Limb lengthening surgery is a orthopedic procedure to correct limb length discrepancies or to increase stature. Despite its transformative potential, the procedure is not without inherent risks and complications. This article provides a detailed exploration of the most common complications associated with limb lengthening surgeries and lengthening process. We will also review advanced treatment methodologies and preventative strategies that healthcare professionals implement to mitigate these risks, enhancing both patient safety and surgical outcomes. This guide serves as an essential resource for potential patients contemplating this procedure and medical professionals seeking to enhance their knowledge and practices in limb lengthening surgery.
Fat Embolism
Fat embolism during or after limb lengthening surgery is a severe complication where fat particles from bone marrow enter the bloodstream during limb lengthening surgery. This typically occurs when the bone is cut and reamed, as in the insertion of intramedullary nails. The fat particles can travel through the bloodstream and block blood vessels, primarily in the lungs, but potentially affecting other organs as well. This blockage can lead to respiratory issues and other severe symptoms, necessitating immediate medical attention.
Symptoms of Fat Embolism Syndrome
The symptoms of fat embolism syndrome (FES) following limb lengthening surgeries can vary in severity and onset, typically appearing within 12-72 hours after the procedure. Common symptoms associated with limb lengthening fat embolism include:
Respiratory Distress: Difficulty breathing, shortness of breath, and hypoxia (low blood oxygen levels) are primary symptoms. Patients may require supplemental oxygen or more intensive respiratory support.
Neurological Symptoms: Symptoms can range from mild confusion and dizziness to severe changes such as seizures, stupor, or coma, resulting from fat globules lodging in small blood vessels in the brain.
Petechial Rash: Small, red or purple spots on the skin, typically appearing on the upper body, neck, or arms. These spots, known as petechiae, result from capillaries bursting under the skin.
Cardiovascular Symptoms: Tachycardia (fast heartbeat) and other heart-related symptoms may occur as the heart struggles to pump blood through blocked vessels.
Fever: A sudden rise in body temperature not linked to an infection, indicative of the body's inflammatory response to fat emboli.
Other Symptoms: Additional signs can include a feeling of illness or malaise, vision changes, jaundice (yellowing of the skin or eyes), and symptoms related to decreased organ function in severe cases.
Prevention of Fat Embolism
The surgeon plays a crucial role in preventing fat embolism during limb lengthening surgeries. Surgeon expertise and meticulous surgical techniques are vital in minimizing bone trauma and managing intramedullary pressure, significantly reducing the risk of fat particles entering the bloodstream.
Careful and Expert Surgical Techniques: Surgeons can adopt methods that reduce intramedullary pressure during procedures, such as using less aggressive reaming techniques or pre-drilling vent holes in the bone before reaming.
Controlled Reaming: Adjusting the speed and pressure of bone reaming during surgery can help minimize the risk of fat embolism. Some advanced surgical tools are specifically designed to control these factors precisely.
Minimizing Bone Trauma: Whenever possible, minimizing trauma to the bone during surgery can reduce the risk of fat embolism. This involves careful handling and stabilization of the bone.
Pharmacological Prophylaxis: Corticosteroids have been studied for their potential to reduce inflammatory responses and stabilize cell membranes, potentially reducing the formation of fat emboli.
Adequate Hydration: Ensuring that the patient is well-hydrated before and after surgery can help maintain normal blood flow and reduce the concentration of fat particles in the blood.
Early Mobilization: Encouraging early postoperative mobilization can enhance blood circulation, helping prevent the stagnation of blood and the formation of emboli.
Monitoring and Support: Close monitoring of patients for symptoms of fat embolism, especially within the first 24 to 72 hours post-surgery. This includes monitoring oxygen saturation, respiratory status, and neurological signs.
Patient Education: Educating patients about the signs and symptoms of fat embolism and the importance of early reporting can lead to quicker response and treatment.
Treatment of Fat Embolism
Fat embolism syndrome (FES) is a serious and potentially life-threatening condition that requires immediate medical attention. Treatment for FES is primarily supportive, focusing on managing symptoms and supporting vital functions while the body clears the fat emboli from the bloodstream.
Intensive Care Monitoring: Most patients with FES are treated in an intensive care unit (ICU) due to the potential severity of their symptoms. Continuous monitoring of vital signs, oxygen saturation, and neurological status is critical.
Oxygen Therapy: Since FES often impacts lung function, leading to hypoxia, supplemental oxygen is commonly administered to help maintain adequate oxygen levels in the blood. In more severe cases, mechanical ventilation may be necessary.
Fluid Management: Intravenous (IV) fluids are essential to manage hypovolemia and prevent shock, which can occur due to the effects of FES on blood circulation. Fluids help maintain blood pressure and support circulation.
Cardiovascular Support: Medications may be administered to support heart function if the embolism affects the heart's ability to pump blood effectively. This can include drugs to manage heart rhythm, improve heart pump function, or treat shock.
Medication: The medication treatment for fat embolism syndrome is largely supportive and aimed at managing the symptoms and preventing further complications. Corticosteroids, blood thinners, vasopressors, diuretics, and heart medications are some of the medications used in treatment.
Deep Vein Trombosis(Blood Clot) and Pulmonary Embolism
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) are serious complications that can occur after any surgery, including limb lengthening procedures. These conditions involve the formation of blood clots that can impede circulation and pose significant risks.
Deep Vein Thrombosis
Venous thrombosis is a medical condition characterized by the formation of a blood clot (thrombus) within a vein. This formation impairs blood flow through the vein, leading to symptoms such as swelling and pain. While venous thrombosis can occur in any part of the venous system, it most frequently develops in the deep veins located in the legs, thighs, or pelvis, a condition known as deep vein thrombosis (DVT).
Pulmonary Embolism (PE)
When a blood clot breaks away from a vein, it can move through the bloodstream to other areas of the body. This moving clot is called an embolus. If the embolus reaches the lungs and gets stuck there, it causes a condition known as pulmonary embolism (PE).
Causes of DVT and PE
Immobilization: Following limb lengthening surgery, patients often experience reduced mobility during the recovery phase. This limited movement can slow down blood circulation, increasing the risk of blood clot formation in the deep veins of the legs.
Traumatic Surgical Technique: The experience and professionalism of the surgeon are crucial. Inexperienced or improper surgical techniques can cause excessive trauma to the blood vessels, increasing the risk of clot formation. It is important that the surgery is performed by skilled surgeons who follow the best practices to minimize vascular damage and other complications.
Hypercoagulability: Surgical procedures can induce a hypercoagulable state, where the body's clotting mechanisms are heightened. This is a natural response to surgery and trauma, intended to prevent excessive bleeding but also increases the risk of thrombosis.
Inflammation: Surgery induces an inflammatory response that can enhance the propensity of blood to clot. Inflammation can increase the levels of clotting factors and decrease the effectiveness of natural anticoagulants in the bloodstream.
Improper Patient Assessment: Incorrect admission of patients with chronic diseases, smokers, those with coagulation problems, or those of advanced age, without adequate evaluation and adjustment in the treatment plan can significantly elevate the risk of DVT and PE. These patients should ideally be rejected or, if accepted, require more intensive monitoring and additional precautions to mitigate their higher risk of thrombosis.
Symptoms
After limb lengthening surgery, it's important to watch for symptoms of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE), as early detection and treatment can significantly improve outcomes. Here are the symptoms for each condition:
Symptoms of Deep Vein Thrombosis (DVT)
Swelling: This can occur in the affected limb. It may be localized to a specific area or involve the entire leg or arm.
Pain or Tenderness: Often described as a cramp or soreness, the pain usually starts in the calf and can feel worse when standing or walking.
Redness or Discoloration: The skin over the affected area may become discolored, showing reddish or bluish hues.
Warmth: The area around the clot may feel warmer to the touch compared to the surrounding skin.
Difficulty Moving the Affected Limb: Due to pain, swelling, or both.
Symptoms of Pulmonary Embolism (PE)
Sudden Shortness of Breath: This can occur at rest or during physical activity.
Chest Pain: Often sharp or stabbing, and it may get worse with deep breaths (pleuritic pain).
Rapid Heart Rate: Feeling of the heart racing or pounding.
Dizziness or Lightheadedness: Severe cases may lead to fainting.
Cough: Sometimes producing bloody or blood-streaked sputum.
Treatments of DVT and PE
The treatment strategies for Deep Vein Thrombosis (DVT) focus on preventing the clot from growing, reducing the risk of the clot traveling to the lungs (which can cause a Pulmonary Embolism), and minimizing the chances of future clots. Here’s a closer look at the typical treatment options and how they contribute to these goals:
Blood Thinners (Anticoagulants): Blood thinners are the primary treatment for DVT. They work by decreasing the blood's ability to clot, which helps prevent existing clots from growing larger and new clots from forming. They can be administered orally, via injection, or through an intravenous (IV) line. Oral anticoagulants include Warfarin (Coumadin, Jantoven), and Direct Oral Anticoagulants (DOACs) such as Rivaroxaban (Xarelto), Apixaban (Eliquis), and Dabigatran (Pradaxa). Injectable anticoagulants include Heparin, which is usually given intravenously in a hospital setting, and Low Molecular Weight Heparin (LMWH), such as Enoxaparin (Lovenox), which is given as an injection.
Clot Busters (Thrombolytics): Thrombolytics are used in more severe cases, such as when there is a significant risk of complications from PE, or when other medications are not effective. These drugs are often administered through an IV or via a catheter directly placed into the clot.
Vena Cava Filters: These are used if anticoagulants are not an option due to contraindications like bleeding disorders. A filter is placed in the vena cava (the large vein carrying blood from the lower body back to the heart) to catch clots and prevent them from traveling to the lungs. Filters are generally considered a temporary solution and are removed when it’s safe to do so or when the patient can go back on anticoagulants.
Percutaneous thrombectomy: A long, thin, hollow tube (catheter) can be threaded through the blood vessel to the site of the embolism guided by X-ray. Once the catheter is in place, it's used to break up the embolism, pull it out, or dissolve it using thrombolytic medicine.
Pulmonary Embolectomy: Pulmonary embolectomy is a surgical procedure employed infrequently to remove a pulmonary embolism (PE). This intervention is typically reserved for critical situations where the PE is exceptionally large, or the patient’s medical condition precludes the use of standard treatments such as anticoagulation and thrombolytic therapy. It is also considered when a patient does not adequately respond to these treatments or if the patient's condition is hemodynamically unstable. This surgical option is pursued as a last resort due to the significant risks involved and the need for immediate, life-saving measures.
Follow-Up Care and Close Monitoring: Effective monitoring of patients with Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) includes regularly checking INR levels for those on warfarin and monitoring kidney and liver functions for those on oral anticoagulants. Regular symptom assessments and follow-up imaging tests, such as ultrasounds for DVT and chest imaging for PE, help track the treatment's progress. Additionally, monitoring patients' mobility and ensuring they understand and follow their treatment plans are crucial for successful outcomes.
Prevention
Preventing Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) after limb lengthening surgery requires a multifaceted approach, emphasizing not only early physical therapy and advanced surgical techniques but also close monitoring of the patient's recovery process. Here’s an updated overview of the comprehensive prevention strategies:
Advanced Surgical Techniques: Minimally Invasive Procedures ,employing less invasive techniques minimizes tissue and vascular trauma, thereby reducing the risk of blood clot formation. Precise Surgical Execution, ensuring the surgery is conducted by experienced surgeons can decrease the overall inflammatory response and trauma, further mitigating the risk of DVT and PE.
