Limb lengthening is a procedure to lengthen the bones in the arms or legs. This is done as a gradual process, so that the bones and soft tissues (skin, muscles, nerves, etc.) slowly increase in length. Typically, the process take several months. Limb lengthening can also be combined with gradual or acute deformity correction.
What are External Fixators?
External fixators are metal devices that are attached to the bones of the arm, leg or foot with threaded pins or wires. These threaded pins or wires pass through the skin and muscles and are inserted into the bone. The majority of the device is outside of the body, which is why it is called an external fixator. Many people only require one external fixator to be applied, but some will need two or more external fixators.
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Before Limb Lengthening Surgery-External Fixators
When are external fixators used?
External fixators can be used to gradually lengthen a bone, straighten a deformed bone or reduce pressure on a joint through joint distraction.
How to Prepare
The surgical team will provide you with more detailed instructions on what you need to do in the days and hours before the surgery. It is recommended that you stay active, eat a healthy diet, and stop smoking prior to any operation to promote optimal healing and a smooth recovery.
You may need to stop taking certain medications in the days leading up to the surgery to prevent excess bleeding or interaction with anesthesia during the operation. Always consult with your doctor about all prescriptions, over-the-counter medications, and supplements that you are taking.
After the operation, you will typically stay in the hospital for two to three days. You will not be allowed to drive to or from the hospital before or after your surgery, so make sure to make arrangements for a friend or family member to provide transportation for you.
Minimizing stress and prioritizing good mental and emotional health are also important to lowering levels of inflammation in the body to aid in your recovery. The healthier you are when you go into surgery, the easier your recovery and rehabilitation will be.
What to Expect
Limb Lengthening Surgery-External Fixators will be a procedure decided between you and your doctor and will be scheduled in advance depending on the availability of your surgeon and the operating room.
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Before the Surgery
On the day of your Limb Lengthening Surgery-External Fixators, you will be taken to a pre-op room where you will be asked to change into a gown. You will undergo a brief physical examination and answer questions about your medical history from the surgical team. You will lie down on a hospital bed, and a nurse will place an IV in your arm or hand for delivering fluids and medications. The surgical team will use the hospital bed to transport you in and out of the operating room.
The osteotomy, or bone cutting, and placement of an external fixator can be performed under general anesthesia, which will put you to sleep during the operation, or under epidural anesthesia, where the anesthesia medication is injected into your low back and numbs you from the waist down. With epidural anesthesia, you may be awake during the surgery, but should not feel any pain from the procedure.
Limb Lengthening Surgery-External Fixators helps correct significant limb length discrepancies, but it carries a number of risks, including:
. Bone infection (osteomyelitis)
. Poor bone healing
. Bone growth restriction
. Nerve damage
. Injury to surrounding muscles and blood vessels
. Excess bleeding
. Adverse reaction to anesthesia
. Blood clots
. Nausea and vomiting
. Joint stiffness
. Bone length may not be exact, such as longer or shorter than planned
. Muscle contraction (muscle shortens)
. Problems with the new bone forming
Always discuss with your doctor about the possible risks of Limb Lengthening Surgery-External Fixators to determine if it is an appropriate option for you given the extent of your limb length discrepancy and how it is affecting your daily functioning.
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What are pin-site infections?
Pin-site infections are the most common problem associated with external fixation treatment. Pin-site infections begin at the level of the skin. If identified early, they are easily treated. If left untreated, they may progress to the deeper soft tissues and possibly even to the bone.
It is important for the patient or family to know the symptoms of a pin-site infection. The most common symptoms are tenderness in an area around a pin site that was not previously tender and increased redness at the pin site. Sometimes the area will have increased warmth, swelling, pain or drainage compared to the other pin sites.
When patients with external fixation leave the hospital, the doctor will give them a prescription for oral antibiotics. If patients develop the signs of a pin-site infection, they should fill the prescription and immediately begin to take the oral antibiotics. It is important to start the antibiotics quickly (within 24 hours). The patient/family does not need to call the office to confirm that the patient has a pin-site infection before the patient starts taking the oral antibiotics. Once the antibiotics are started, call us within 24 hours to let us know that you are treating a pin-site infection. The redness, tenderness and drainage should improve within 24 to 48 hours of starting the antibiotics.
The risk of a more serious infection (i.e., toxic shock syndrome or necrotizing fasciitis) that can be life-threatening is extremely rare.
The signs of a more serious infection are pin-site pain along with one or more of the following symptoms:
. Vomiting, and/or
. Appearing glassy-eyed, pale or flushed.
