when present, were corrected. Lengthening averaged 3 cm. At follow-up, two patients had serious sequelae after vascular injuries. Seven patients had postoperative neurological complications, which in four cases resolved completely. The time required for solid union of the lengthened segment averaged 10 months. Bone grafting two or more times was performed in six patients. Seventeen patients were assessed an average of 7 years (range 3-10) after surgery. Thirteen of these were satisfied with the results of the lengthening. Complications of the procedure and/or a remaining major leg length inequality could explain the dissatisfaction of the others. A majority of the patients complained of low-back pain both preoperatively and at follow-up. Few complaints about the joints in the long leg were expressed. Preoperative pain about the hip and knee in the short leg existed in more than half of the patients, and these complaints were reduced on a weak statistical level at follow-up. Walking ability improved in 12 patients, working ability in 10, and recreational activity level in eight. Direct leg lengthening is generally regarded as major, demanding surgery, entailing potential risks of serious complications, and should be used with great care and only in selected cases.
The techniques earlier used for leg lengthening were notorious for their complications, and as late as the 1960s some authorities would not consider lengthening unless amputation was the alternative. The method introduced by Wagner in the 60s had the advantage of a stable external fixation, permitting the patients to be mobilized. The drawback was that at least three operations were needed: external fixation and osteotomy, bone grafting and internal fixation, and, finally, removal of the plate. With the Ilizarov technique, no bone grafting is needed and bone lengthening up to at least 15 cm is possible. The main problems in leg lengthening are related to joints and soft tissue. Every surgeon performing leg lengthenings should be familiar with the possible problems and complications. He must establish very good relations with the patient and be ready to spend a considerable amount of time with the patient during the process.
We have used Ilazorov's method of distraction epiphyseolysis for leg lengthening since 1977 and his new method of corticotomy or compactotomy since 1983. The first method was carried out in 22 lower limbs with an average lengthening of 8.25 cm (range 4 to 18 cm); included in this group are 2 patients with achondroplasia in whom both legs were lengthened 12 cm. In the second method, a corticotomy is carried out at the metaphyseal-diaphyseal junction followed by distraction in Ilazorov's apparatus (4 x 0.25 mm a day). We lengthened 30 legs; included are 5 patients who had both legs lengthened from between 8 and 12 cm. In the remainder an average of 7.9 cm of lengthening was achieved (range from 4 to 15 cm). The index for the treatment time per cm achieved (time from operation until full weight-bearing per cm of lengthening) was shorter after distraction epiphyseolysis than after corticotomy. Complications were also a little less after the latter procedure. Distraction epiphyseolysis has to be limited to children from aged 12 years until growth ceases. The advantage with corticotomy is that it can be done at any age from 5 to 30 years. Care is needed in both cases to avoid complications.
Since 1971, we have performed 189 leg lengthening procedures using the Wagner method at our institution. The results obtained in the first 26 cases (1971-1973) showed a high complication rate, which led us to reconsider the indications for this procedure. In the present paper, we analyze the results of 37 leg lengthening procedures carried out in 32 patients during the last 10 years (1981-1990) in the children's unit of the orthopedic department of the University of Basle. We found a complication rate of 78%, and in 46% of cases there was more than one major complication. We did not distinguish between "complications" and "problems", because such distinctions are of little importance to the patient. The average age at the time of surgery was 14.8 years, and the average increase in length was 4.3 (2.2-9.2) cm. For each 1 cm of lengthening, an average of 21 days in hospital and 64 days of reduced weight-bearing were needed. Our conclusion is that the Wagner method makes it possible to attain the goal of leg lengthening, but the second step cannot reduce the length of stay in hospital or the length of time the patient needs the help of crutches. Bone remodeling is disturbed. Our preliminary experience with the Ilizarov method is more encouraging.
The purpose of this investigation was to compare the tissue response during mono- and bifocal limb lengthening. The study includes four patients undergoing leg lengthening. All patients started out bifocally with a total diurnal distraction of 1.75 mm, but proceeded monofocally with a rate of 1 mm a day when the distal distraction was terminated due to contractures or pain. The tissue response was monitored by registration of axial force in the distraction rods. The force increased linearly during bifocal lengthening, but culminated or decreased in the period of monofocal lengthening. Average tissue stiffness, defined as the immediate force increase due to each 0.25 mm distraction increment, was significantly higher in the bifocal lengthening phase. The force decay between each distraction was significantly lower during bifocal lengthening, thus indicating decreased tissue accommodation. Details in the force registrations indicated that the soft tissue, not the regenerate, was the main contributor to the tensile force. Conclusively, the tissues at the two osteotomy sites do not lengthen independently. Bifocal lengthening exposes the entire soft tissue to large loads, resulting in increased tissue stiffness and reduced ability to adapt to the increased length. Accordingly, bifocal leg lengthening requires special attention to soft tissue adaptation.
A new femur distractor has been developed, lengthening the leg. This instrument is electronically controllable and can be implanted totally. It is possible to regulate transcutaneously by radio control the operation "forward motion", "stop" and "backward motion". After testing this instrument in sheep, the lengthening of human femur by this system can be introduced.
Nineteen leg lengthenings by Wagner's technique were reviewed. Average patient age was 13 years (range, 8-18 years). The gain averaged 3.9 cm (range, 1.1-10 cm). Complications were prolonged treatment period (9 cases), metal-work failure (6), loss of gain (5), malunion (6), fracture (5), deep infection (2), and joint problem (6). The osteogenesis in the elongation gaps affected the results. No callus formation by 40 days after osteotomy and no bridging callus by the end of elongation period were warning signs of poor osteogenesis. All tibial lengthenings and femoral lengthenings of more than 5 cm or 13% of the original length were at risk of poor osteogenesis. Proper stabilization and bone grafting were the most effective measures for poor osteogenesis. Currently, Wagner's technique is not the treatment of choice because new techniques with fewer complications are available. However, Wagner's technique is useful in the cases to which the new procedures are not applicable.
Distraction osteogenesis is widely used for leg lengthening, but often requires a long period of external fixation which carries risks of pin-track sepsis, malalignment, stiffness of the joint and late fracture of the regenerate. We present the results of 20 cases in which, in an attempt to reduce the rate of complications, a combination of external fixation and intramedullary nailing was used. The mean gain in length was 4.7 cm (2 to 8.6). The mean time of external fixation was 20 days per centimetre gain in length. All distracted segments healed spontaneously without refracture or malalignment. There were three cases of deep infection, two of which occurred in patients who had had previous open fractures of the bone which was being lengthened. All resolved with appropriate treatment. This method allows early rehabilitation, with a rapid return of knee movement. There is a lower rate of complications than occurs when external fixation is used on its own. The time of external fixation is shorter than in other methods of leg lengthening. The high risk of infection calls for caution.
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