Anticoagulant Medication: Patients must be prescribed anticoagulants before and after surgery to decrease blood clotting. Options include Low Molecular Weight Heparin (LMWH) such as Enoxaparin, and Direct Oral Anticoagulants (DOACs) such as Rivaroxaban or Apixaban.
Blood Circulation Support: Compression Stockings aid in improving blood flow and preventing clot formation. Intermittent Pneumatic Compression Devices enhance blood circulation mechanically. These devices inflate and deflate periodically around the legs.
Early and Regular Mobilization: Prompt movement after surgery is encouraged to stimulate blood flow, with simple leg movements significantly reducing the risk of clots.
Early Physical Therapy: Initiating physical therapy early can significantly enhance venous return and reduce clotting risks, with therapists guiding patients through exercises that increase circulation without overstressing the limb. Custom exercises adjusted based on the patient’s recovery progress help maintain optimal blood flow.
Patient Education: Educating patients on the signs and symptoms of DVT and PE ensures they seek timely medical help if such symptoms occur.
Close Monitoring:
Postoperative Follow-up: Regular follow-up appointments allow for the assessment of the clotting status, effectiveness of anticoagulation therapy, and overall recovery.
Monitoring for Complications: Watchful monitoring for any signs of complications such as increased pain, swelling, or changes in skin color, which can indicate clot formation.
Adjustment of Treatments: Continuous assessment may lead to adjustments in medication, physical therapy, or other interventions based on the patient's response to treatment.
Compartment Syndrome
Compartment syndrome is a serious medical condition that occurs when excessive pressure builds up within an enclosed muscle space in the body. This space, known as a compartment, is surrounded by tough membranes called fascia that do not easily expand. Each compartment includes muscles, nerves, and blood vessels. Excessive pressure in these compartments can decrease blood flow, preventing oxygen and nourishment from reaching nerve and muscle cells. Compartment syndrome requires immediate medical attention and follow up.
Causes of Compartment Syndrome
Poor and Traumatic Surgical Technique: Incorrect and traumatic surgical techniques during limb lengthening surgery can significantly increase the risk of developing compartment syndrome. Precise surgical skill is crucial because the procedure involves deliberate bone fractures (osteotomy), drilling and the placement of lengthening devices that manipulate bone and surrounding soft tissues. If the osteotomy and drilling are performed inaccurately, or if the lengthening device is applied improperly, it can cause excessive trauma to the soft tissues. This additional trauma can lead to increased bleeding or swelling within the muscle compartments, elevating the pressure unnaturally.
Improper Postoperative Care and Immobilization: Improper postoperative care and prolonged immobilization can significantly increase the risk of compartment syndrome after surgery. Managing postoperative swelling is essential, utilizing methods such as elevating the limb, using compression garments, early mobilization and physical therapy. Encouraging patients to begin moving soon after surgery, within safe limits, helps enhance blood circulation and lymphatic drainage, preventing fluid accumulation. Activities like guided walking and gentle exercises not only prevent muscle stiffness and weakening but also aid in a quicker recovery by maintaining muscle function and reducing the risk of pressure buildup.
Rapid Lengthening Rate: If the bone is lengthened too quickly, it can excessively stretch the surrounding soft tissues, including muscles, nerves, and blood vessels, resulting in increased compartmental pressures.
Patient-Specific Factors: Individual factors such as previous vascular problems, coagulation disorders, or pre-existing inflammatory conditions can increase the risk of compartment syndrome.
Symptoms of Compartment Syndrome
After limb lengthening surgery, it's crucial to be vigilant for symptoms of compartment syndrome, as this condition requires immediate attention to prevent serious complications. The symptoms of compartment syndrome typically include:
Severe Pain: The pain is often disproportionate to the injury itself and does not subside with regular pain medication. It may be significantly more intense than typical post-surgical pain.
Swelling: Increased swelling in the affected limb, beyond typical postoperative swelling, can indicate rising pressures within the compartments.
Pressure Measurement: Direct measurement of the intracompartmental pressure is a key diagnostic tool for compartment syndrome. This is typically done using a needle or catheter connected to a pressure transducer. A pressure of 30 mmHg or higher is a strong indicator of compartment syndrome.
Tightness: A feeling of tightness or fullness in the muscle, where the limb feels unusually hard or firm when touched.
Paresthesia: Tingling or burning sensations in the skin, which may indicate nerve compression or damage within the pressured compartment.
Pallor or Pale Skin: The skin over the affected area may appear paler than surrounding areas, suggesting compromised blood flow.
Numbness: Reduced ability to feel touch, which may progress to numbness, is a warning sign of worsening compartment syndrome.
Weakness or Paralysis: In severe cases, there may be a noticeable decrease in strength or ability to move the affected part of the limb, indicating potential muscle and nerve damage.
Treatment of Compartment Syndrome
When compartment syndrome is diagnosed early and treated promptly, the likelihood of a full
recovery is high. It's important to position the affected extremity at the level of the heart and ensure the patient is well-hydrated to maintain stable arterial blood pressure. Monitoring compartment pressures accurately is also crucial.
If compartment syndrome is suspected and intra-compartment pressures are only slightly elevated, medical decompression, such as a mannitol infusion, may be attempted. Mannitol can help resolve the condition by reducing swelling through its osmotic diuretic effects.
Physical therapy and gradual mobilization are critical for recovery. Therapy starts with gentle movements to enhance circulation and maintain joint mobility. As healing progresses, exercises are introduced to strengthen muscles and improve function. The goal is to gradually restore the patient’s normal activity levels
However, if conservative measures fail to break the cycle of swelling and ischemia, a fasciotomy, or surgical decompression, may be necessary. This procedure involves making a surgical incision through the skin and fascia of the affected compartments to allow the tissue to bulge out, which helps decrease pressure and restore normal blood flow. The timing of a fasciotomy is critical; ideally, it should be performed within 6 hours of symptom onset and no later than 12 hours to prevent permanent muscle and nerve damage.
Prevention of Compartment Syndrome
Preventing compartment syndrome after limb lengthening surgery involves a combination of careful surgical planning, vigilant postoperative monitoring, and proactive management of patient recovery. Here are key strategies to minimize the risk of developing this serious condition:
Careful Surgical Technique: Ensuring precise surgical methods, precise osteotomy, less drilling and the correct placement of lengthening devices can reduce trauma and minimize tissue damage. Less trauma, less bleeding and less risk.
Controlled Lengthening Rate: Adhering to a safe rate of limb lengthening, typically around 1 mm per day for femur and 0.75 mm per day for tibia helps prevent excessive stretching and stress on the tissues. During the lengthening period, the lengthening rate can be adjusted according to the symptoms.
Regular Monitoring: Frequent clinical evaluations to assess swelling, pain, and limb function can help detect early signs of compartment syndrome. Measuring compartment pressures in high-risk patients can be a direct method for early detection.
Postoperative Care: Regularly adjusting casts or external fixators to accommodate swelling and ensuring they are not overly tight can prevent external pressure increases.
Early Mobilization and Physical Therapy: Encouraging gentle movement and physical therapy as soon as safely possible after surgery can enhance blood circulation, reduce swelling, and decrease the risk of compartment syndrome.
Patient Education: Informing patients about the symptoms of compartment syndrome empowers them to report critical changes immediately, facilitating prompt intervention.
Axial Deviation (Misalignment)
In a normally aligned lower limb, the mechanical axis, an imaginary line drawn from the center of the hip joint to the center of the ankle joint, passes through the center of the knee joint. This alignment ensures that weight is evenly distributed across the knee, which is essential for proper biomechanics, gait, and overall limb function. The anatomical axis of the femur (thigh bone) and tibia (shin bone) also align in a way that supports efficient movement and load distribution.
The normal alignment of the lower limb can be negatively affected by limb lengthening surgery if not performed with precise techniques. Incorrect placement of osteotomies (bone cuts), improper positioning of fixation devices, or errors in the distraction process can lead to misalignment. When the bone segments are not aligned properly during the lengthening process, it can result in axial deviation, where the bone deviates from its intended axis. This misalignment can affect the overall mechanics of the limb, leading to abnormal gait, increased joint stress, and potential long-term complications.
Causes of Axial Deviation
Lack of Preoperative Planning: Insufficient preoperative assessment and planning can lead to unrecognized deformities or misalignment issues that become problematic during the lengthening process.
Technical Errors During Surgery:
Improper Placement of Fixators or Nails: Accurate positioning of external fixators or intramedullary nails is critical. Misalignment at the outset can magnify over the lengthening process, leading to significant deviations. Especially the correct choice of the entry point and position of the intramedullary nail is very important for true alignment.
Inaccurate Osteotomy: The initial bone cut must be precise. An oblique or uneven osteotomy can cause the bone segments to shift out of alignment during distraction.
Blocking Screw: The blocking screw technique is an effective technique for correction of deformity and prevention of deformity. The use of block screws is essential in internal or some external methods that are not capable of deformity correction. Especially in tibial lengthening, the risk of valgus deformity (x leg) is high due to incomplete or missing block screws.
Incorrect Fixator Selection: It is very important to choose the fixator according to the bone to be lengthened. Monorail fixator for femur and circular frame fixator for tibia are suitable except in cases with special deformities. The use of an easy-to-apply monorail fixator for the tibia may cause serious alignment problems.
High Lengthening Amount Over Safe Limit: Lengthening the bone beyond safe limits can increase the risk of axial deviation. Excessive lengthening can change the axial angle of the bone, leading to misalignment.
Lack of X-ray Alignment Follow-up During the Lengthening Period: Regular X-ray follow-up during the extension period is crucial to ensure that the bone segments remain aligned as they lengthen. Lack of frequent imaging can allow minor deviations to go unnoticed until they become significant.
Soft Tissue Imbalance: The muscles, tendons, and ligaments surrounding the lengthening bone exert forces that can pull the bone segments out of alignment. This is particularly problematic when there is an imbalance in soft tissue tension. In particular, IT band tension in femoral lengthening and lateral and posterior muscle tension in tibial lengthening may change the correct line of lengtheing. Therefore the surgeon performs the necessary releasing during surgery and intensive physical therapy during lengthening period are important.
Symptoms of Axial Deviation
Axial deviation following limb lengthening surgery can manifest through a variety of symptoms. Early detection and timely intervention are crucial to managing this complication and ensuring optimal functional and aesthetic outcomes. Common symptoms of axial deviation include:
Pain:
Localized Pain: Patients may experience pain at the site of deviation, which can be exacerbated by movement or weight-bearing activities.
Increased Discomfort: Compared to the expected level of discomfort associated with the lengthening process, patients with axial deviation often report heightened or unusual pain levels.
Visible Deformity:
Angular Deformity: A noticeable bowing or angulation of the limb may become apparent, resulting in a valgus (outward) or varus (inward) deformity.
Rotational Deformity: The limb may appear twisted or rotated, affecting its overall alignment and symmetry.
Lateral Translation: The bone may shift sideways, creating a visible misalignment.
Radiographic Imaging:
X-rays: Standard radiographs (X-rays) are essential for evaluating the alignment of the bone segments. Anteroposterior (AP) and lateral views of the affected limb are typically obtained to assess the mechanical and anatomical axes.
Computed Tomography (CT) Scans: CT scans provide detailed cross-sectional images of the bone and surrounding soft tissues, allowing for precise assessment of the alignment and detection of subtle deviations.
3D Imagining: Advanced imaging software can create 3D models of the limb from CT or MRI scans, providing a detailed visualization of the bone structure and alignment.
Gait Abnormalities:
Limping: Patients may develop a limp or an uneven gait due to the misalignment of the limb.
Balance Issues: Difficulty maintaining balance and stability while walking or standing can occur, leading to an increased risk of falls.
