Leg extension

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Classification according to ICD-10
M21. Other acquired deformities of the extremities and other congenital malformations of the extremity (s)
  • M21.7 - Different limb lengths ( acquired )
  • Q74.9 - Unspecified congenital malformation of extremities
ICD-10 online (WHO version 2019)

The leg lengthening ( English Leg lengthening , German synonyms: lengthening osteotomy ; callus distraction ; segment distraction ; shortening compensation; leg length compensation ) is a treatment method in orthopedics and trauma surgery.

definition

Leg lengthening is a procedure used in orthopedics and trauma surgery . It is understood as the operative lengthening of a leg in order to compensate for a leg length difference. Both legs can also be lengthened for cosmetic reasons.

history

The history of leg lengthening goes back to the 19th century. Hopkins and Penrose extended a bone intraoperatively in 1889 by inserting a bone block. In 1905, Alessandro Codivilla introduced surgical techniques to lengthen the lower extremities. These early surgical techniques had a high rate of complications , especially during the bone healing phase . Often the goal of bone lengthening was not achieved. The starting point for the modern extension treatment, however, came from A. Codivilla from Bologna. Using a heel-nail pull cast, a method that is discontinuous according to today's understanding, a sudden single pull was applied to a femoral osteotomy and the leg was then fixed in a pelvic cast. The nail was modeled into the plaster of paris.

Today's method of bone lengthening goes back to Gavriil Abramowitsch Ilisarov . Since the 1950s, Ilisarow used a ring fixator of the Ilisarow ring fixator in the Soviet Union . He carried out extensive basic research to optimize this procedure and made the procedure so safe that it could be incorporated into clinical routine. At the same time, experiments were carried out with intramedullary fixators and intramedullary nails as early as 1893. The first fully implantable closed systems were developed by Rainer Baumgart and Augustin Betz in Munich in the early 1990s .

indication

A medical indication for leg lengthening exists in the case of leg shortening as a consequence of an accident, in the case of congenital malformations or short stature . In the case of short stature within the normal range, the statutory health insurance companies regularly refuse to assume the costs and, if there is a mental disorder, refer to possible psychotherapy. In most cases, the only option left is to pay the treatment costs yourself, as it is a purely cosmetic leg extension.

Surgical methods for leg lengthening

Renewal Procedure

Leg lengthening is a procedure for the artificial lengthening of skeletal bones, mostly long tubular bones. On the one hand, the treatment is suitable for correcting pathological malpositions (e.g. functionally significant difference in leg length); on the other hand, it is also used as a pure cosmetic operation without a medical indication being recognized. The surgeon cuts the bone to be lengthened and pulls the two halves apart slowly and continuously along the desired growth axis over several weeks using conventional external fixation or fully implantable medullary lengthening nails. Fresh bone substance ( callus ) is constantly forming between the two halves of the bone .

External fixator

The external fixator treatment (first described in 1855) was developed during the Soviet era by the Russian orthopedic surgeon Gavril Ilisarow in Kurgan in order to eliminate birth defects and help war casualties. It is still used on many patients today. Here, the thigh or lower leg bone is severed, then a metal construction, the ring fixator, is mounted around the leg. Six rods are attached to this construction, which protrude into the bone and are fixed there with drill wires and screws. Lengthening can begin one week after the bone has been cut. Lengthening works by the patient adjusting the bars himself. The bone is stretched apart, and bone mass grows back in the gap. One millimeter in length can be gained per day, for five centimeters you need 150 to 200 days, including the time it takes for the bone to solidify. After the leg has been successfully extended, the external fixator is surgically removed.

Taylor Spatial Frame

A further development of the external fixator is the hexapod marketed as "Taylor Spatial Frame", which, like the external fixator, is screwed onto the rods implanted in the bone above and below the bone separation (corticotomy). In addition to the axis extension, it can also correct considerable accompanying axis deviations and rotational errors with the aid of a computer. Its use is increasing, especially in pediatric orthopedics , as the daily adjustment is no longer done manually, but with a computer. However, it is also used for postoperative malpositions and in acute use with complex fractures. The Hexapod is reusable, only the implanted rods need to be replaced.

