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Genij Ortopedii 1, 2001

Elongation of the femur using the Albizzia® intramedullary rod
D.A.Popkov, J.-M.Guichet, P.Lascombes


The result of treatment of 22 patients, subjected to femoral elongation by the Albizzia® intramedullary rod (in 8 cases bilaterally), are analysed in the work. The obtained lengthening is 5,5 cm (13,3%) on the average. The result of treatment (by S.O.F.C.O.T., 1990) are following: I class – 7 (31,8%), IIb class – 8 (36,4%), III class – 0 (0%). An x-ray picture is described for such a technique of elongation. Positive aspects of elongation with the Albizzia intramedullary rod are emphasized.

Currently, the problem of rehabilitating patients with shortening of limbs provokes a great interest of orthopedists since the occurrence of this pathology is rather frequent [3, 13}. So, the number of new-born babies with abnormal skeletogeny amounts to 1.33-2.47%, among those developmental disorder of lower limbs being at 57.9-61.1% {2,4}. The Western European countries encounter this pathology frequent as well. For instance, 54 228 sick persons in France needed orthopedic alignment of lower limbs in 1987, at that operative therapy is given to 400 persons annually on the average {13}.

Using Ilizarov’s method and frame, Orthofix system on a broad scale and Vagner’s apparatus to a lesser extent, some authors admit that therapeutic indications to using external fixation appliances are restricted with relatively frequent infectious complications or lack of patient’s comfort. In view of these conditions, elastic intramedullary nail (Albizzia) was developed in France following Bliskunov’s system {1}. That nail allows elongation of thigh by growing distraction regenerate due to preserving periosteal coverage {10}.

Experimental and mechanical tests {11} proved possible clinical use of this system. As of today, results of treatment using Albizzia nail have been published, with one of works giving an account of 52 cases with application of this method {12} that arouse interest of orthopedists in the USA and Western European countries. This article analyzes the nail application experience in children’s orthopedic department in Nancy, France for the period of 1992- 2000, with most operations being performed by J.- M.Guichet.


MATERIAL AND METHODS

Albizzia nail consists of two telescopic pipes - external and internal sliding pipes connected with a special unit allowing elongation by way of rotating to one direction. Turn in the reverse order restores the system in neutral position without losing elongation value due to the unit that prevents reverse longitudinal displacement of the sliding pipe. Rotational angle of the nail’s internal part is 200 and 15 backward motions correspond to 1 mm elongation. The nail is equipped with a system providing partial transfer of compressive efforts to distraction regenerate at limb’s axial load. There is also a system suppression elongation when a preset target is achieved. A device restricts rotational motions another one suppresses them at the end of elongation.

Rotational displacement of fractured fragments relative to each other preventing reparative regeneration loses its negative effect so far as dehiscence of fractured fragments takes place. Experimental data indicate much lower displacement of these fragments during the unit’s rotation as compared to diastase value (1-2% at 5 cm elongation) {11}.

We have analyzed results of treating 22 patients, 15 women and 7 men, among those 8 cases were elongation of both thighs. As of the day of operation, average age of patients was 18.3 (13.3 – 38.3) years old. The shortening of limbs was the outcome of different diseases and damages (Table 1).

Table 1

Characteristics of patients per etiology of limb shortening – group of monolateral elongation

Etiology
Quantity of patients
Inborn shortening
6
Posttraumatic shortening
3
Outcomes of inborn dislocation of thigh joint
2
Turner syndrome
1
Oilier disease
1
Achondroplasia
1
Total
14

Sick persons undergone bilateral elongation of thighs were short by body-type (6 cases), had Turner syndrome (1 case), Recklinghausen disease (1 case). It should be noted, though, that initial height of these patients was 145.8± 7.6 cm.

As for cases of monolateral elongation, limb shortening averaged 4.01 cm (ranging from 2 to 10 cm). 10 patients also had the following and accompanying disorders:

  • Coxa vara – 3 cases (1100, 1150, and 1160);
  • Internal torsion of thigh - 1 (200);
  • Talipes varus of thigh, middle third (110) in combination with Genu valgum (1610) – 1;
  • Genu valgum – 1 (1660);
  • Genu varum – 1 (1650, 1660);
  • valgus of shank – 1 (100);
  • external torsion of shank – 1 (500).