Functional Limitations:
Reduced Range of Motion: Axial deviation can restrict the range of motion in the affected joints, making it difficult to perform daily activities.
Weakness: Muscle weakness around the affected area may develop due to improper alignment and altered biomechanics.
Degenerative Joint Disease(Long term):
Osteoarthritis: Misaligned bones place uneven stress on joints, which can accelerate wear and tear, leading to early onset osteoarthritis. This condition causes joint pain, stiffness, and swelling.
Joint Instability: Chronic misalignment can contribute to joint instability, increasing the risk of injuries and further joint degeneration.
Treatment of Axial Deviation
Treating axial deviation after limb lengthening surgery is crucial to restore proper alignment, function, and aesthetics of the limb. The treatment approach depends on the severity of the deviation, the stage of the lengthening process, and the specific needs of the patient. Here are the primary treatment options for managing axial deviation:
Adjustments During the Lengthening Period:
Gradual Correction with External Fixator: If axial deviation is detected early during the lengthening process, gradual correction can be attempted by adjusting the external fixator or intramedullary lengthening device. Careful, incremental adjustments help guide the bone segments back into proper alignment. For patients using external fixators, adjusting the tension and positioning of the pins or wires can help correct the alignment. This requires frequent follow-up visits and precise adjustments by the surgeon.
Shortening Procedure: In cases where lengthening has led to significant axial deviation, a shortening procedure may be considered. This involves gradual shortening the bone to correct the alignment. If the deviation is not due to a surgical mistake but rather to excessive lengthening beyond safe limits, a shortening procedure can help restore proper alignment.
Surgical Interventions:
Osteotomy and Realignment: In cases of significant axial deviation, a corrective osteotomy may be necessary. This involves surgically cutting the bone and realigning it to the correct position. The bone is then stabilized using internal fixation devices such as plates and screws, or an external fixator.
Changing Entry Point and Position of Intramedullary Nail: If axial deviation is related to improper entry point placement of the intramedullary (IM) nail, changing the entry point can be an effective corrective measure. This involves repositioning the entry point to ensure proper alignment and reduce deviation.
Changing External Fixator Position: Repositioning the external fixator can help correct misalignment. This involves adjusting the placement and orientation of the fixator to ensure that the bone segments are aligned properly during the lengthening process.
Blocking Screw Technique: Using blocking screws can help prevent axial deviation by providing additional stability to the bone during lengthening. Blocking screws are strategically placed to guide the bone segments and maintain correct alignment, especially in the presence of angular deformities.
Muscle or tendon release: If the cause of misalignment is excessive tension in the muscle or tendon, muscle tendon release may help to correct the misalignment. This complication occurs especially with IT band tension in femoral lengthening.
Prevention of Axial Deviation
Preventing axial deviation after limb lengthening surgery involves meticulous planning, precise surgical techniques, and thorough postoperative management. Here are key strategies to minimize the risk of axial deviation:
Thorough Preoperative Planning:
Detailed Presurgery Assessment: Conduct a comprehensive assessment of the patient’s limb alignment using detailed imaging studies such as X-rays, CT scans, or MRIs. This helps in understanding the existing alignment and planning the osteotomy and lengthening procedures accurately.
Computer-Assisted Planning: Utilize computer-assisted planning tools and 3D modeling to simulate the surgery and predict potential complications. This allows for precise planning of the osteotomy location and alignment.
Correction of Preexisting Deformities: Identify and plan for the correction of any preexisting angular deformities to ensure proper alignment during the lengthening process.
Precise Surgical Techniques:
Accurate Osteotomy Placement: Ensure that the osteotomy is placed accurately based on preoperative planning. This is critical for maintaining proper alignment during the bone lengthening process.
Proper Fixator Application: Apply external fixators or internal lengthening devices with precision. Ensure that the fixators are correctly positioned and calibrated to guide the bone segments during lengthening.
Intraoperative Alignment Checks: Perform intraoperative alignment checks using fluoroscopy or other imaging techniques to verify proper alignment during surgery.
Tendon or Muscle Releasing: Perform necessary tendon or muscle releases to alleviate tension and prevent deformities. This can be especially important in preventing contractures and maintaining proper alignment during the lengthening process.
Intramedullary Nail Positioning: Ensure correct entry point and positioning of intramedullary nails to avoid misalignment. Adjusting the entry point if necessary can help maintain proper alignment.
Blocking Screws: Use blocking screws to provide additional stability and guide the bone segments during lengthening, especially in cases with angular deformities.
Postoperative Follow-up and Care:
Regular Follow-Up Visits: Schedule regular follow-up visits to monitor the alignment and progress of the bone lengthening. Frequent imaging studies, such as X-rays, are essential for early detection of any deviations.
Physical Therapy: Asymmetric excessive muscle and tendon tension may force the external fixator or the intramedullary nail and cause alignment distortion. A physical therapy program specifically aimed at controlling the tension of these muscles and tendons reduces the risk of axial deviation.
Avoiding Excessive Lengthening: Follow established guidelines for safe lengthening limits to prevent overextension of the bone. Excessive lengthening increases the risk of axial deviation due to changes in the axial angle of the bone.
Nerve Complications
Nerve damage is a significant risk in limb lengthening surgery because nerves naturally react with irritation to the stretching involved in the procedure. These reactions can range from mild, temporary issues to serious, permanent injuries. Evaluating these nerve reactions accurately is crucial to differentiate between normal post-surgery sensations and dangerous symptoms that require urgent attention. Having an experienced medical team is essential, as they can identify which symptoms are normal and which are warning signs of nerve damage. By taking the right precautions and closely monitoring patients, the risk of nerve damage can be minimized, leading to better outcomes and safer limb lengthening procedures.
Nerve Irritation
Nerve irritation after limb lengthening surgery is a common issue resulting from the mechanical stress and tension placed on nerves during the lengthening process. This condition can cause a range of symptoms that, while often temporary, require careful management to prevent progression to more severe nerve damage. Understanding nerve irritation involves knowing its causes, symptoms, and appropriate management strategies.
Causes of Nerve Irritation
Lengthening:
Gradual Lengthening: As the bone is slowly lengthened, nerves and surrounding tissues are stretched, leading to irritation.
Rate of Lengthening: Rapid lengthening can exacerbate nerve irritation due to increased tension on the nerves.
Compression:
Fixation Devices: External or internal fixation devices used to stabilize the bone can compress nearby nerves if not properly placed or adjusted.
Postoperative Swelling: Swelling after surgery can increase pressure on nerves, leading to irritation.
Inflammation
Surgical Trauma: The body’s inflammatory response to the trauma of surgery can affect nerves and cause irritation.
Scar Tissue Formation: Scar tissue that forms around the surgical site can entrap or compress nerves, leading to irritation.
Symptoms of Nerve Irritation
Sensory Changes
Numbness: A tingling or “pins and needles” sensation in the affected area.
Hypersensitivity: Increased sensitivity to touch, temperature, or pressure in the affected region.
Reduced Sensation: Decreased ability to feel sensations such as touch, temperature, or pain.
Pain
Sharp, Shooting Pain: Intense, sudden pain that radiates along the pathway of the irritated nerve.
Burning Pain: A persistent, burning sensation in the area supplied by the affected nerve.
Aching or Throbbing Pain: Continuous, dull pain that can worsen with movement or pressure.
Muscle Symptoms
Muscle Spasms: Involuntary contractions or twitching of muscles near the irritated nerve.
Cramps: Sudden, painful muscle contractions.
Muscle Weakness: Reduced strength in the muscles innervated by the affected nerve, often mild and temporary.
Motor Symptoms
Difficulty Moving: Challenges in performing movements that require the affected muscles, such as lifting or bending a limb.
Coordination Issues: Problems with coordination and fine motor skills in the affected area.
Treatments of Nerve Irritation
Treating nerve irritation after limb lengthening surgery involves a combination of conservative and interventional strategies to alleviate symptoms, promote healing, and prevent progression to more severe nerve damage. Here are the primary treatments:
Adjustments to Lengthening Protocol
Slower Lengthening Rate: Reducing the rate of limb lengthening to allow nerves more time to adapt. At low lengthening speed, the nerves adapt better.
Pausing the Lengthening: Pausing the lengthening process if severe irritation occurs, allowing the nerve to recover.
Medications
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen or naproxen to reduce inflammation and relieve pain.
Corticosteroids: Oral or injectable steroids to decrease inflammation and swelling around the nerve.
Neuropathic Pain Medications: Medications like gabapentin, pregabalin, or amitriptyline to specifically target nerve pain.
Physical Therapy
Gentle Stretching and Strengthening Exercises: To maintain mobility and prevent stiffness without exacerbating nerve irritation.
Range of Motion Exercises: To keep joints flexible and maintain muscle function.
Nerve Gliding Exercises: To promote normal nerve movement and reduce adhesions that might cause irritation.
Soft Tissue Massage: To relieve muscle tension and improve circulation around the affected area.
Manual Therapy: Techniques to mobilize the nerve and reduce adhesions.
Nerve Damage
Nerve damage after limb lengthening surgery is a serious complication distinct from nerve irritation. Unlike nerve irritation, which often presents as temporary and less severe, nerve damage can lead to significant and potentially permanent impairments. Ignoring the symptoms of nerve irritation and not taking necessary precautions can increase the risk of progressing to nerve damage. Here are the key aspects of nerve damage after limb lengthening surgery:
Causes of Nerve Damage
Excessive Lengthening Rate and Amount: Rapid or excessive elongation of the limb can cause severe stretching of nerves beyond their tolerance, leading to damage. The safe limit of extension varies from person to person, but is 1 mm dailiy and 8 cm max for femur and 0.75 mm dailiy and 6 cm max for tibia. If these safe limits are exceeded, the nerve cannot adapt to the lengthening and can suffer various levels of damage.
Direct Trauma: Direct nerve trauma in surgery refers to injury to a nerve caused by surgical instruments or techniques. This can happen when a nerve is accidentally cut, stretched, compressed, or damaged by heat during the procedure. This complication occurs due to a high degree of surgical inexperience, so with an experienced surgical team following the procedure, the risk of direct nerve trauma is almost non-existent.
Prolonged Compression
Fixation Devices: Continuous pressure from poorly placed or adjusted fixation devices.
Postoperative Swelling: Persistent swelling after surgery can compress nerves over a prolonged period.
Ignoring Nerve Irritation Symptoms
Lack of Early Intervention: Failing to address symptoms of nerve irritation promptly can allow the condition to worsen and lead to more severe nerve damage. It is important to determine the severity of nerve irritation symptoms.
Inadequate Precautions: Not taking necessary precautions to protect irritated nerves can result in further injury and damage. Adjusting the daily extension rate, especially after symptoms of nerve irritation, is very important and should not be delayed.
Symptoms of Nerve Damage
Sensory Loss
Complete Numbness: Loss of sensation in the area supplied by the affected nerve.
Persistent Tingling: Continuous “pins and needles” sensation without improvement.
Severe Pain
Constant Pain: Intense, ongoing pain that does not respond well to standard pain relief measures.
Burning or Stabbing Pain: Extreme discomfort that may indicate severe nerve involvement.
Motor Impairments
Muscle Weakness: Significant reduction in muscle strength, often leading to difficulty in moving the affected limb.
Paralysis: Complete loss of muscle function in severe cases.
Atrophy
Muscle Wasting: Shrinking of muscles due to prolonged nerve dysfunction and disuse.
Autonomic Dysfunction
Skin Changes: Altered skin color and temperature, increased or decreased sweating in the affected area.