Fully implantable intramedullary lengthening nails

Fully implantable extension nails are sold under the brand names Albizzia, Fitbone II and ISKD . The Fitbone is extended by a built-in motor, the other two models mechanically by a ratchet mechanism. All systems are fully implantable “intramedullary” or intramedullary nails, with which the patients themselves can carry out the daily incremental lengthening. All systems are removed again after the extension and the bone healing. There are no comparative studies.

  • ISKD (Intramedullary Skeletal Kinetic Distractor, used since 2002): Lengthening takes place by rotating the leg. Inside there is a threaded rod that is connected to the proximal and distal parts via a ratchet mechanism . The ratchets allow the two parts to rotate by three to nine degrees against each other. After a 160 degree rotary movement of three degrees, a distraction of approx. 1 millimeter has occurred.
    X-ray of a Fitbone implant in the right femur after a distal transverse osteotomy
  • Fitbone from the German company Wittenstein intens (market launch 1997) was developed in collaboration with Rainer Baumgart. The distraction is achieved via an integrated motor and a multi-stage gear, which drives a threaded rod. The required energy is supplied by induction via a receiver implanted under the skin; the patient must operate a control set.
  • Albizzia This method of leg lengthening, which required a rotation of 20–30 ° of the leg, was replaced by the Guichet Nail.
  • Guichet Nail was developed by the French Jean-Marc Guichet and can be described as a further development of the Albizzia. The way it works is similar to that of the ISKD nail. The intramedullary nail is extended by 10 ° when the leg is turned. Fifteen rotations per day are necessary to achieve an extension of 1 mm. The Guichet nail is mainly used in France.

Advantages and disadvantages of the extension methods

As with most surgical interventions, leg lengthening carries the risk of risks and side effects. In any case, it is an operation under anesthesia .

The external fixator is the most frequently used method in the world for the surgical treatment of leg length differences. The reason for this is the low price and the possibility of using this method even with small children. The advantages of the fully implantable intramedullary distraction nails, on the other hand, are greater comfort and fewer restrictions in everyday life. The leg can also be loaded earlier than with the ring fixator. The risk of inflammation and infection is relatively low as there are no open sores.

In the past, three models of the ISKD nail have broken the nail and there have been product recalls. Electromechanical extension nails, such as B. the Fitbone, are more expensive than mechanical systems due to their more complex design. While the ring fixator basically allows unlimited extensions, these are possible up to 10 cm with the Albizza and up to 8 cm with the Fitbone. The twisting movements of the Guichet Nails caused such severe pain in some patients that further prolongation was only possible with strong painkillers or under anesthesia. However, full weight bearing on the leg is possible shortly after the operation.

The possibility of correcting the axis deviations and rotational errors that are also often present is not available with the intramedullary nail, but in principle with the external fixator and, thanks to the computer-aided procedure, significantly better with the Taylor Spatial Frame .

Comparative and independent studies on comfort, patient satisfaction, outcomes and complication rates do not exist. In comparison to the worldwide use of the external fixator that has proven itself over many years, the intramedullary nails are only used in individual clinics. Due to the material requirements, they are considerably more expensive than the reusable ring fixator.

Cost of a cosmetic leg extension

The cost of a cosmetic leg extension is usually not covered by health insurance. The amount of the costs depends on whether only a thigh or lower leg extension is carried out on both sides or a thigh and lower leg extension on both sides. The cost of using intramedullary extension nails is between 45,000 and 80,000 EUR for the entire treatment.

This generally covers these services:

  • Hospital stay of four to seven days for extension surgery and two to three days for nail removal
  • Surgical costs for nail insertion and removal
  • Cost of surgery and anesthesia
  • Costs for medical treatment in the hospital (possibly radiologist, internist)
  • Physiotherapy during the hospital stay
  • Complete follow-up treatment with x-ray controls in the practice

The following costs are not included:

  • physiotherapy
  • Travel expenses to the clinic and to the follow-up controls in the practice
  • Costs for crutches, aids, if necessary

literature

  • Fritz Hefti: Pediatric Orthopedics in Practice. Springer, Heidelberg 2015, ISBN 978-3-642-44994-9 .
  • Felix Frankenberg: Comparison of two intramedullary lengthening nails in a matched pair study. Dissertation at the medical faculty of the Ludwig Maximilians University in Munich, 2015. Online (PDF file)

