Limb Lengthening and Innovative Ilizarov Surgeries

Limb lengthening is a surgical procedure aimed at improving or correcting the length of limbs. The procedure involves elongating the bones in a patient’s arms or legs while simultaneously stretching the surrounding muscle, tendon, and ligament tissues. This gradual process allows the bones and soft tissues to lengthen over a period of several months. The procedure begins with a Paediatric Orthopaedic Surgeon in Bangalore performing an osteotomy, which involves cutting into the bone to facilitate its lengthening. The limb, typically the upper or lower leg, is then stabilised using one of several external fixation devices or internal fixation frames.

Ilizarov Surgery

The orthopaedic surgeon may opt to use the limb correction technique known as the “Ilizarov” method. This clinically-proven orthopaedic approach is used for lengthening or straightening bones and soft tissues. Ilizarov surgery employs a device called an ‘Ilizarov apparatus’ or ‘Ilizarov fixator,’ which is used to extend or reshape broken bones in the arms or legs; it serves as a limb-sparing technique.

The Ilizarov technique leverages the natural healing process of bone growth or regeneration to fix malformed bones. This process involves carefully separating two halves of a bone by mere millimetres. During this separation, the body’s inherent ability to generate bone bridges the gap between the two halves, thereby correcting deformities or increasing the bone’s length. The innovative Ilizarov device and technique have the potential to preserve limbs that would otherwise necessitate amputation.

Indications for the surgery

• Comminuted fractures in the limbs, accompanied by skin loss.
• Correction of both congenital and acquired limb deformities.
• Sequelae of poliomyelitis, involving the correction of deformities and alleviation of limb issues.
• Malunilateral fractures and non-union fractures.
• Bone infections.
• Height enhancement procedures, particularly applicable to individuals with dwarfism.

The Ilizarov Method of Treatment

In contrast to traditional external fixators, the Ilizarov fixator consists of a set of internal fixators, including rings, rods, and Kirschner’s wires. These external fixators encase the limb in the form of a cylinder, and instead of pins, the bone is attached to the rings by wires. The principle of Ilizarov is based on Ilizarov’s Principle of Osteogenesis.

Osteogenesis is the process of forming new bone by controlled and gradual pulling apart of bone surfaces. Osteogenesis is induced by the distraction of the bone surfaces. Initially, this distraction of the bone results in neovascularization, which stimulates new bone formation. Simultaneously, there is histogenesis of muscles, nerves, and skin. In bone diseases, this newly formed bone replaces diseased bone with healthy bone. This concept is groundbreaking; diseases that previously had no treatment can now be successfully managed using this technique.

Preparation of the Procedure

Prior to the operation, the patient’s medical history will be examined to determine, in particular, if they are allergic to anaesthesia. A blood test may also be conducted. The surgeon may request the following:

• Discontinuation of any medications that interfere with bone healing.
• Abstaining from smoking during the recovery period, as it may impede the healing process.
• Additionally, it is advised to arrange transportation for the patient to return home after the procedure.

Ilizarov Procedure

This procedure, also known as Transosseous Osteosynthesis, is typically performed under general anaesthesia. The duration of an Ilizarov frame operation depends on the type of limb being treated and the scope of the treatment. During the operation, 1.5mm diameter wires are percutaneously passed through the bone and the skin using a drill. The protruding ends of these wires are then attached to rings using special ‘wire fixation’ bolts. These rings are connected and attached to each other using threaded rods. Once the frame is in place, the Ilizarov apparatus provides stability to the injured limb. The next step involves a Corticotomy, which is an osteotomy that detaches the bone from its periosteal area. The rods are adjusted to create the desired compression or distraction between the ends of the bone, and deformities are corrected simultaneously. Upon completion of the treatment, the ring fixator will be removed.

What are the potential risks associated with this surgery?

The patient will be administered a general anaesthetic during the procedure to facilitate the installation of the frame. The primary risks associated with the surgery include:

• Nausea and vomiting caused by the anaesthesia.
• Constipation, which can be caused by dietary alterations, the analgesic medication administered during the procedure, and the surgical procedure itself.
• Bruising or bleeding may occur around the pin sites following the operation; this should resolve within a few days.
• In very rare cases, patients may develop a blood clot in the legs, which could be life-threatening.
• Some patients might experience joint or muscle stiffness, but this is preventable by engaging in regular physical activity involving the affected limb and joints at both ends of the body.
• At some point in the course of treatment, most individuals develop an infection of the skin and surrounding tissues associated with a pin.
• Nerve damage can manifest as numbness or loss of movement in a limb, such as a foot.

Advantages of the Ilizarov surgery

There are many advantages to having Ilizarov surgery, including:

• The skin is not cut in the same way as in a traditional operation. There are significantly fewer incidents of bleeding, tissue injury, and infection.
• The entire process is considered minimally invasive, as the bones are attached to the rings by wires only, resulting in minimal soft tissue damage.
• An Ilizarov fixator can be used in a variety of ways. Due to its cylindrical shape, it can be fixed in three dimensions simultaneously.
• The patient continues to be able to move freely throughout the treatment. The early initiation of intensive physiotherapy has resulted in a decrease in joint stiffness and contraction issues, leading to a reduction in the patient’s hospitalisation rate.
• Since the Ilizarov fixator is positioned on the outside of the limb, there are no remaining metal components in the body after treatment.

Recovery after the procedure

The patient will be unable to drive, and it is necessary to arrange for someone to accompany them home. The pain should subside in a few days, and the patient should continue taking any pain medications as required. It is essential to maintain all pin sites in a highly hygienic and dry environment. Baths should be avoided due to the potential for infection in pin sites.

Patients should continue to engage in physical activity and exercise as recommended by their physiotherapist, as physical activity promotes bone growth. Patients begin to walk the day following the limb lengthening surgery, provided they have access to some form of support, typically a walking aid or crutches, prescribed by their surgeon.

The duration of time an individual is required to wear the frame is likely to be at least three months. However, in the majority of cases, patients are required to wear their frames for six to twelve months.

Apollo Hospitals, also known as Top Pediatric Orthopaedic Hospital in Bangalore, specialises in limb lengthening and deformity correction procedures for adults and children. We are equipped with state-of-the-art facilities to provide our patients with the highest quality of care. Book an appointment at Apollo Hospitals to learn more about Ilizarov surgery with the help of the best experts.