7 cases were accompanied with contracture of adjacent movable joints:

  • Extensive contracture of thigh joint - 2 (lack of bending 200,350);
  • flexion contracture of thigh joint - 2 (lack of bending 150,250);
  • lack of rotational movements inwardly – 1 (150);
  • Extensive contracture of knee-joint - 1 (lack of bending 200).

No instability of knee-joints and thigh joints was registered for either case. 10 persons undergone operation of shortened limb:

  • elongation with Ilizarov’s frame – 2;
  • elongation with Orthofix frame – 1;
  • pelvic osteotomy per Solter’s method – 1;
  • pelvic osteotomy per Hiary’s method – 2;
  • pull-through of greater trochanter – 3;
  • artificial ankylosis – 1.

The planned value of two-side elongation averaged 7 cm (ranging from 6 to 8 cm), monolateral elongation averaged - 4.3 cm (ranging from 2 to 6 cm).

The essence of operation is as follows. Drilling of marrowy canal is carried out 1 mm wider than the nail diameter. Osteotomy is commonly made using center-medullar satterlee on the border of upper and middle thirds of femur shaft. If required, osteoclasia is performed additionally. When the nail is placed intramedullary, it is supposed to be fixed with one male screw proximally and with two male screws distally. After that, one-moment elongation to several millimeters is made. The value of operative approach shall not exceed 5-6 cm for nail insertion and 2-3 cm for male screws’ location.

Average distance from greater trochanter to osteotomy level was 15.6±1.8 cm. Osteoclasia accompanied osteotomy in 20 cases out of 30. Discission of bone was completed using scoop. The integrity of periosteal coverage was considered intact in 20 cases. Diastasis between fragments achieved at operating table averaged 6.1±2.3 mm. V-like partial discussion of thigh’s fascia lata was made in three cases. Two patients underwent orthopedic alignment of knee-joints at the expense of additional orthopedic alignment. One patient underwent elimination of internal torsion of thigh, another - orthopedic alignment of neck of femur.

Elongation was commenced on the fifth day after operation (sometimes on the sixth or seventh day due to pain syndrome).Rotational movements were made by exercise physiologist, doctor or a patient himself. If required, antalgesics were prescribed (non-steroid anti-inflammation medicines) as well as tranquillizers to patients. The elongation rate, as a rule, was 5 maneuvers three times a day. In some case the tempo was speeded up (commonly, by the end of the 2-nd or 3-rd week of distraction) which is explained with considerable growth of distraction efforts and hazard to lockout the nail’s mechanism.

The period of distraction lasted 59 days on the average with its maximum of 83 days. When walking the patient could use crunches with full support of the limb since the 1-st day of fixation. In the course of elongation, flexion contracture of knee-joints and thigh joints frequently occurred. So, by the 30-tieth day of distraction flexion contracture of thigh joints had been registered for 8 patients (lack of bending from 50 to 350) and knee joints (lack of bending from 50 to 400) had been registered for 8 patients as well. By the end of the second month of distraction, 9 out of 15 patients going on with elongation had flexion contracture of thigh joint (100 -450) and five patients – knee joint (100 -250). This type of contractures is characteristic for bilateral elongation of thigh.

In the course of treatment therapeutic physical training was conducted in the Rehabilitation center. Classes began in a few hours after operation, during these classes passive bending and unbending of a knee joint (mechanotherapy). It is important that stay at orthopedic dept. approximately lasted for two weeks after operation.

As of the moment of analyzing results, 15 completed their treatment course (22 nails had been removed). The rest (7 patients) would complete their treatment in the nearest future. Actual rate of elongation amounted to 1.04 mm/ day. The achieved elongation averaged 5.5 cm (13.3% from the segment’s initial length). The duration of osteosynthesis which is not of vital importance for intraosseous elongation - among patients having their nails removed - was 459 days (from 261 to 895 days). Thus, osteosynthesis factor amounted to 98 days/cm (from 47 to 220 days/cm).In cases of bilateral elongation average growth was 153.2±6.9 cm. Renovation of initial movement amplitude in knee and thigh joints was registered 8-9 months after the operation.