Treatments of Nerve Damage
Nerve damage after limb lengthening surgery is often caused by inexperience and poor process management. It is crucial to address nerve irritation promptly to prevent it from developing into nerve damage by taking necessary precautions and treatments. The level and duration of recovery after a nerve injury depends on the severity of the damage, the treatment and the healing capacity of the nerve tissue. The nerve damage treatment protocol is as follows.
Surgical Intervention
Nerve Decompression: Surgical release of pressure on the affected nerve, particularly if it’s caused by scar tissue or anatomical constraints.
Neurolysis: Removal of scar tissue or adhesions that are constricting the nerve.
Nerve Repair or Grafting: Surgical repair of a damaged nerve or grafting a healthy nerve segment from another part of the body to replace the damaged section.
Adjustments to Lengthening Protocol
Stop or Decrease Lengthening Rate: Stop or slowing the limb lengthening process if nerve damage is detected to prevent further injury and allow for recovery.
Shortening: In severe cases, reversing some of the lengthening by shortening the limb to relieve nerve tension and facilitate healing.
Medications
Stronger Pain Management: Use of opioids and other stronger painkillers to manage severe pain that is often associated with nerve damage.
Neuropathic Pain Medications: Higher doses or different combinations of medications such as gabapentin, pregabalin, or duloxetine to manage chronic and severe neuropathic pain.
Physical Therapy
Advanced Rehabilitation Programs: More intensive physical therapy to restore function, improve strength, and increase range of motion.
Functional Electrical Stimulation (FES): Use of electrical impulses to stimulate nerve and muscle activity, which can help maintain muscle mass and improve nerve regeneration.
Transcutaneous Electrical Nerve Stimulation (TENS): More targeted and higher intensity compared to that used for irritation, aimed at pain relief and promoting nerve healing.
Regular Monitoring and Follow-Up
Frequent Assessments: Regular check-ups to monitor nerve function and adjust treatments as necessary.
Electrophysiological Tests: Repeated nerve conduction studies and electromyography (EMG) to track nerve recovery and guide rehabilitation efforts.
Which nerves are most commonly affected in the process of leg lengthening?
Limb lengthening surgeries, particularly those involving the femur and tibia, can affect various nerves due to the stretching and manipulation involved in the process. Here are the most affected nerves classified according to femur lengthening and tibia lengthening, along with their symptoms:
Femur Lengthening
Sciatic Nerve
Location: Runs down the back of the thigh.
Symptoms:
Pain radiating from the lower back to the leg.
Numbness or tingling in the leg or foot.
Weakness in the knee or foot movements.
Difficulty in bending the knee or lifting the foot.
Femoral Nerve
Location: Runs down the front of the thigh.
Symptoms:
Pain in the groin, thigh, or knee.
Numbness or tingling in the front of the thigh or knee.
Weakness in extending the knee.
Difficulty in walking or standing from a seated position.
Tibia Lengthening
Peroneal Nerve
Location: Runs along the outer side of the knee and down the front of the shin.
Symptoms:
Foot drop (inability to lift the front part of the foot).
Numbness or tingling in the top of the foot or outer part of the upper leg.
Weakness in ankle or toe movements.
Pain along the outer side of the lower leg.
Tibial Nerve
Location: Runs down the back of the leg.
Symptoms:
Pain in the calf or sole of the foot.
Numbness or tingling in the sole of the foot.
Weakness in foot and toe movements, particularly in pointing the toes.
Difficulty in walking, particularly pushing off with the foot.
Sural Nerve
Location: Runs down the back of the lower leg.
Symptoms:
Numbness or tingling along the outer edge of the foot.
Pain or burning sensation in the back of the calf or heel.
Prevention of Nerve Complications
Choosing Experienced Surgeon and Surgical Team
Minimally Invasive Techniques: Use minimally invasive techniques to reduce tissue trauma and nerve stretching.
Nerve Identification and Protection: Identify and carefully protect nerves during surgery to avoid direct trauma.
Gentle Manipulation: Handle tissues gently to prevent unnecessary stretching or compression of nerves.
Use of Neuromonitoring: Employ intraoperative nerve monitoring to detect and prevent nerve injury during surgery.
Gradual and Controlled Lengthening Process
Safe Lengthening Amounts Limits: Ensure that limb lengthening is within safe limits for the patient’s anatomy and overall health. Safe limits of lengthening are 6 cm for the tibia and 8 cm for the femur. However, these are maximums and the patient’s personal maximum is determined during the process. Depending on the patient’s symptoms during the process, the surgeon can modify the maximum lengthening goal. It is therefore important to set realistic goals.
Safe Lengthening Speed: Lengthen the limb at a safe and controlled speed to minimize nerve tension and reduce the risk of complications. The lower the speed of neural adaptation, the better. However, considering other criteria, the optimal daily lengthening rate for femur is 1 mm and 0.75 mm for tibia.
Regular Lengthening Adjustments: Adjust the lengthening device as needed based on the patient’s response and any signs of nerve irritation. Depending on the symptoms during the process, the surgeon and medical team may decide to change the patient’s lengthening rate. If nerve irritation is increasing despite all treatment and precautions and nerve damage is predicted, the option of interrupting or completely stopping the lengthening may be applied.
Physical Therapy: Physical therapy, specifically nerve rehabilitation, is essential in preventing and managing nerve complications after limb lengthening surgery. Effective nerve rehabilitation helps maintain nerve function, promote healing, and minimize the risk of long-term damage.
Nerve Gliding Exercises: Perform specific exercises designed to mobilize and stretch the nerves, reducing the risk of adhesions and maintaining nerve flexibility.
Manual Therapy: Include gentle massage and mobilization techniques to alleviate nerve compression and improve circulation.
Nerve Stretching: Incorporate gentle nerve stretching exercises to maintain nerve elasticity and prevent tension buildup.
Modalities: Utilize heat, cold therapy, and ultrasound to manage pain and reduce inflammation around the nerves.
Regular Assessment and Follow-Up
Regular Assessments: Continuously monitor nerve function, including sensory and motor assessments, to track progress and identify any early signs of complications.
Patient Feedback: Encourage patients to report any symptoms of nerve irritation, such as numbness, tingling, or weakness, to make timely adjustments to the therapy plan.
Bone Healing Complications
Premature Consolidation (Early Union)
Premature consolidation in limb lengthening surgery is a complication where the bone heals too quickly at the site of the osteotomy (surgical bone cut), forming a callus that bridges the gap intended for gradual lengthening. This early bone formation prevents the continuation of the lengthening process, as the bone consolidates before achieving the desired length. Premature consolidation necessitates additional surgical intervention, typically involving re-breaking the bone to restore the gap and allow for further lengthening. This condition can occur if the bone regeneration rate exceeds the distraction rate.
Causes of Premature Consolidation
Premature consolidation in limb lengthening surgery can be caused by several factors, including:
Genetic Rapid Bone Healing: Some patients naturally heal more quickly, which can cause bone to form faster than the distraction process is occurring. This is especially common in younger patients, as their bones tend to heal more rapidly.
Slow Distraction Rate: If the bone segments are not being pulled apart quickly enough, the body may start healing the osteotomy site too soon, leading to early bone formation.
Failure of Fixator or Extensible Intramedullary Nail: Malfunction or failure of the external fixator or extensible intramedullary nail can lead to improper or halted lengthening. This can cause the bone to consolidate prematurely, as the intended gradual separation is not achieved. Regular monitoring and maintenance of the devices, along with immediate corrective action if a failure is detected, are necessary to prevent this complication.
Patient Errors: The patient may not perform the lengthening process correctly or may not perform it at all. Incorrect or missed adjustments can prevent proper distraction and lead to premature consolidation.
Inconsistent Follow-Up: Lack of regular medical check-ups, including routine X-ray assessments, can result in delayed identification and correction of issues related to the distraction process, leading to early consolidation. Regular imaging is crucial for monitoring the progress of bone lengthening and ensuring timely adjustments.
Incomplete Osteotomy: If the osteotomy, or surgical bone cut, is not completely through the bone, it can result in insufficient separation of the bone segments. This can cause early bridging and premature consolidation as the bone attempts to heal the incomplete cut, preventing effective lengthening. Ensuring a complete and clean osteotomy is essential to avoid this issue.
Failure of Fixator or Extensible Intramedullary Nail: Malfunction or failure of the external fixator or extensible intramedullary nail can lead to improper or halted lengthening. This can cause the bone to consolidate prematurely, as the intended gradual separation is not achieved. Regular monitoring and maintenance of the devices, along with immediate corrective action if a failure is detected, are necessary to prevent this complication.
Symptoms of Premature Consolidation
Reduced Distraction: Observable slowing or cessation of the lengthening process despite proper adjustments to the lengthening device.
Discomfort and Hardness During Lengthening: Increased pain or discomfort during dailiy lengthening, possibly due to resistance from prematurely consolidated bone. With external fixator, there may be increased resistance during lengthening or lengthening may not be possible. In the internal method, there may be strain and unusual sounds from the ERC system and intramedullary nail.
Radiographic Evidence: X-rays or other imaging studies showing early bone bridging or callus formation at the osteotomy site before the desired length is achieved.
Loss of Lengthening Amount: A noticeable lack of progress in the lengthening measurements, indicating that the bone is not separating as expected.
Leg Length Discrepancy: A difference in leg lengths may become apparent if premature consolidation prevents one leg from reaching the desired length, leading to functional and gait issues.
Inability to Continue Lengthening: The lengthening process may be completely halted due to premature consolidation, necessitating surgical intervention to re-break the bone and restart the lengthening process.
Treatments of Premature Consolidation
Re-Osteotomy Surgery: If the bone is too consolidated and hardened to allow for lengthening, the only solution is surgery. This involves surgically re-breaking the prematurely consolidated bone. This procedure helps to restore the gap needed for further lengthening.
Increasing Daily Lengthening Speed: If the risk of early union is detected and the lengthening process becomes difficult, increasing the amount of daily lengthening can prevent early union. Increasing the rate of bone distraction for a short period can help prevent further premature consolidation. The surgeon may modify the lengthening schedule to ensure that the new bone formation does not outpace the distraction process. However, increasing the lengthening rate may increase the risk of other complications. Therefore, when the risk of early union is eliminated, the normal lengthening rate should be returned.
Device Replacement or Adjustment: If the lengthening device is malfunctioning or inadequate, it may need to be replaced or adjusted.
Enhanced Monitoring and Follow-Up: Closer and more frequent follow-ups, including regular X-ray assessments, are crucial. This allows for early detection of premature consolidation and timely intervention to adjust the lengthening protocol.
Prevention of Premature Consolidation
Ensuring Complete Osteotomy: Ensure that the initial osteotomy (surgical bone cut) is complete and precise. An incomplete osteotomy can lead to uneven bone separation and increase the risk of premature consolidation.
Proper Distraction Rate: Maintain an optimal distraction rate as prescribed by the surgeon, typically around 1 mm per day, divided into several adjustments throughout the day. Adjustments can be made to the rate if there are signs of premature consolidation.
Lengthening Device Control During Surgery: Ensure that the lengthening device is properly calibrated and functioning correctly during the surgery. This includes checking the device’s mechanisms and ensuring it is accurately placed and ready for gradual distraction.
Regular Follow-Ups: Schedule frequent follow-up appointments with X-ray assessments to monitor the progress of bone lengthening and detect any early signs of premature consolidation. This allows for timely adjustments to the lengthening protocol if necessary.
Patient Education: Educate patients thoroughly on the importance of adhering to the prescribed lengthening schedule and making necessary adjustments to the device. Understanding the process and the importance of compliance can prevent errors that lead to premature consolidation.