If the patient has any of these symptoms, we need to know urgently; contact your doctor or the doctor on call. Again, these types of infection are rare; however, if they occur, treatment is straightforward but must be started immediately. The treatment normally requires a trip to an emergency room and a dose of IV antibiotics for 24 hours.
Purpose of Limb Lengthening Surgery-External Fixators
Many patients who are candidates for limb lengthening surgery have two legs/arms of different lengths as the result of:
. A congenital birth defect
. Growth plate injury to a leg/arm bone as a child
. Malunion of a previous fracture where the leg/arm bone heals out of alignment
. Nonunion of a previous fracture where the leg/arm bone does not heal at all
Patients with skeletal dysplasias or other bone disorders may also qualify for limb lengthening surgery if there is a significant difference in leg/arm lengths between the right and left sides, affecting their ability to walk and move properly.
Other conditions that can cause a significant limb length discrepancy requiring limb lengthening surgery include:
. Cerebral palsy
. Legg-Calve-Perthes disease
If you suspect you have a limb length discrepancy, you should receive a physical examination from an orthopedic physician to determine if there is a true limb length discrepancy due to different leg/arm bone lengths or if there is an apparent limb length discrepancy where one leg/arm appears to be shorter even though both leg/arm bones are the same length.
Apparent limb length discrepancies can result from problems with the spine, hips, or sacroiliac joints. Physical therapy is often effective for restoring proper alignment of the muscles and joints to correct the issue. If your doctor suspects you may have a true limb length discrepancy, x-rays will be used to confirm the difference in bone length.
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During Limb Lengthening Surgery-External Fixators
How are external fixators applied?
During surgery, the doctor will make small incisions and then insert pins or wires into the bone. The external fixator frame will be attached to these pins and wires and secured using clamps and rods. If the bone is to be lengthened or straightened, the doctor will then surgically cut the bone (osteotomy) to create two separate bone segments.
Types of external fixators
External fixators have many different designs. The two main types are circular/ring external fixators and monolateral external fixators. Both types of external fixators can be hinged to allow the elbow, hip, knee or ankle joint to move during treatment.
. Circular External Fixators
Circular external fixators can completely or partially encircle the arm, leg or foot that is being treated. These fixators are made up of two or more circular rings that are connected by struts, wires or pins.
The Taylor Spatial Frame (TSF) is one type of circular fixation that we use often. The TSF consists of two rings that are connected by six struts. The TSF simultaneously corrects angular, translational and rotational deformities. After the TSF is applied, details about the frame/struts and its position on the body are entered into a computer program. The computer program then generates a correction schedule that instructs the patient (or family member) on how to adjust the TSF several times a day to slowly pull the bone segments apart.
Ilizarov external fixators are another type of circular fixation that we use. The patient (or family member) may need to use a small wrench to adjust the device several times a day. The Ilizarov external fixator was the “original” circular (ring) fixator. Its use has largely been supplanted by the TSF, but we still occasionally use the classic Ilizarov, particularly in small children.
. Monolateral External Fixators
Monolateral external fixators have a straight bar that is placed on one side of the arm, leg or foot. It is connected to the bone by screws that are often coated with hydroxyapatite to improve the screws’ “hold” in the bone and prevent loosening. The patient (or family member) may need to adjust the device several times a day by turning knobs.
After Limb Lengthening Surgery-External Fixators
What happens after the external fixator is applied?
After surgery, the bones are allowed to rest for 5 to 7 days to begin the healing process. After this period of time, the distraction phase of treatment begins. The patient (or family member) will be given a schedule that instructs them how to adjust the fixator several times a day by turning small knobs or other parts of the device to slowly pull the bone segments apart.
This gradual process of slowly separating the bone segments is called distraction, which means “pulling apart.” As the bone segments are pulled apart at a slow rate of approximately 1 mm (0.04 inches) per day, new bone forms in the space between them. The new bone is called regenerate bone. The distraction phase lasts until the bone is straight or corrected. The patient will need to see the doctor every 10 to 14 days during the distraction phase.
After the correction has been achieved, the consolidation phase begins in which the regenerate bone slowly hardens. During this phase of treatment, the external fixator normally remains in place so that it can support the bone as it heals. The bone has consolidated (“healed”) when the regenerate bone has completely hardened and calcified.
The consolidation phase typical takes twice as long as the distraction phase. For example, if distraction is completed in 1 month, then consolidation will take 2 months. In this example, the external fixator would remain on the patient for a total of 3 months through both the distraction and consolidation phases.
To help the bone heal, patients should avoid nicotine in any form, make sure that their diet includes lots of protein and take vitamin and mineral supplements. During the consolidation phase, your doctor may tell you to start putting some weight on the arm/leg, which will also encourage the bone to harden and heal.