Particularly interesting is reparative regeneration of bones under these conditions of osteosynthesis. X-ray photographs of 17 patients had been analyzed. The key roentgenographic evidences, their occurrence with regard to treatment terms are reflected in Table 2.

Table 2

Frequency of occurrence of main roentgenographic evidences in the course of elongation

Roentgenographic evidences
Period of treatment
5-10 day distraction
25-35 day distraction
40-45 day distraction
55-60 day distraction
1-2 months fixation
No regeneration signs
13
1
1
0
0
Nebulous shadows of low density in diastases
6
10
2
1
1
Periosteal reaction of fractured fragments
9
15
14
8
2
Periosteal reaction at diastases level
2
5
10
6
2
Alteration of low and middle density sections, regenerate is structureless
1
7
8
3
0
Full homogeneous regenerate without clear structure filling diastases to full extent
0
2
3
4
3
Dense homogeneous regenerate, striated longitudinally
0
2
2
1
1
Edge defect
0
4
4
4
2

Specific feature of distraction regenerate is the absence of “growth zone”. The main component is periosteal reaction observed at diastases level and on adjacent fractured fragments. Intermediary component is homogeneous regenerate of low or medium optical density without definite structure. It should be added that edge defects of regenerate were taken into account when neither periosteal nor intermediary components were available during distraction. Defects were always reported when violation of periosteal coverage integrity was suspected during operation (penetration of centermedullar file beyond cortical plate or use of scoop). Full consolidation took place in 2-6 months of fixation depending upon elongation value, X-ray photographs showed.

Changes in biochemical axis occurred with a tendency to valgization, axis displacement relatively to knee joint was inwardly with no considerable deformations for the whole group in general. (Table 3). However, it should be noted that 16 patients had misalignment of biochemical axis that may be considered unfavourable: negative – if axis misaligns inwardly from the center of knee joint or positive – is axis misaligns outwardly over 10 mm from the center of knee joint. After complete elongation 15 patients had unfavourable misalignment of biochemical axis (11 patients had inward misalignment and 4 – outward misalignment).

Table 3

Changes of biomechanical axis of lower limb occurring due to thigh elongation with Albizzia nail

Index
Before operation
After elongation
Genu Valgum
- 1.5 ±3.08 0
- 0.5 ±3.4 0
Misalignment of biochemical axis
from the center of knee joint; mm
- 5.3 ±10.1 0
- 1.7 ± 12.0 0


Complications

All complications observed can fall into mechanical / arthral/ infectious complications, skeletal-related and neuron-vascular events.

Mechanical complications. Albizzia nails not providing elongation after a while of distraction were replaced in the course of treatment in four cases. A proximal male screw did not fix the nail due to patient’s osteoporosis, therefore, elongation procedure was postponed for 14 months. Another case – rather long distal male screw came into contacts with sinews of semi-membranous muscle and semitendinous muscle inducing pain in knee joint during movement. Fracture of the nail itself occurred once.

Skeletal-related events. Reportedly, overcorrection of co-existing talipes varus of thigh occurring during operation on the nail insertion took place (1 case); suppression of consolidation (1 case); fracture on regenerate’s level on the 4-th day after nail removal (1 case); neoarthrosis (1 case).

Arthral complications: incomplete dislocation of hip joint (1); flexion contracture of knee and thigh joints in case of bilateral elongation of thighs regressing up to 100 for the period of over one year (1).

Infectious complications revealed as surface infection of a proximal seam – one case; suspected osteomyelitis not proved bacteriologic ally required intravenous antibiotic therapy – one case;

Part of complications occurred required taking unscheduled operative measures:

  • replacement of nail to proceed with elongation (4 cases);
  • nail removal (2);
  • repeated real-time correction of accompanying deformation (1);
  • intrameddular osteosynthesis of thigh fracture at regenerate’s level (1);
  • administration of bone marrow liquor with hydroxuapatite into edge defect area (1);
  • autoplastic of thigh nearthrosis area, intramedullar osteosynthesis (1).