Device Maintenance: Regularly check and maintain the lengthening device to ensure it is functioning correctly. Address any mechanical issues promptly to avoid disruption in the lengthening process.
Delayed Bone Healing
Delayed bone healing is a complication where the bone healing process takes longer than expected after limb lengthening surgery. Proper management of the delayed union process during the lengthening period is crucial to avoid the more severe complication of nonunion.
Causes of Delayed Bone Healing
Surgical Technique: Insufficient or improper fixation of bone segments can prevent bone healing.
Osteotomy Type: The specific method of bone cutting (osteotomy) used can influence healing times. More complex osteotomy types may lead to delayed union due to larger or irregular cuts, which can affect the stability and blood supply to the bone segments. Use of techniques such as the optimal multiple drilling technique with an osteotome can influence the healing process. This technique, if not performed correctly, can impact the precision and effectiveness of the bone cut, potentially leading to delayed healing.
Excessive Lengthening Rate: Excessive distraction rate refers to the process of lengthening the bone too quickly during limb lengthening surgery. This can lead to complications such as delayed union. The callus(new bone tissue) bridge is a critical structure in the bone regeneration process. It forms as a soft, initial bridge between the bone segments that gradually mineralizes and hardens. If the distraction rate is too high, the formation of the callus bridge can be disrupted, resulting in weak or incomplete bone healing.
Excessive Lengthening Amount: As the amount of lengthening increases, bone healing becomes more difficult. Excessive lengthening can lead to insufficient callus formation, which is essential for bone healing. A poorly formed callus bridge can result in delayed union, as the bone segments may not properly connect and mineralize. Therefore, the goal of lengthening must be within safe limits.
Low Genetic Bone Healing Rate: Some patients naturally heal bones more slowly due to their genetic, which can increase the risk of delayed union.
Insufficient Mobilization and Walking: Lack of adequate mobilization and weight-bearing exercises can hinder the bone healing process. Weight-bearing stimulates bone growth and helps in proper alignment and healing. Insufficient physical activity and weight-bearing exercises post-surgery can delay bone union by reducing mechanical stimulation necessary for bone regeneration.
Poor Nutrition: Inadequate intake of essential nutrients like proteins, vitamins (especially Vitamin D and Vitamin C), and minerals (such as calcium and phosphorus) can impair bone healing.
Infection: Infections are a significant risk factor for delayed bone union in limb lengthening surgeries. Infection can lead to necrosis of bone and soft tissues, impairing regeneration. Infections can disrupt the normal healing process and lead to complications that may require additional interventions.
Patient Factors: Factors such as smoking, diabetes, and other underlying health conditions can contribute to delayed bone healing.
Symptoms of Delayed Bone Healing
Increased Pain with Activity: Increased pain during walking or physical activities suggests that the new bone is not yet strong enough to handle these stresses. This indicates that the bone regeneration process is inadequate, leading to discomfort during activities that place pressure on the limb.
Delayed Formation of Callus: Slow or absent formation of callus, the new bone tissue around the surgical site, indicates an impaired bone healing process. Callus formation is crucial for bridging the gap between bone segments created during surgery, and its delay suggests insufficient conditions for effective bone regeneration.
Delayed Radiographic Healing: Imaging studies such as X-rays showing a lack of sufficient bone formation or hardening over time indicate delayed healing. Continued visibility of the gap between bone segments or lack of bone density increase on radiographic images suggests that the bone is not consolidating as expected
Instability: A sensation of instability or weakness in the affected limb, especially during weight-bearing activities or movement, suggests that the newly forming bone is not providing adequate structural support. This implies that the bone segments have not adequately healed and connected, leading to a lack of stability and an increased risk of further injury.
Delay in Starting to Walk Without Support: Prolonged difficulty or delay in transitioning from using crutches or other supports to walking independently indicates that the bone has not fully consolidated and is not strong enough to bear full weight. This suggests that the bone healing process is significantly delayed, requiring extended use of supportive devices and potentially additional interventions to facilitate complete bone regeneration and consolidation.
Treatments of Delayed Bone Healing
Adjusting the Lengthening Rate:
Slowing Down the Distraction Rate: Reducing the rate at which the bone segments are pulled apart, typically from the standard 1 mm per day to a slower rate, such as 0.5 mm per day, gives the newly forming bone more time to consolidate and strengthen. This reduces mechanical stress and improves healing conditions.
Temporary Halting of Distraction: Pausing the lengthening process entirely for a specified period (e.g., a few days to a week) allows the bone callus to catch up and stabilize before resuming the distraction process.
Shortening and Re-Lengthening:
Shortening: Reversing the distraction process to bring the bone segments closer together. This involves gradually adjusting the external fixator to shorten the gap between bone segments and closely monitoring with regular imaging to ensure proper alignment and bone health. This technique compresses the bone callus, stimulating healing and improving bone quality, particularly useful if there is a significant gap or poor bone formation.
Re-Lengthening: After a period of shortening and consolidation, the lengthening process is resumed. Once the bone shows signs of healing and consolidation (verified through imaging), the lengthening process is gradually restarted at a controlled rate. Careful monitoring of the patient’s progress with regular clinical and radiographic assessments is essential to achieve the desired limb length while ensuring optimal bone healing and stability.
Sequential Shortening and Lengthening (Accordion Technique):
Accordion Technique: This involves alternating cycles of slight shortening and lengthening. The bone segments are shortened slightly (e.g., by a few millimeters) to compress the callus and stimulate bone healing. After a brief consolidation period, the bone segments are lengthened again at a slow rate. This cycle is repeated as needed based on bone healing progress. This technique enhances callus formation and bone regeneration by creating a stimulating environment through mechanical compression and distraction.
Biological and Cellular Treatments:
Bone Marrow-Derived Mesenchymal Stem Cells (BM-MSC): Harvesting mesenchymal stem cells from the patient’s bone marrow and injecting them into the delayed healing site. These stem cells have the potential to differentiate into osteoblasts and other bone cells, promoting bone regeneration and healing.
Stem Cell Treatments: Using stem cells, including BM-MSCs and other types, to enhance bone healing. These cells can be applied directly to the site of delayed union, where they contribute to new bone formation and repair by differentiating into bone-forming cells and releasing growth factors that stimulate the healing process.
Increasing Weight-Bearing Exercises and Walking:
Mechanical Stimulation: Weight-bearing exercises provide mechanical stimulation to the bone, which is essential for bone remodeling and strengthening. The stress applied to the bone during these exercises promotes the deposition of new bone tissue and enhances the mineralization process. Walking is a natural form of weight-bearing exercise that applies consistent, gentle stress to the bone. This repetitive loading encourages bone formation and consolidation, helping to bridge gaps in delayed bone healing.
Improved Blood Flow: Engaging in weight-bearing activities and walking increases blood flow to the affected area, supplying essential nutrients and oxygen required for bone healing. Enhanced circulation also helps remove waste products from the site, supporting a healthier healing environment.
Muscle Strengthening: These exercises help strengthen the muscles surrounding the affected bone. Stronger muscles provide better circulation,support and stabilization to the bone, reducing the risk of further injury and facilitating more effective healing.
Hormone Treatment:
Hormone treatments can be an effective adjunct therapy for promoting bone healing in cases of delayed union after limb lengthening surgery.
Parathyroid Hormone (PTH) Analogues: Parathyroid hormone (PTH) and its analogues, such as teriparatide, are used to stimulate bone formation. PTH works by increasing the activity and number of osteoblasts, the cells responsible for bone formation. It promotes bone remodeling and enhances the bone regeneration process. Teriparatide is typically administered as a daily subcutaneous injection for a prescribed duration, often several months, to improve bone healing.
Growth Hormone (GH): Growth hormone can be used to stimulate bone growth and improve healing rates.GH stimulates the production of insulin-like growth factor 1 (IGF-1), which plays a key role in bone growth and remodeling. GH and IGF-1 promote osteoblast proliferation and differentiation, enhancing bone formation. GH is administered through subcutaneous injections, with the dosage and duration tailored to the patient’s specific needs and medical condition.
Ultrasound Therapy: Applying low-intensity pulsed ultrasound to the affected area to accelerate bone healing by promoting cellular processes involved in bone regeneration. This non-invasive technique enhances cellular activity, increases blood flow, and promotes the formation of new bone tissue, thus aiding in the healing of delayed unions.
Prevention of Delayed Bone Healing
Surgical Technique:
Optimal Osteotomy: Utilize precise and minimally invasive osteotomy techniques to reduce trauma to the bone and surrounding tissues. Multiple driling hole osteotome technique is the most current technique with the best bone union.
Stable Fixation: Ensure proper alignment and stabilization of the bone segments using external fixators or internal fixation devices to minimize movement and promote healing.
Correct Nail Size Selection: Choose the appropriate nail size for intramedullary nailing to ensure optimal stabilization and support for the bone segments, promoting better alignment and healing.
Minimal Compact Bone Reaming: Perform minimal reaming of the compact bone during intramedullary nailing to reduce bone trauma and preserve the bone’s natural structure, aiding in quicker recovery and better bone health.
Controlled Distraction Rate:
Gradual Lengthening: Adhere to recommended distraction rates (typically around 1 mm for femur and 0.75mm for tibia per day) to allow the bone sufficient time to regenerate.
Adjustments: Modify the distraction rate based on the patient’s response and healing progress, slowing down or temporarily halting if necessary.
Weight-Bearing Exercises and Physical Therapy:
Weight-Bearing Exercises: Encourage gradual weight-bearing activities to provide mechanical stimulation that promotes bone growth.
Physical Therapy: Implement a structured physical therapy program to improve blood flow, muscle strength, and overall limb function, supporting the bone healing process.
Nutritional Support and Supplement Support:
Proper Diet: Ensure patients maintain a balanced diet rich in protein, vitamins, and minerals essential for bone healing.
Supplements: Recommend supplements such as calcium and Vitamin D if dietary intake is insufficient. Calcium is crucial for bone mineralization, while Vitamin D helps with calcium absorption. In addition, as a vitamin Vitamin C,K and B and as a mineral magnezium,phosphorus,zinc are effective in bone healing.
Monitoring and Follow-Up:
Regular Assessments: Schedule regular follow-up visits to monitor healing progress through clinical evaluations and imaging studies (X-rays).
Early Detection: Identify and address any signs of delayed healing or complications early to implement timely interventions.
Non-Union
Non-union is a critical complication that can arise after limb lengthening surgery, characterized by the cessation of bone healing. While delayed union signifies a slower-than-expected healing process that may still resolve with conservative measures, non-union indicates that the bone ends have ceased to progress towards healing, necessitating more aggressive intervention. The FDA defines non-union as a fracture that is at least 9 months old and has not shown any signs of radiographic healing within the last 3 months.
Causes of Non Union
The causes of non-union are the same as those for delayed bone healing. If delayed bone healing is not addressed and treated, the bone’s ability to heal gradually decreases and eventually stops. This stop of the bone regeneration process results in the complication known as non-union, characterized by a complete halt in healing that cannot be resolved without significant medical or surgical intervention. Non-union thus represents a chronic failure of the bone to heal, necessitating comprehensive and often aggressive treatment strategies to achieve successful bone consolidation.
Treatments of Non Union
Bone Graft Surgery: Bone grafting is a crucial intervention for managing nonunion after limb lengthening surgery, where the bone fails to heal properly, leaving a gap or instability at the surgical site. Different types of bone grafts, including autografts, allografts, synthetic grafts, and composite grafts, are used depending on the patient’s condition and clinical needs.
Autograft Techniques
Iliac Crest Bone Graft:
Procedure: Bone is harvested from the iliac crest of the pelvis, which is rich in cancellous (spongy) bone that promotes healing.
