HY ? HEN ? HERE ? of of lim limb b le lengthening ngthening - - PowerPoint PPT Presentation

SUCCESS IS A JOURNEY NOT A DESTINATION

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limb b le lengthening ngthening

• 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.

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

LIMB LENGTHENING

PHYSEAL DISTRACTION THROUGH BONE CHONDRODIASTESIS ANDERSON WAGNER ILIZAROV WASSERTAIN TECHNIQUE ILIZAROV + CORTICAL ALLOGRAFT LON(Lengthening

• n Nail)

ILIZAROV / Threaded Tibular 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

Apparatus T.F. Syndesmosis

Diaphyseal corti. Lengthening

• 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]

Apparatus T.F. Syndesmosis

• Corti.  Lengthening

 Plate + B.G. L Plate Final

Post infective hypo plastic hip with coxa- vara treated by valgus osteotomy followed by Wagnor lengthening

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
• riginal 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
• f regenerate
• No need of bone grafting

PHYSEAL DISTRACTION A second method which may be used for

• btaining 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