Web links

  • Rolf Haaker, Michael Kamp, Engelhardt (Eds.): Leg extension. Lexicon orthopedics. Extract (PDF file) from October 12, 2010. SpringerMedizin
  • Vera Schroeder: Size madness. (Editor. Article on motivations and experiences as a cosmetic treatment) Neon-Magazin Online, Stern Medien, accessed on January 19, 2017

Individual evidence

  1. ↑ Quoted after PB Magnuson: Lengthening shortened bones of the leg by operation. Ivory screws with removable heads as a means of holding the two bone fragments . In: Surgery, Gynecology & Obstetrics . No. 17 , 1913, pp. 63-71 (English).
  2. ↑ Alessandro Codivilla: On the means of lengthening in the lower limbs, the muscles, and tissues which are shortened through deformity . In: American Journal of Orthopedics Surgery . Vol. 2, 1905, pp. 353 (English).
  3. ^ V. Mosca, CF Moseley: Complications of Wagner leg lengthening and their avoidance . In: orthop. trans. Vol. 10, 1986, pp. 462 (English).
  4. ↑ Veronika Toren: On the development of invasive treatment methods for the leg length difference. Dissertation at the Medical Faculty of the Ludwig Maximilians University in Munich. 2002, p. 32
  5. ↑ Stefanie Pip: Intramedullary lengthening with the ISKD nail. Dissertation to obtain the doctor medicinae of the medical faculty of the Westphalian Wilhelms-Universität Münster, 2014. pp. 11–13
  6. ↑ cf. Sample judgment Az .: 1 RK 14/92 (BSG) from February 10, 1993 on the case of a woman with a height of 164 cm ( reproduction online on the website of the University of Marburg, accessed on January 19, 2016)
  7. ↑ Health insurance: no cost coverage for leg extension. Interest grouping of insured persons, savers and investors (geldundverbrauch.de), June 24, 2016
  8. ↑ Leg extension in the operating room. (Online article from issue 11/2008) Verlagshaus der Ärzte - Society for Media Production and Communication Consulting
  9. ↑ Milind Chaudhary (2016): Taylor Spatial Frame . Chapter 147 in: GS Kulkarni: Textbook of orthopedics and trauma (3rd ed.). Volume 2, pages 1193-1198. Jaypee Brothers Publishers. ISBN 978-9385891052 .
  10. ↑ a b Leg extensions with fully implantable extension nail. Hannover Medical School, accessed on January 19, 2016
  11. ^ J. Pfeil, W. Siebert, A. Janousek, C. Josten: Minimally invasive procedures in orthopedics and traumatology. Springer-Verlag, Heidelberg 2000. ISBN 3-540-66168-9
  12. ↑ Other systems on the Jean-Marc Guichet homepage (English)
  13. ↑ Guichet Lengthening Nai (leg-limb-stature-lengthening-taller-height-increase-cosmetic.eu)
  14. ^ Theresa Maria Reuther: Comparison of the stability of Schanz screws in the bone in the external fixator network. Dissertation for obtaining the academic degree Doctor medicinae submitted to the Medical Faculty of the Charité. 2005. pp. 17-18
  15. ↑ Recall to Orthofix clinics (FSCA 3008524126-1-15-15-001), January 15, 2015
  16. ↑ A. Betz, P.-M. Hax, R. Hierner, H.-R. Kortmann: Corrections in length of the lower extremity with fully implantable intramedullary distraction nails - system comparison based on case studies. In: Trauma und Berufskrankheit, issue 1/2008 (short text online at SpringerMedizin), accessed on January 19, 2016
  17. ↑ Fitbone Product Information. Wittenstein intens, accessed on January 19, 2016
  18. ^ Sanjeev Sabharwal: Pediatric Lower Limb Deformities: Principles and Techniques of Management. Springer; 2015. ISBN 978-3-319-17096-1
  19. ↑ Extension methods in comparison ( Memento from March 8, 2018 in the Internet Archive )
  20. ↑ Leg extension Munich Pullach - specialists with experience . In: BFZB - leg lengthening, axis correction and more in the Bavarian Leg and Foot Center in Munich Pullach . ( beinverlaengerungszentrum.de [accessed on October 5, 2017]).