Use: Ideal for filling small to moderate-sized defects and providing osteogenic (bone-forming) cells.
Technique: The surgeon makes an incision over the iliac crest, extracts the bone graft, and then places it into the nonunion site. The donor site is then closed and managed for healing.
Fibular Graft:
Procedure: A segment of the fibula (a non-weight-bearing bone in the lower leg) is harvested.
Use: Suitable for structural support in larger defects.
Technique: The fibula is carefully removed, shaped as needed, and transplanted to the nonunion site. This technique provides both structural integrity and osteogenic potential.
Allograft Techniques
Cancellous Allograft:
Procedure: Processed donor bone, which retains its porous structure, is used to fill bone defects.
Use: Best for filling large defects where structural support is less critical.
Technique: The allograft is packed into the nonunion site, often combined with other materials to enhance osteoconductivity (the ability to support new bone growth).
Cortical Allograft:
Procedure: Dense, strong bone from a donor is used to provide structural support.
Use: Suitable for large, load-bearing defects.
Technique: The cortical allograft is shaped to fit the defect and secured in place with screws or plates to ensure stability and integration.
Synthetic Graft Techniques
Hydroxyapatite Grafts:
Procedure: Synthetic bone substitute made from hydroxyapatite, a naturally occurring mineral in bone.
Use: Used to fill defects and promote bone in-growth.
Technique: The hydroxyapatite graft is molded to fit the defect and placed in the nonunion site, often in combination with autograft or allograft materials to enhance integration.
Tricalcium Phosphate Grafts:
Procedure: Synthetic bone substitute made from tricalcium phosphate, which is resorbable and promotes new bone formation.
Use: Ideal for filling small to moderate defects.
Technique: The tricalcium phosphate graft is placed in the defect, where it gradually resorbs and is replaced by new bone.
Shortening and Re-Lengthening
Shortening: Reversing the distraction process to bring the bone segments closer together. This involves gradually adjusting the external fixator to shorten the gap between bone segments and closely monitoring with regular imaging to ensure proper alignment and bone health. This technique compresses the bone callus, stimulating healing and improving bone quality, particularly useful if there is a significant gap or poor bone formation.
Re-Lengthening: After a period of shortening and consolidation, the lengthening process is resumed. Once the bone shows signs of healing and consolidation (verified through imaging), the lengthening process is gradually restarted at a controlled rate. Careful monitoring of the patient’s progress with regular clinical and radiographic assessments is essential to achieve the desired limb length while ensuring optimal bone healing and stability.
Sequential Shortening and Lengthening (Accordion Technique)
Accordion Technique: This involves alternating cycles of slight shortening and lengthening. The bone segments are shortened slightly (e.g., by a few millimeters) to compress the callus and stimulate bone healing. After a brief consolidation period, the bone segments are lengthened again at a slow rate. This cycle is repeated as needed based on bone healing progress. This technique enhances callus formation and bone regeneration by creating a stimulating environment through mechanical compression and distraction.
Biological and Cellular Treatments
Bone Marrow-Derived Mesenchymal Stem Cells (BM-MSC): Harvesting mesenchymal stem cells from the patient’s bone marrow and injecting them into the delayed healing site. These stem cells have the potential to differentiate into osteoblasts and other bone cells, promoting bone regeneration and healing.
Stem Cell Treatments: Using stem cells, including BM-MSCs and other types, to enhance bone healing. These cells can be applied directly to the site of delayed union, where they contribute to new bone formation and repair by differentiating into bone-forming cells and releasing growth factors that stimulate the healing process.
Increasing Weight-Bearing Exercises and Walking
Mechanical Stimulation: Weight-bearing exercises provide mechanical stimulation to the bone, which is essential for bone remodeling and strengthening. The stress applied to the bone during these exercises promotes the deposition of new bone tissue and enhances the mineralization process. Walking is a natural form of weight-bearing exercise that applies consistent, gentle stress to the bone. This repetitive loading encourages bone formation and consolidation, helping to bridge gaps in delayed bone healing.
Improved Blood Flow: Engaging in weight-bearing activities and walking increases blood flow to the affected area, supplying essential nutrients and oxygen required for bone healing. Enhanced circulation also helps remove waste products from the site, supporting a healthier healing environment.
Muscle Strengthening: These exercises help strengthen the muscles surrounding the affected bone. Stronger muscles provide better circulation,support and stabilization to the bone, reducing the risk of further injury and facilitating more effective healing.
Hormone Treatment: Hormone treatments can be an effective adjunct therapy for promoting bone healing in cases of delayed union after limb lengthening surgery.
Parathyroid Hormone (PTH) Analogues: Parathyroid hormone (PTH) and its analogues, such as teriparatide, are used to stimulate bone formation. PTH works by increasing the activity and number of osteoblasts, the cells responsible for bone formation. It promotes bone remodeling and enhances the bone regeneration process. Teriparatide is typically administered as a daily subcutaneous injection for a prescribed duration, often several months, to improve bone healing.
Growth Hormone (GH): Growth hormone can be used to stimulate bone growth and improve healing rates. GH stimulates the production of insulin-like growth factor 1 (IGF-1), which plays a key role in bone growth and remodeling. GH and IGF-1 promote osteoblast proliferation and differentiation, enhancing bone formation. GH is administered through subcutaneous injections, with the dosage and duration tailored to the patient’s specific needs and medical condition.
Ultrasound Therapy: Applying low-intensity pulsed ultrasound to the affected area to accelerate bone healing by promoting cellular processes involved in bone regeneration. This non-invasive technique enhances cellular activity, increases blood flow, and promotes the formation of new bone tissue, thus aiding in the healing of delayed unions.
Prevention of Non Union
Early intervention is crucial in preventing nonunion after limb lengthening surgery, as there is a phase of delayed bone healing before nonunion fully develops. During this phase, it’s important to closely monitor the healing process through regular check-ups and imaging studies to catch any early signs of trouble, such as slow bone growth or gaps at the surgery site. Ensuring the patient has good nutrition, especially adequate calcium and vitamin D, supports bone health. Maintaining mechanical stability with properly adjusted external fixators or internal devices is essential to keep the bone in the correct position and evenly distribute weight. Physiotherapy should be gentle to avoid putting too much stress on the healing bone while still promoting good blood flow and muscle strength. If delayed healing is detected, treatments like low-intensity pulsed ultrasound (LIPUS) or electrical stimulation can help stimulate bone growth. Addressing any underlying issues, such as infections or poor blood supply to the bone, is also important. By taking these steps during the delayed healing phase, the risk of developing nonunion can be significantly reduced, leading to better overall outcomes and less need for invasive treatments like bone grafting.
Infection
Infections following limb lengthening surgery can be a significant complication, influenced by various methods used during and after the procedure. The primary methods involved in limb lengthening are external fixators and internal devices, each associated with different types of infection risks and management strategies. Infections can range from mild redness and swelling to severe cases that can affect the bone and delay healing. Serious infections can even lead to conditions like osteomyelitis, a deep bone infection that requires extensive treatment. Understanding the different levels of infection, recognizing early signs, and knowing how to manage them effectively are essential for a successful recovery.
Causes of Infection
Surgical Factors
Aseptic Technique Failures:
Inadequate sterilization of surgical instruments or operating environment.
Breaks in sterile technique during the procedure.
Intraoperative Contamination:
Introduction of bacteria into the surgical site during the procedure.
External Fixator-Related Factors
Pin Site Infections:
Bacteria entering through the pin sites where external fixators are attached.
Poor pin site care and hygiene post-surgery.
Patient-Related Factors
Compromised Immune System: Conditions such as diabetes, HIV/AIDS, or use of immunosuppressive drugs can reduce the body’s ability to fight infections.
Chronic Health Conditions: Conditions like chronic kidney disease, vascular diseases or diabetes can increase infection risk.
Postoperative Care Factors
Inadequate Wound or Pin Sites Care: Improper cleaning and care of pin sites and surgical wounds.
Delayed Diagnosis and Treatment: Failure to recognize early signs of infection and promptly initiate treatment.
Improper Use of Antibiotics: Incorrect or incomplete antibiotic regimens can lead to antibiotic-resistant infections.
Mechanical Factors
Movement and Stress at Pin Sites: Excessive movement or stress at the pin sites can cause microtrauma, providing an entry point for bacteria.
Wrong weightbearing protocol: Walking without support during lengthening period.
Loosening of Pins: Loose pins can create a gap where bacteria can enter and cause infection.
Symptoms of Infection
Grade 1: Minor Infection Symptoms
Slight redness around the pin site.
Tenderness at the pin site.
No discharge or only a small amount of clear discharge.
Minimal pain.
Grade 2: Moderate Infection Symptoms
Increased redness and swelling around the pin site.
Pain at the pin site.
Serous (clear) or seropurulent (cloudy) discharge.
Pin site may feel warm to the touch.
Moderate tenderness.
Grade 3: Severe Infection Symptoms
Pronounced redness, swelling, and pain extending beyond the pin site.
Significant purulent (pus-like) discharge.
Possible formation of small abscesses.
Systemic symptoms such as low-grade fever may be present.
Severe tenderness and warmth at the pin site.
Grade 4: Osteomyelitis Symptoms
Severe redness, swelling, and pain extending beyond the pin site.
Heavy purulent discharge.
Systemic symptoms like high fever, chills, and malaise.
Evidence of deep tissue involvement or osteomyelitis (bone infection).
Significant pain and tenderness over the affected bone.
Grade 5: Chronic Infection Symptoms
Persistent or recurrent signs of infection despite treatment.
Chronic pain and continuous or intermittent discharge.
Potential for bone involvement and chronic osteomyelitis.
May impact the success of the limb lengthening procedure.
Possible formation of fistulas or sinuses.
Grade 6: Severe Chronic Infection with Bone Involvement Symptoms
Severe, persistent infection with extensive bone involvement.
Chronic osteomyelitis.
Significant impact on limb function and overall health.
Severe and continuous pain.
Chronic discharge, often with the presence of fistulas or sinuses.
Systemic symptoms such as weight loss, fatigue, and fever may be present.
Classification of Infection
Checketts-Otterburn Classification
Treatments of Infection
Grade 1: Minor Infection Treatments
Enhanced Pin Site Care:
Clean the pin site daily with antiseptic solutions such as chlorhexidine or saline.
Apply sterile dressings to maintain cleanliness.
Monitoring:
Observe for any progression to more severe infection.
Educate the patient on maintaining proper hygiene practices.
Grade 2: Moderate Infection Treatments
Local Wound Care:
Clean the pin site more frequently, typically twice daily, with antiseptic solutions.
Apply topical antibiotic ointments to reduce bacterial load.
Oral Antibiotics:
Prescribe oral antibiotics based on clinical judgment and, if available, bacterial culture results.
Common antibiotics include amoxicillin-clavulanate, cephalexin, or clindamycin.
Increased Frequency of Cleaning:
Intensify the routine cleaning of pin sites to prevent further bacterial growth.
Grade 3: Severe Infection Treatments
Oral or Intravenous Antibiotics:
Depending on the severity, administer oral or intravenous antibiotics.
Choose antibiotics guided by culture and sensitivity results, if available.
Frequent Local Wound Care:
Intensive cleaning and debridement of the pin sites to remove infected tissue.
Apply antiseptic dressings to maintain a sterile environment.
Possible Removal or Replacement of Affected Pins:
Remove or replace infected pins if necessary.
Ensure new pins are placed using sterile techniques.
Surgical Debridement:
Remove abscesses or significantly infected tissue through minor surgical procedures.
