Leg lengthening

LEG LENGTHENING GEORGE Associate

Professor

of Clinical

Orthopedic

ANOPOL,

YORK

NEQUAL

lower extremities have a twofoId deIeterious effect upon the patient-mechanical and cosmetic.

FIG.I.z-excision to shorten femur or other tong bone, and kangaroo

F.A.C.S.

Surgery, New York Post-Graduate CoIumbia University NEW

U

M.D.,

suture of fragments.

The probIem of correcting the disability has been in the minds of surgeons, and especiaIIy of orthopedists, for many years. Attempts to equaIize the extremities have often been made through conservative means, i.e., building up the soIe and hee1 of the shoe on the affected side. A difference greater than three-quarters of an inch is often detected by the Iimp of the individua1. And with greater differences the norma mechanics of the body are offset so that a vicious cycIe is created. The shortened Iimb gets less and Iess physica strain in waIking, as most of the weight and function is carried by the Ionger limb. As a resuIt there is stimuIation to the longer and further incentive to shortening of the other. ScoIiosis, with resuItant poor posture, is a common end resuIt of inequaIity of the Iower extremities. With these changes, there is a whoIe gamut of interna and somatic reactions from which patients seek reIief. In the victims of poIiomyeIitis such are more common and, deveIopments 422

Medical

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and Hospital,

CITY

of course, more severe because of the secondary muscuIar invoIvement-paresis to paraIysis. The muscle sense through a regular soIed shoe is much more acute than through cork build-ups, especiaIIy where 2 or 3 inches of soIe are necessary. Even in .the poIiomyeIitics the mechanics of the entire body may be assisted through proper skeIeta1 equaIization. EspeciaIIy is this true in flail knee cases. Such patients, with arthrodesed ankIes, can Iock their knees in extension when waIking. One can dispense with braces with Iock devices. A cork build-up of 2 or 3 inches, and in many cases less, wiI1 not permit such Iocking at the knee. The lever action of the foot is lost because of the buiIt-up. The pubIic at Iarge has not reached a stage in which it wiI1 readily accept the cork, Ieather and metal braced empIoyee who is seeking work. Appearance counts for a great dea1 in obtaining the opportunity to demonstrate that one can do as we11 or better than the physicaIIy unhandicapped individua1 on the same job. It is therefore up to the surgeons to continue to perfect their techniques or accept those of others to obtain the more physioIogic (skeIeta1) increase in Iength. Such Iengthening wiI1 aid the job-seekers, where artificia1 soIes can onIy hamper him. UnfortunateIy, because of many factors -cumbersome apparatus, operative trauma and mismanaged postoperative convaIescence, leg equaIization by lengthening has been given up by many for Ieg shortening, a more simple operative procedure. This, however, shouId not decide the operation for the patient. An open operation carries a certain risk. A patient shouId

NEW SERIES VOL. XLIII,

Anopol-Leg

No. 2

Lengthening

FIG. 3. PIastic

A

osteotomy

Journd

of Surgery

423

braces, extend over a year. Their argument that Ieg Iengthening also carries a Iong convaIescent period and that therefore

be permitted to have one good Ieg to stand on. For that reason and for the more normal physioIogy obtained, the equaIiza-

FIG. 2. Apparatus

American

used for leg lengthening.

of tibia.

B

AB equals

C

A’B’. AA’ equa1.s ZAB.

D

open osteotomy of tibula, middle third. R, insertion of Steinmann nails into tibia. c, long semiIunar skin incision over anteromedia1 surface of tibia. D, spira1 incision of periosteum of tibia.

FIG.

4. A,

tion shouId be obtained by Iengthening in the affected side. When one witnesses the surgery of femora1 shortening by some of those who are giving up Ieg Iengthening, one soon reaIizes the many mechanica shortcomings of this procedure. These surgeons remove a cyIinder of femur and reIy on onIy the cross-section contact for union in the presence of marked resuItant atonicity of the thigh muscIes. It is no wonder that the convaIescent period, with pIaster and

the femoral shortening is more advisable, is not consistent. A z-excision with kangaroo suture of the fragments would improve the technique if the shortening operation must be undertaken. (Fig. I .) I have used this procedure to shorten Iimbs when overgrowth is on the affected side. SoIid union is obtained in eight weeks. If surgeons wouId study the problem seriousIy and become famiIiar with the tissues that must be handIed in preparation to Iengthening their resuIts wouId be

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better. Lengthening shouId be performed in seIected cases, and the patients shouId try eIevated shoes in order to correct

Lengthening

FEBRUARY,

1939

caIiber. If this is done too rapidIy thrombosis may resuIt in the distal portions because of the diminished rate of flow.

