Surgical lengthening of lower limbs in adults using the Ilizarov technique Текст научной статьи по специальности «Клиническая медицина»

SURGICAL LENGTHENING OF LOWER LIMBS IN ADULTS USING THE ILIZAROV TECHNIQUE.

A. V. Popkov, M.D.

(All-Russian Kurgan Scientific Center Restrorative Traumatology and Orthopaedics)

Covering a long path from first attempt of lengthening bone through skeletal traction, to the automatic distraction with modern apparatus for transosseous osteosynthesis, the surgical lengthening of the lower limb has been actively developed over a period of more than 70 years.

At present, surgical lengthening uses two different principles:

A). UNILATERAL EXTERNAL FIXATION PRINCIPLE

1. Wagner method - Three surgical interventions are necessary: diaphyseal osteotomy, distraction using the Wagner apparatus on 1,5 - 2,0 mm/ day; bone plastics using bone grafts on the newly formed bone defect with fixation by metal plate and screws; removal of plate and screws after consolidation of bone fragments.

2. Ilizarov method - In this method, progressive distraction of the bone after partial corticotomy, stimulates regeneration of bone tissues.

TABLE 1

This surgical technique is less traumatising and practically does not damage the osteogenic tissues. Bone grafts are not used, and there is no necessity for additional fixation. Optimal distraction rate preserves full volume of blood supply in fragments under lengthening and does not disturb innervation of the limb. Rigid fixation of bone fragments at any part of the limb gives an opportunity for functional loading during the treatment.

In this article, the treatment of 631 patients, 357 females and 274 males, aged average 28,6 + J0 ( from 18 to 56 years of age), operated between 1972 and 1990, are subdivided according to etiology of shortening.(Table I).

PERCENTAGE OF SHORTENING

29,3 % .

15,8 %

9,9 %

35,4% 9,6 %

ETIOLOGY OF SHORTENING

Congenital Shortening

Hematogenic Osteomyeliti.

Tuberculosis of bones and joints.

Residual Polio

Trauma

Subdivision of 63 1 patients

Majority of patient had a total limb shortenin of more than 6 cms. 44.6 % had a shortening of on segment (femur or tibia), 55.4 % had shortening c both segments. The average shortening of the feint was 8,5 cms ± 3,0 cms and the average shortenin of the tibia was 6,2 c'ms. A majority of cases showe an accompanying pathology of the adjacent joints o foot. (Table 2).

TABLE 2

i--------------------

ASSOCIATED PATHOLOGY PERCENTAGE NO. OF PATIENTS

Ankylosis of hip joint in malposition

Flexion contracture of hip joint

Valgus, varus or recurvation of ankle joint

Fool Deformities

6.X %

6.5 "«

20 "„

21.2 %

54.52

43

41

126

134

344

The remaining 287 patient (45.48 %) did not present any aassociated pathology or foot deformity. Diaphyseal deformities of long bones were found in 80 cases (57 - femur, 23 - tibia).

In the Ilizarov technique, following classification of transosseous osteosynthesis is used.

DISTRACTION AL.OSTEOSYSTH ESI S f~- -

Monosegmental Polysegmental

i-^-1 i-

Monolocal Polylocal Monolocal Polylocal

Combined compression - distractional osteosynthesis

The whole period of treatment after the surgery includes the period of distraction, fixation with Ilizarov frame and functional rehabilitation. The duration of distraction depends on the amount of lengthening, the rate of distraction, the selected technique for distractional osteosynthesis, the dynamics of repa'rative process, the neuromuscular system in the lengthening limb and the functional position of the adjacent joints. The amount of anatomic femoral lengthening varied between 2 and 11 cm ( 5 - 50%) of total lengthening. The amount of anatomic tibial lengthening varied between 2 and 13 cm ( 5 - 50%) of total lengthening.

Monosegmental lengthening was performed in 346 cases (147 - femoral lengthening, 199 - tibial lengthening),.In 123 casesthelengtheningwasdone withbilocal distractional osteosynthesis. In 36 cases femoral and tibial lengthening was performed simultaneously, (average 22,9+1,4% of initial level). Simultaneously with femoral lengthening malposition of hip joint was corrected, and the axis of limb became even.

In 134 cases together with tibial lengthening surgery on the foot was done, (arthrodesis of foot joints, foot lengthening, corrective osteotomies).

The average rate of distraction in monolocal distractional osteosynthesis was 0,9 mm per day in femural lengthening and 0,8 mm per day in tibial lengthening. The average increase of distractional osteosynthesis was 1,5 times in tibia and 1,9 times in the femur. In both tibial and femoral lengthening the rate of distraction was not more then 1,5 mm daily. The consolidation of the bone fragment is obtained during the fixation period with the ilizarov apparatus. Giving functional load on the operated limb, without additional fixation, helps to obtain good bone regeneration. The period of fixation depends on: the etiology, the amount of lengthening, the level of segmental osteotomy and or complications during lengthening. The period of distraction using bilocal osteosynthesis in femur or tibia can be reduced by 1,5-2 times period of distraction, and period of fixation reduces in 1,3-1,4 times.

In table 3 and 4,the percentage of lengthening of femur with ilizarov apparatus in monolocal distractional osteosynthesis depending on the level of osteotomy and the etiology of the shortening is shown.