Grade 4: Osteomyelitis Treatments
Intravenous Antibiotics:
Administer broad-spectrum antibiotics, which may later be adjusted based on culture results.
Continuous IV antibiotic therapy until significant improvement is observed.
Hospitalization:
Admit the patient to the hospital for intensive care and monitoring.
Provide supportive care such as fluids, pain management, and fever control.
Surgical Debridement:
Extensive surgical removal of infected and necrotic tissue.
Possible involvement of orthopedic surgeons for debridement of bone if osteomyelitis is present.
Possible Removal of External Fixator:
In severe cases, the entire external fixator may need to be removed to control the infection.
Consider alternative fixation methods during the healing process.
Grade 5: Chronic Infection Treatments
Long-Term Antibiotics:
Prolonged antibiotic therapy, often guided by culture and sensitivity results.
Oral or IV antibiotics as needed for ongoing infection control.
Comprehensive Surgical Intervention:
Multiple surgical procedures may be necessary to manage chronic infection.
Debridement, bone grafting, and other reconstructive techniques may be required.
Possible Removal of External Fixator and IM nail:
Removal of the external fixator and replacement with alternative fixation methods, such as internal nails or plates.
Ensuring the new fixation method is less prone to infection.
Multidisciplinary Approach:
Involve infectious disease specialists, orthopedic surgeons, and wound care experts to provide comprehensive care.
Regular follow-ups and coordination among various healthcare providers to ensure optimal management of chronic infection.
Grade 6: Severe Chronic Infection with Bone Involvement Treatments
Intensive Long-Term Antibiotics:
Aggressive and prolonged antibiotic therapy based on culture and sensitivity results.
May require a combination of oral and IV antibiotics.
Extensive Surgical Intervention:
Use of bone grafts, vascularized grafts, or advanced fixation methods to reconstruct the limb.
Consideration of external or internal fixation depending on infection control and patient needs.
Comprehensive Rehabilitation:
Extensive physical therapy and rehabilitation to restore limb function.
Pain management and psychological support to address the impact of chronic infection.
Multidisciplinary Care:
Coordinated care involving infectious disease specialists, orthopedic surgeons, plastic surgeons, and rehabilitation specialists.
Regular and long-term follow-up to manage ongoing infection risk and ensure optimal recovery.
Preventions of Infection
Intraoperative Measures
Sterile Technique:
Aseptic Environment: Maintain a sterile surgical environment with strict adherence to aseptic techniques by all surgical staff.
Sterile Instruments: Ensure all surgical instruments and equipment are thoroughly sterilized.
Surgeon and Surgical Team Preperation: Proper hand washing and use of sterile gloves, gowns, and masks by the surgical team.
Antibiotic Prophylaxis:
Preoperative Antibiotics: Administer appropriate antibiotics within an hour before the incision to reduce the risk of infection.
Intraoperative Antibiotics: Continue antibiotic prophylaxis during surgery, especially for longer procedures.
Minimizing Surgery Duration:
Efficient Procedure: Aim to minimize the duration of the surgery to reduce the exposure to potential contaminants and infection risk.
Postoperative Measures
Wound and Pin Site Care:
Regular Cleaning: Clean surgical wounds and pin sites regularly with antiseptic solutions such as chlorhexidine or saline.
Dressing Changes: Use sterile dressings and change them regularly to keep the site clean and dry.
Topical Antibiotics: Apply topical antibiotic ointments as recommended by the healthcare provider.
Professional Dressing Team:
Specialized Care: Utilize a professional dressing team trained in advanced wound care techniques.
Regular Assessments: The dressing team should perform regular assessments and changes of dressings to ensure optimal healing conditions and early detection of any signs of infection.
Advanced Techniques: Implement advanced wound care products and techniques, such as antimicrobial dressings, negative pressure wound therapy, and moisture-retentive dressings as appropriate.
Monitoring and Early Detection:
Frequent Inspections: Inspect the surgical and pin sites frequently for any signs of infection, such as redness, swelling, warmth, pain, or discharge.
Patient Education: Educate patients and caregivers on how to recognize early signs of infection and the importance of reporting any concerns promptly.
Follow-Up Care:
Regular Appointments: Schedule regular follow-up appointments with the limb lengthening team to monitor healing and address any issues early.
Imaging and Lab Tests: Utilize imaging and laboratory tests to detect any underlying issues that may not be apparent during a physical examination.
Antibiotic Treatment:
Prophylactic Continuation: Continue prophylactic antibiotics as recommended post-surgery, particularly if there were complications during surgery.
Correct Antibiotic Use: Using the right antibiotic at the right time is very important in treating infection.
Targeted Antibiotics: If an infection is suspected, obtain cultures and start targeted antibiotic therapy based on sensitivity results.
Patient and Caregiver Training:
Hygiene Practices: Instruct patients and caregivers on proper hand hygiene and care techniques for surgical and pin sites.
Activity Restrictions: Advise on any activity restrictions to avoid trauma or excessive movement that could disrupt the surgical site or fixator.
Comparison of PRECICE(Internal) and LON(Combined) Methods in Terms of Infection
Limb lengthening surgery can use either internal methods like the PRECICE system or combined methods such as Lengthening Over Nails (LON), each with different infection risks. The PRECICE system uses an internal nail that can be extended magnetically, minimizing exposure to infection. Infections with PRECICE are rare and usually result from surgical contamination or systemic issues, presenting symptoms like redness, swelling, pain, and fever. Treatment includes antibiotics and sometimes surgery, with prevention focused on sterile techniques and good postoperative care.
On the other hand, the LON method uses external fixators during the initial phase, which increases the risk of pin site infections. These infections can range from mild redness and swelling to severe deep infections, possibly affecting the bone. Symptoms include pain, discharge, and fever. Diagnosing and treating pin site infections involves regular monitoring, antibiotics, and potentially surgical intervention. Preventive measures include meticulous pin site care and patient education.
Muscle and Tendon Complications
Muscle and tendon complications, such as tightness and contractures, are notable concerns following limb lengthening surgery. These complications arise due to the rapid bone growth outpacing the ability of muscles and tendons to adapt, leading to increased tension and potential shortening of these tissues. Such issues can significantly impact the recovery process, causing pain, reduced range of motion, and functional limitations. Early intervention, including proactive rehabilitation and appropriate medical management, is essential to mitigate these complications and ensure optimal surgical outcomes.
Muscle and Tendon Tightness
Muscle tightness is a common issue following limb lengthening surgery due to the stretching of muscles, tendons, and surrounding tissues as the bones are gradually lengthened. Here are some key points regarding muscle tightness after limb lengthening surgery:
Causes of Muscle and Tendon Tightness
Surgical Effect: Tissue damage and inflammation from the surgery can cause muscle and tendon tightness. This is a direct result of the surgical incision and manipulation of tissues during the procedure.
Lengthening Process: Gradual bone lengthening stretches muscles and tendons beyond their normal range. This continuous stretching can lead to discomfort and tightness as the soft tissues adapt to the new length.
Rate of Lengthening: The rate at which the bone is lengthened can influence the degree of muscle tightness. Faster lengthening rates can place more immediate strain on the soft tissues. A slower, more gradual lengthening process might allow the muscles and tendons more time to adapt, potentially reducing tightness.
Excessive Lengthening Rate and Amount: Rapid or excessive elongation of the limb can cause severe stretching of muscles beyond their tolerance, leading to damage. The safe limit of lengthening varies from person to person, but is 1 mm dailiy and 8 cm max for femur and 0.75 mm dailiy and 6 cm max for tibia. If these safe limits are exceeded, the muscles cannot adapt to the lengthening and can suffer various levels of tightness.
Immobilization and Reduced Activity: After surgery, there is often a period of reduced mobility to allow for initial healing. Lack of movement can lead to muscle stiffness and atrophy.Immobilization can exacerbate muscle tightness as the muscles and tendons become less flexible due to disuse.
Inadequate Physical Therapy: Insufficient physical therapy and stretching exercises can lead to persistent muscle and tendon tightness. Regular rehabilitation is crucial for maintaining muscle flexibility and preventing stiffness.
Lack of Exercises: Not engaging in regular exercise can result in muscle weakness and tightness. Muscles need activity to maintain their strength and flexibility, and a lack of exercise can lead to deterioration and increased tightness.
Symptoms of Muscle and Tendon Tightness in Femur and Tibia Lengthening
Muscle and tendon tightness after femur and tibia lengthening often results in aching or pain, especially during movement or stretching, and persistent soreness even at rest. Patients may feel stiffness, making it hard to move the limb fully, and localized swelling can worsen this tightness. Muscle weakness and fatigue after minimal activity are common, along with painful muscle spasms and increased tenderness. This tightness can limit the range of motion, affecting activities like bending or straightening joints. While some tightness is normal during the lengthening period, it should be managed to remain at a normal level. Significant improvement in muscle tightness is typically observed during the post-lengthening recovery period(consolidation period).
Tightness and restricted movements in femur and tibia lengthening are as follows:
Femur Lengthening
Quadriceps Muscles (Vastus Lateralis, Vastus Medialis, Vastus Intermedius, Rectus Femoris)
Muscle Tightness: Quadriceps
Limited Movement: Knee flexion (bending the knee)
Details: The quadriceps are the primary muscles responsible for extending the knee. Tightness in these muscles can significantly limit the ability to bend the knee, making it difficult to perform activities such as sitting down, squatting, or climbing stairs. Patients may experience pain and a sensation of tightness at the front of the thigh.
Hamstrings (Biceps Femoris, Semitendinosus, Semimembranosus)
Muscle Tightness: Hamstrings
Limited Movement: Knee extension (straightening the knee) and hip flexion (lifting the thigh towards the torso)
Details: The hamstrings are crucial for bending the knee and extending the hip. Tightness in the hamstrings can restrict the ability to straighten the knee fully and lift the thigh towards the torso. This can result in difficulties with walking, running, and performing activities that require a full range of motion in the hip and knee.
Iliotibial (IT) Band
Muscle Tightness: IT band
Limited Movement: Hip adduction (bringing the thigh inward)
Details: The IT band runs along the outside of the thigh from the hip to the knee. Tightness in the IT band can cause pain and tightness along the outer thigh and knee, limiting movements that involve bringing the leg inward. Patients might experience discomfort during running, walking, or prolonged standing.
Adductors (Adductor Longus, Adductor Brevis, Adductor Magnus, Gracilis, Pectineus)
Muscle Tightness: Adductors
Limited Movement: Hip abduction (moving the thigh outward)
Details: The adductors are responsible for bringing the legs together. Tightness in these muscles can limit the ability to move the thigh outward, making activities that require leg separation, such as side lunges or straddling, difficult and uncomfortable. Groin pain is a common symptom.
Hip Flexors (Iliopsoas, Rectus Femoris)
Muscle Tightness: Hip flexors
Limited Movement: Hip extension (moving the thigh backward)
Details: The hip flexors are key for lifting the thigh towards the torso. Tightness in these muscles can limit the ability to move the thigh backward, causing difficulties with walking, running, and activities that involve hip extension. Lower back pain may also occur due to compensatory movements.
Tibia Lengthening
Gastrocnemius and Soleus (Calf Muscles)
Muscle Tightness: Calf muscles (Gastrocnemius and Soleus)
Limited Movement: Dorsiflexion (lifting the toes up)
Details: The calf muscles are responsible for plantarflexing the foot (pointing the toes down). Tightness in these muscles can limit the ability to lift the toes up. Patients may experience calf pain and difficulty in activities requiring ankle mobility.