FIG. 5. A, incision of interosseous membrane. B, two Iong circuIar saw incisions at right angIes to the anteromedia1 surface of the tibia. c, two saw cuts from upper ends diverging to periphery of tibia for a distance equa1 to increase to be obtained. D, compIetion of pIastic osteotomy-cross cut anteromedial surface of tibia between lower ends of Iong incisions.

A

B

D

FIG. 6. A, tested for break in continuity. B, sezeral interrupted sutures in periosteum. c, skin wounds closed with pIain o catgut. D, vaseIine gauze dfessing in&ding upper pin and up to Iower pin. Separate vaseIine dressing to foot incIuding the Iower pin.

secondary conditions such as scoIiosis before the operation on the extremity is undertaken. The physioIogy and function of the tissues to be Iengthened must be kept in mind. Trauma of the structures at operation might produce a poor end resuIt because of ensuing compIications. The arteries must be remembered, since as they are stretched the Iumen decreases in

Experience has shown that if the Iimb is kept eIevated above the patient’s heart Ievel to ease the venous and Iymphatic return and that if the Iengthening process is gradua1, no circuIatory compIications wiI1 resuIt. Increase of Iength of not more than jd2 inch twice a day has been accepted by the writer as a safe procedure in actua1 practice. Under simiIar conditions periphera1 nerve function has not been

Anopol-Leg

NEW Smms VOL. XLIII. No. z

interfered with. This is poIiomyeIitic cases. After the Ieg Iengthening

true

in

non-

operation

has

Lengthening

American

Journal

of Surgery

425

isometric parts of the apparatus proper consist of teIescope tubes, the inner one caIibrated. These have posts attached

c D plaster including knee, upper pin, and operative area up to Iower pin. Separate pIaster for foot incIuding the lower pin. c, application of apparatus mediaIIy and IateraIIy to pins. D, incorporation of apparatus to the casts with pIaster. A

B

FJG. 7. A, thin sterile dressings. B, circular

been decided upon, the operative technique and apparatus shouId be considered. Any apparatus famiIiar to the surgeon that wiI1 retain the fragments in a functiona aIignment during the process of gradua1 Iengthening and thereafter unti1 union has taken pIace is satisfactory. One shouId, however, aIso consider the nursing probIem and the safety of a patient whiIe at the same time preventing any damage or interference to the operation. Many of the apparatus used are too cumbersome. Patients cannot move whiIe the apparatus is in use. The writer has designed a simple leg Iengthening apparatus combined with pIaster of Paris technique that answers the purpose admirabIy. The fragments are heId in practicaIIy anatomic position if a simpIe ruIe in appIying it is remembered. It remains as part of the circular pIaster unti1 union is demonstrated by x-ray. And because of Iightness and its contro1 of the operative site the patient can be moved about with ease. If necessary, he can be permitted to slide down a chute in case of a fire aIarm, with safety to Iife and limb. The apparatus consists of two Steinmann naiIs, one for each fragment. Two

between which is a turn-buckle arrangement for Iengthening after the set is appIied to the Steinmann naiIs and fixed with

FIG. 8. X-ray

at end of Iengthening. Shows fragments in good aIignment aIthough lower pin broke.

pIaster. There piece of meta

is a simpIe gauge-a Aat with a hoIe at each end so

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distanced as to give the distance between the end posts when the instrument is cIosed or at zero.

FIG. 9. Photograph

Lengthening

FEBRUARY, rgjg

parallel to the crest of the tibia. This is very important for obtaining a resultant functional alignment. When properly car-

taken just before patient returned home. Turnbuckles had not yet been covered with plaster.