TABLE 3

| Level of % of lengthening

| osteotomy Congenital Acquired |

sh6rtcning shortening!

[ Proximal 14.1±1,8 14.3±1,5 j mctaphvses

I Diaphvscs 17.5±2.3 12.\±i.S I

I I

* Distal mctaphvses 17,7±2.5 13.3±2,4 J

TABLE 4

i--------------------1

| Level of Period of fixation

| osteotomy Contenital Acquired |

shortening shortening

I Proximal 14.8±0.7 I2.()±2.X I I mctaphvses

I I

| Diaphvscs 14.7±2;7 24.2±5.1

I Distal metaphvses 17.6±2,3 17.6*1,7 I

i_____________________i

Tibial lengthening was performed, as a rule, in proximal metaphyseal zone of the tibia and the average period of fixation in congenital shortening was 22,07±1,4 days and in acquired shortening 25,07 ± 1,4 days.

In the next two tables (5 and 6), the influence of the character of the osteotomy of femur on the percentage of lengthening and period of of fixation respectively is analysed.

TABLE 5

Character of % of lengthening

osteotomy Congenital Acquired

shortening shortening

Partial 15.4±2.3 I6.7± 1.8

Cortictomv

Osteotomy 16.5±L7 15.8±2.3

Fragmentai 16.8±2.2 16.4±2.1

Osteotomy

TABLE 6

Character of Period of fixation (days)

osteotomy Contcnital Acquired

shortening shortening

Partial 12.0±0.9 8.9±2.3

Corticotomv

Osteotomy 18,9±3.0 18.7±2.4

Fragmentai 28.3±5,3 27.8±5.02

Osteotomy

As seen from Table 6, the period offixation in femoral lengthening increases in more traumatic surgical intervention. The patients, 2-3 months after the removal of apparatus walked with full load on operated limb.

During the treatment, complications appeared in 143 cases (22,7%). Only in 48 cases, complications influenced the results of treatment. In all the other cases, complications were diagnosed but did not influence the results of treatment, but thfe period

of osteosynthesis was increased in these cases. ( 6-12 days per 1 cm of lengthening).

In complications being observed during lengthening, following observations were made:

1. purulent inflamations (5%)

2. sublaxation of femur (0,1%)

3. tibia (1,1%)

4. paresis of personeal (0,75%)

5. angulation deformity of segments (13,7%)

6. flexion contracture of knee joint (2,6%)

7. Contracture of the ankle joint (2,6%), Delayed consolidation of bone fragments (3,7%).

In some cases combined complications wen observed. Stable extension contracture of kne< joint (average amplitude of movements - 55,3± 12,( degrees) was formed in 18 cases: (14 patients - afte lengthening of lower third. The average lengthening was 17,6 cm. The etiology of shortening in 50% wa: congenital. Amplitude of movements in ankle join was restored in 2-3 months and in long-terms perioc of observations reached the inital stage in all cases

Comparative analysis of gained data with tin data of literature showed that it became possible no only to reduce the number of complications, bu even to eliminate such complications as infecte( hematoma, sepsis, thrombosis and thromboembolism injuries of main vesels and nerve trunks with th help of the technique of osteotomy, elaborating th stability of osteosynthesis and using the method o quantitative control for the lengthening.

The analysis the results of treatment allow the conclusion that the complex of techniques o distractional osteosynthesis after Ilizarov (mono and bilocal, mono- and polysegmental) gives th

opportunity for individual and differential treatment of the patients, depending on the/degree of shortening and accompanying deformities.

CONCLUSION

Methodical principlesofcontrolleddistractional. osteosynthesis which makes possible to unite the stages of treatment of orthopaedic cases, to incfluence on speed of distraction and terms of reconstraction of bone regenerate, is a real way for reducing of period of treatment in patients with shortening of lower limbs.

versary Conference with international participation, Kurgan, June 13-15, 1991, pp. 137-138. 7.Wagner H. (1971). operative Beinverlangerung, Chirurg 42; 260-266.

LITERATURE

1. Abott I. C. (1927). The operative lengthening of the tibia and fibula. J. Bone.Joint Surg. 9: 128 -152.

2. Anderson W. V. (1952). Leg Lengthening. J.Bone Joint Surg.(Br) 34; 150.

3. Franke J., Grill F., Hain G , Simon M. (1990) Correction of clubfoot relapse uwing Ilizarov's apparatus in children 8-15 years old.

4. Ilizarov G. A. (1983). The significance of the complex of the optimum mechanic and biological factors in the regenerative process in transosseous osteosynthesis. Abstracts of Ail-Union Symposium, Kurgan 20-22.09., pp. 19-22.

5. A. V. Popkov et al. Possibilities of complex estimations of soft tissues of the lengthened limb. "Method of Ilizarov: theory, experiment, clinic". Abstracts of the Anniversary Scientific Conference with International Participation, Kurgan, June 13-15, 1991, pp. 137-138.

6. G. A. Ilizarov, A. V. Popkov, G. S. Tataev, V. A. Schurov. The Ilizarov efect and its manifestation in children and adolescents rehabilitation\vith congenital shortening of low limb. "Method of Ilizarov: theory, experiment, clinic". Abstracts of the Anni-