Tibialis Anterior
Muscle Tightness: Tibialis Anterior
Limited Movement: Plantarflexion (pointing the toes down)
Details: The tibialis anterior muscle helps in dorsiflexing the foot (lifting the toes up). Tightness in this muscle can limit plantarflexion, making it difficult to point the toes down.
Peroneal Muscles (Peroneus Longus, Peroneus Brevis)
Muscle Tightness: Peroneal muscles
Limited Movement: Inversion (turning the sole of the foot inward)
Details: The peroneal muscles are involved in everting the foot (turning the sole outward). Tightness in these muscles can limit inversion. Patients may experience discomfort along the outer lower leg.
Achilles Tendon
Tendon Tightness: Achilles tendon
Limited Movement: Dorsiflexion (lifting the toes up)
Details: The Achilles tendon connects the calf muscles to the heel bone and is vital for plantarflexion of the foot. Tightness in the Achilles tendon can severely limit dorsiflexion Pain and tightness in the back of the ankle and lower leg are common symptoms.
Treatments for Muscle and Tendon Tightness
Physical Therapy
Stretching Exercises: Regular, gentle stretching helps maintain and improve flexibility in the muscles and tendons.
Self-Stretching: Incorporating self-stretching techniques, as guided by a physical therapist, to maintain flexibility and manage tightness at home. These exercises empower patients to actively participate in their recovery and ensure consistent stretching outside of therapy sessions.
Strengthening Exercises: Targeted exercises to build muscle strength and support the newly lengthened bone.
Range of Motion Exercises: Activities that promote joint mobility and prevent stiffness.
Manual Therapy: Techniques such as massage and myofascial release to reduce tightness and improve muscle function.
Adjustment of Daily Lengthening Rate
Monitoring Lengthening: Carefully adjusting the daily rate of bone lengthening to ensure it is gradual enough to allow muscles and tendons to adapt without becoming excessively tight. Regular consultations with the surgical team to determine the optimal lengthening rate based on individual progress and response. 1 mm for femur and 0.75 mm for tibia is the limit for muscle and tendon adaptation. In patients with excessive muscle and tendon tightness, the daily lengthening rate can be reduced. Adaptation of all soft tissues, including muscles, is better at a lower lengthening rate.
Hydration and Nutrition
Staying well-hydrated supports muscle health and function. A diet rich in protein, vitamins, and minerals aids in muscle repair and recovery. Taking the necessary amount of protein for new muscle building and adaptation reduces muscle tightness.
Supportive Devices
Braces and Splints: Provide support and reduce strain on muscles and tendons during the healing process.
Surgical Intervention
If Necessary: In severe cases where muscle tightness leads to significant functional impairment, surgical intervention such as tendon lengthening may be considered.
Muscle Contracture
Muscle contracture is a severe and chronic condition where muscles become permanently shortened and resistant to stretching, resulting in a fixed and often painful limitation of movement. Muscle contracture following limb lengthening surgery, during the lengthening period, represents an advanced and serious stage of muscle tension that occurs when proper preventive measures or treatments are not implemented. While muscle tension can be a manageable, temporary condition, muscle contracture is a chronic, pathological state that should ideally be prevented or promptly treated to avoid severe functional impairment.
Causes of Muscle Contracture:
Prolonged and excessive muscle tension without adequate intervention and treatment during limb lengthening period can lead to muscle contracture, a severe and chronic condition where muscles become permanently shortened and resistant to stretching. This situation arises when the natural adaptive capacity of the muscles is overwhelmed by the stress and strain of the lengthening process, and preventive measures are not effectively implemented.
Insufficient Physical Therapy: Regular and intensive physical therapy is crucial to stretch and strengthen the muscles during the lengthening process.I nadequate physical therapy allows muscles to tighten and shorten, increasing the risk of contracture.
Prolonged Immobilization: During the lengthening process, periods of immobilization can be necessary. However, prolonged lack of movement can lead to muscle shortening and stiffness. Immobility contributes to muscle contracture by preventing regular stretching and movement, essential for maintaining muscle length and flexibility.
High Daily Lengthening Speed: Limb lengthening involves gradually stretching the bone and surrounding tissues. When the lengthening process is done too quickly, the muscles, tendons, and other soft tissues do not have adequate time to adapt and stretch. Excessive daily lengthening can lead to acute muscle tension, which, if not managed, progresses to permanent contracture as the muscles cannot elongate sufficiently to match the bone growth.
Exceeding Total Safety Lengthening Limit: There are established safe limits for the total amount of lengthening that can be achieved based on individual patient factors and the specific surgical technique used. Exceeding these limits puts excessive stress on the muscles and other soft tissues. When the total lengthening surpasses safe limits, it significantly increases the risk of muscle and tendon shortening, fibrosis, and subsequent contracture.
Formation of Scar Tissue: Surgical procedures and the lengthening process itself can lead to scar tissue formation within the muscles Scar tissue is less flexible than normal muscle tissue and can contribute to the development of contractures by restricting normal muscle elongation.
Symptoms of Muscle Contracture
Persistent Muscle Tightness: The muscles feel constantly tight and do not relax, even with rest. This persistent tightness is a key indicator of contracture, differentiating it from temporary muscle tension.
Reduced Range of Motion: There is a significant and lasting limitation in the ability to move the affected limb through its normal range of motion.
Visible Deformity: The affected limb may appear visibly deformed or held in an abnormal position due to the contracted muscles pulling on the joints. This deformity can be a clear sign of severe muscle contracture.
Pain and Discomfort: Persistent pain and discomfort, particularly during attempts to move or stretch the affected limb. The pain can be chronic and may worsen with activity, limiting the patient's ability to participate in physical therapy or daily activities.
Muscle Weakness: The affected muscles may become weaker over time due to the chronic contracture. Muscle weakness further impairs mobility and function, making it harder to perform even simple tasks.
Stiffness and Rigidity: The muscles and joints feel stiff and rigid, making movements slow and difficult. This stiffness can severely limit the patient’s ability to walk or perform lower extremity movements.
Abnormal Gait: The way the patient walks may change due to the restricted movement in the lower extremity. An abnormal gait can lead to additional strain on other parts of the body, potentially causing further complications.
Common Muscle Contractures During Femur Lengthening
Knee Extension Contracture - Quadriceps (Front Thigh Muscles):
Function: The quadriceps are involved in extending the knee (straightening the leg) and flexing the hip (lifting the thigh).
Contracture: Contracture of the quadriceps can cause knee extension contracture, making it difficult to bend the knee.
Symptoms: Limited knee flexion, difficulty sitting, walking and tightness in the front of the thigh.
Knee Flexion Contracture - Hamstrings (Back Thigh Muscles):
Function: The hamstrings are responsible for flexing the knee (bending the leg) and extending the hip (moving the thigh backward).
Contracture: Contracture of the hamstrings can lead to knee flexion contracture, making it difficult to straighten the leg.
Symptoms: Limited knee extension(straight), difficulty standing or walking with the leg fully extended, and tightness in the back of the thigh.
Anterior Pelvic Tilt Contracture (Duck ...) - Iliopsoas (Hip Flexors):
Function: The iliopsoas muscle group is involved in hip flexion (lifting the thigh) and maintaining upright posture.
Contracture Presentation: Contracture of the iliopsoas can cause hip flexion contracture, resulting in a bent position of the hip.
Symptoms: Difficulty in fully extending the hip, increased lordosis and anterior tilt of the pelvis leading to a forward-leaning posture and tightness in the groin area.
Wide Leg (Abduction) Contracture - Iliotibial (IT) Band:
Function: The IT band is a thick band of fascia that runs along the outside of the thigh, helping to stabilize the knee and hip during movement.
Contracture: Contracture of the IT band can lead to IT band syndrome, characterized by pain and tightness along the outer thigh and knee. The legs are opened to the sides and adduction and inward closing movements cannot be performed. That's why patients walk with their legs abducted (open to the side).
Symptoms: Tightness and pain on the outer side of the thigh, knee pain, and difficulty with movements that involve bending or straightening the knee. Wide leg walking.
Common Muscle Contractures During Tibia Lengthening
Ballerina Syndrome(Plantar Flexion) Contracture - Gastrocnemius and Soleus (Calf Muscles):
Function: These muscles are involved in plantar flexion of the ankle (pointing the toes downward).
Contracture: Contracture of the gastrocnemius and soleus can lead to equinus deformity (foot pointing downward) and difficulty in dorsiflexing the ankle (lifting the foot upward).
Symptoms: Limited ankle dorsiflexion, walking on the toes(ballerina syndrome), and tightness in the calf.
Dorsiflexion Contracture - Anterior Tibialis:
Function: This muscle is responsible for dorsiflexion of the ankle (lifting the foot upward).
Contracture: Contracture of the anterior tibialis can result in a drop foot deformity (difficulty lifting the front part of the foot).
Symptoms: Difficulty in lifting the foot while walking, leading to a dragging of the toes.
Treatment of Muscle Contracture
Treating muscle contracture after limb lengthening surgery requires a multifaceted approach that combines physical therapy, medical interventions, and sometimes surgical procedures. Here are the primary strategies for managing muscle contracture:
Non-Surgical Treatments
Agresive Physical Therapy:
Stretching Exercises: Regular, targeted stretching exercises help to lengthen the contracted muscles and improve flexibility. Specific stretches will depend on the affected muscle group but generally involve passive and active stretching techniques.
Manual Therapy: Techniques like massage, myofascial release, and other hands-on methods can help reduce contracture and improve tissue flexibility.
Adjustment of Lengthening Protocol:
Reduce Daily Lengthening Speed: Slowing down the rate of daily lengthening can give muscles and tissues more time to adapt, reducing the risk of contracture.
Pause Lengthening Temporarily: Taking a break from lengthening can allow for intensive physical therapy to address muscle tightness and prevent further contracture.
Orthotic Devices:
Braces and Splints: Use of braces, splints, or orthotic devices to hold the affected limb in a stretched position can help prevent further shortening and encourage lengthening of the muscle over time.
Dynamic Splints: These are designed to apply a gentle, continuous stretch to the contracted muscle, promoting gradual elongation.
Surgical Treatments
Muscle and Tendon Releasing Surgery: A combination of muscle and tendon release surgeries can be performed to address multiple contractures. The surgeon releases tight muscle and tendon fibers to restore length and improve function. This comprehensive approach can significantly enhance range of motion and functional ability, especially when multiple muscle groups are affected.
Orthopedic Device(Nail and Fixator) Failure
Orthopedic device failure in limb lengthening procedures, such as the LON (Lengthening Over Nail) and PRECICE methods, poses significant risks to patient outcomes. In the LON method, failures can involve the external fixator, where pins and wires may loosen, bend, or break due to mechanical stress or improper care, and the solid intramedullary nail, which can bend or fracture under excessive load or improper alignment. The PRECICE method, relying solely on a magnetically controlled intramedullary nail, also faces risks of nail breakage or mechanical failure, particularly if subjected to premature weight-bearing or high-impact activities. Both methods require meticulous surgical technique, strict adherence to post-operative care protocols, and regular monitoring to minimize the risk of device failure and ensure successful limb lengthening.
Result
Minimizing Complications in Limb Lengthening Surgery: The Importance of Expert Care and Follow-Up
Limb lengthening surgery carries the risk of various minor and major complications, but these can be effectively prevented and managed with the right approach. To minimize complications, it is crucial to implement a comprehensive surgical and postoperative follow-up protocol. Early detection and prompt treatment of initial issues are vital to prevent them from escalating into severe problems. Therefore, choosing an experienced surgeon and a skilled professional team, along with a reputable medical center, is essential for ensuring optimal outcomes and reducing the risk of complications. Proper care and attention throughout the treatment process are key to achieving successful results in limb lengthening procedures.