The writer has found this procedure successful in obtaining an average increase of length of 234 inches in tibiae. The steps of the operation follow. The operation is performed with a tourniquet apphed we11 above the knee. The order of the steps is important. I. Open osteotomy of fibula at junction of the lower and middle third, 2. Subcutaneous tenotom,y of tendon Achilles in contracted cases. 3. Insertion of the Steinmann naiIs paralIe1 to each other and in a plane

ried out in practice the alignment has been practically anatomic. The nails are distanced apart with the aid of the simple guide. 4. Semi-eliptica1 skin incision on anteromedia1 surface of the tibia is made between the nails. 5. The periosteum is cut in modified spiral to permit proper retraction while doing the plastic osteotomy and later to produce a periosteal tube. 6. With great care the interosseous membrane is then severed. The Iine should

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be between the break in continuity of the periosteum on tibia and the osteotomy in the fibuIa. 7. Having by now the break in continuity of the fibuIa, interoseous membrane and periosteum of the tibia, the next procedure is the plastic osteotomy of the tibia. This consists of the foIIowing steps. Two long saw cuts, sIightIy cIoser together distaIIy, about 55 inch apart, and twice as Iong as the increase in Iength desired, are made into the anteromedia1 surface of the tibia, i.e., if the increase is to be 3 inches, the Iong saw cuts must be 6 inches long. With the same AIbee saw two cuts are made from the upper ends of the Iong cuts diverging towards the periphery of the tibia for a distance equa1 to the increase to be obtained. These Iatter incisions are connected subperiosteIIy (posteroIatera1 aspect of tibiaj with a GigIi saw. The plastic osteotomy is then compIeted when the two Iong incisions are connected by a saw cut at their dista1 ends. 8. At this point a test for compIete break of continuity of the necessary tissues is checked upon by puIIing the Steinmann naiIs apart. If the procedure has been carried out carefuIIy the fragments of the tibia can be puIIed apart about fi inch without very much tension. g. The wound is now cIosed. The periosteum is sutured with severa interrupted No. o chromic catgut sutures. The skin is cIosed with No. o pIain. IO. Vaseline gauze dressing is applied in two parts. One incIudes the upper pin region, the knee and Ieg up to the lower pin. Care must be taken not to incIude the Iower pin in the first part. The second part incIudes the Iower pin region and foot. The gauze dressing is applied simiIarIy in two sections. I I. The circuIar plaster dressing is aIso appIied in two parts just as the vaseIine gauze and gauze dressings. The break in continuity is just above the Iower pin. 12. At this point the isometric parts of the apparatus are appIied to the pins mediaIIy and IateraIIy and fastened with

Lengthening pIaster bandages to the circular plasters aIready appIied. The patient is returned to his bed with

FIG. IO. End result compared to patient’s normnl leg.

instructions to have the extremity elevated. The turnbuckles for lengthening are turned about twelve hours postoperatively. The turns are made twice a day to obtain 352 inch increase or $is inch in twenty-four hours. With this amount of increase the writer has had no morbidity or mortality. The average total Iengthening has been 23,i inches in patients ranging in ages from I I to 36 years. Shortening had been due to poIiomyeIitis, arrested growth secondary to osteomyelitis of femur and tubercuIosis of the knee. When the required increase in Iength has been obtained severa turns of pIaster bandage are appIied over the turnbuckles to prevent meddling. The patient is observed severa days and then discharged to go to his own or a convaIescent home, with instructions to keep the Iimb eIevated unti1 the time for readmission to the hospita1 in two months for remova of the apparatus.

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Under gas oxygen anesthesia the pIaster is cut anteriorIy and posteriorIy. One haIf is removed carefuIIy. The protruding pins are scraped free of a11 pIaster, carboIized with 95 per cent and washed with aIcoho1 to remove the phenol. The remainder of the pIaster with the pins is then removed. A snugIy fitting circuIar plaster is appIied, incIuding the knee joint and mouIded about the tibia1 condyles. If x-rays confirm union the patient is permitted to bear weight. PIaster is discontinued onIy when x-rays show good bone structure at the site of Iengthening.

Lengthening SUMMARY

LegIengthening operation is more physi0Iogic than Ieg shortening in same type of case. The new pIastic osteotomy described has shortened the convaIescence period by severa months. Increase in Iength of not more than $s2 inch twice a day with the Ieg Iengthening apparatus described has not resuIted in any morbidity or mortaIity. The average tota increase has been 29i inches in patients varying in age from I I to 36 years.

PRIMARY shock is essentiaIly neurogenic and is due to an overstimuIation of nervous paths by either psychica or traumatic (mechanica1, thermal, chemica1) influences.