After the bone is fully consolidated, the external fixator can be removed during an outpatient surgical procedure (the patient does not stay in the hospital overnight after the removal procedure). To provide additional protection for the new bone, our doctors may apply a cast or ask the patient to use a brace for 3 to 4 weeks after the external fixator is removed.
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What happens if the bone is lengthened too slowly?
Even though the typical rate of lengthening is 1 mm per day, each person responds differently to bone lengthening. Some people’s bones heal very quickly, and the regenerate bone may harden before treatment is completed. This is called premature consolidation. When the regenerate bone hardens, the two bone segments cannot be pulled apart anymore. The bone may heal before it reaches the desired length. The doctor will want to see the patient often during the distraction phase to prevent premature consolidation.
When premature consolidation is seen on X-rays during a follow-up visit, one option is to increase the rate that the bone segments are pulled apart. For example, the rate of distraction may be increased from 1 mm per day to 1.5 mm or even 2 mm per day. If the regenerate bone has entirely consolidated, the bone may need to be surgically cut again so that lengthening can continue. This requires a trip back to the operating room, typically as an outpatient procedure, which means the patient does not stay in the hospital overnight.
What happens if the bone is lengthened too quickly?
Even though the typical rate of lengthening is 1 mm per day, some people’s bones take much longer to heal and regenerate bone might not have time to form. For example, healing may be slower in smokers and diabetics. The regenerate bone needs to form so that it can act as a bridge between the two bone segments that are being pulled apart. The doctor will want to see the patient every 7 to 14 days during the distraction phase to make sure that the regenerate bone, muscles and nerves are responding well to lengthening.
In cases of poor regenerate bone formation, it is possible to adjust the orthopedic device to temporarily shorten the bone until the regenerate bone improves. A more aggressive surgical option to help the body create regenerate bone involves inserting bone tissue (called bone graft) into the gap between the two bone segments. After the regenerate begins to fill in between the bone segments, the doctor will allow the patient to continue lengthening the bone.
Another issue that can occur during limb lengthening is that the soft tissues (muscles, nerves, ligaments, tendons) may resist being stretched during the lengthening process, which can cause them to become very tight. A non-surgical option to treat tight muscles is to increase the amount of stretching during the physical therapy sessions. Throughout the distraction process, the patient will need to attend physical therapy two to five times per week. Muscle/tendon contractures can also be treated surgically if necessary. If a nerve is “pinched” or compressed, a surgical procedure called a nerve decompression can be performed that reduces pressure on the nerve (similar to the surgical treatment for carpal tunnel syndrome).
How much can each bone be lengthened?
During each lengthening treatment, a bone is typically lengthened 2 inches (5 cm) or less. In the legs, 2 inches of lengthening can be done simultaneously in the femur (thigh bone) and the tibia (shin bone) to make the total lengthening 4 inches (2 inches in the femur and 2 inches in the tibia).
In severe cases, greater amounts of lengthening may be possible during one treatment. For example, children and adults who have large lengthening goals may be able to tolerate more than 2 inches of lengthening in each bone. This is determined on a case-by-case basis by our surgeons. To maximize the amount of length, some children have three separate lengthening treatments before they are 16 years old. Often, this is combined with other procedures (deformity correction, epiphysiodesis).
What could prevent me from achieving my lengthening goal?
If patients do not attend physical therapy sessions or perform home exercises, their muscle strength and range of motion could be affected and the doctor may have them stop lengthening. Muscle contractures can result in stiff joints or even dislocated joints. The doctor may stop the lengthening process, either temporarily to allow recovery of function or permanently.
Keep in mind that large lengthening goals may require more than one lengthening. For example, instead of a single 4-inch lengthening, it may be easier to perform a 2-inch lengthening and then a few years later do another 2-inch lengthening. Some patients may need to undergo additional surgical procedures before or after limb lengthening to address other pre-existing orthopedic issues.
Do lengthened arms and legs function well after treatment?
Adults and children typically can lead normal, active lives after limb lengthening.
Most of our patients have achieved increased function (better walking/gait), improved muscle strength and maintained their range of motion (flexibility). A large part of the success depends on having experienced surgeons, support staff and physical therapists working together with motivated patients through every stage of the process. Another important part of lengthening is physical therapy; patients may need to attend physical therapy sessions multiple times per week to maintain range of motion (flexibility) and muscle strength during the distraction phase. Our physical therapists have years of experience and have developed unique exercises, splints and other treatments to help maximize the chances of success.
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