Special attention should be paid to one-moment growth of diastases under general anesthesia (13 patients – total 30 cases). In these cases elongation value varied from 4 to 10 mm. However, one patient had undergone 13 procedures under general anesthesia, since he could not sustain pain syndrome accompanying rotational movements. The result of treatment was formation of a false joint and fracture of the nail. After replacing the nail and drilling of canal, concrescence took place with no losses of elongation. On the average, the ration was one patient/ 1.36 unplanned cases of general anaesthesia not accompanied with operative measures.

In line with SO.F.C.O.T. classification (1990) treatment outcomes were divided by categories in the following manner:

Category I – 7 patients (31.8%), 5 among those had no complications at all.
Category IIa (one or several elongations under general anaesthesia without operative measures) – 7 patients (31.8%).
Category IIb (unplanned operative measures) – 8 patients (36.4%).
Category III - no patients.


DISCUSSION AND CONCLUSIONS

Following Bliskunov's system {1}, Albizzia nail proved its possible clinical use. In case of its application distraction regenerate is obtained due to preservation of periosteal coverage. Known are the works proving significant role of periosteal coverage in reparative regeneration of bones {14,15}. The nail inventor indicates that consolidation process will take place anyway for young patients in case periosteal coverage is preserved during operation {10}. One may suppose that the reason entailing minor one-moment elongations under general anesthesia (13 patients) was bone reparative regeneration by the end of the 2-nd and the 3-rd week of distraction when the nail mechanism was unable to overcome the developed distraction efforts at an ordinary pace. None the less, patients older 20 years shall be informed of likely bone autotransportation of defect {10}.

From the other hand, works of Russian scientists proved required preservation of two osteogeny sources for the purpose of speeded formation and maturation {6,7}.

Intramedullar elongation system was established due to dissatisfaction of surgeons with available methods of treating shortened limbs: thigh elongation with external fixation mechanisms may entail infectious complications, lack of comfort for patient as stated in works of J.C. Pouliquen et al., 1989 [8] and J.P. Damsin et al. [9]. Besides that, limb elongation by Ilizarov’s method requires high level of experts’ training {5,7}.

Undoubted advantages of intramedullar elongation method using Albizzia nail thanks to which it competes with other modern methods of treatment are as follows:

  1. good result in terms of appearance (minor surface scars);
  2. tendon-muscular system remain intact during treatment and speeded restoration of initial function of limb joints;
  3. possible elongation by 7-8 cm without any danger of deformation at regenerate level;
  4. retention of patients? comfort;
  5. stability of osteosynthesis;
  6. possible one-moment correction of accompanying deformations at the same time with nail insertion.

Thus, this method is quite reliable and trustworthy in case indications are determined correctly.


LITERATURE:
  1. A.I. Bliskunov Intramedullar distraction of thighbones // Orthopedic traumatology, - 1983 - # 4 – pages 59-63.
  2. M.V. Volkov Bone disorders of children - Moscow, Medicine, 1985 – 511 pages
  3. S.M. Zhuravlev, P.Ye. Novikov Modern problems of traumatism, orthopedic disorder occurrence and their unfavorable consequence. //Annals of traumatology and orthopaedy – 1996 - # 2 – Pages 5-11.
  4. Ye.V. Lunina Etiology of inborn anomalies of human skeleton// Inborm deformations of supporting-motor apparatus – Collection of scientific works – Tashkent, 1981 – pages 40-45.
  5. A.V. Popkov, D.A Popkov Sone issues of biomechanics related to thigh elongation by operations // Genius of orthopaedy - 1997 - #1, pages 24-26.
  6. Theoretical and practical aspects of limb elongation by way of perosseous ostheosynthesis // G.A. Ilizarov, V.I. Shevtsov, V.I. Kalyakina etc.// Plenum of research council on traumatology and orthopaedy, Academy of Medical Sciences of the USSR – Perm, 1982
  7. V.I. Shevtsov. G.I. Ilizarov’s contribution to development of traumatology and orthopaedy // Genius of orthopaedy – 1996 - # 2-3, pages 15-18.
  8. Allongement du femur chez l’enfant et l”adolescent. Etude comparative d’une serie de 82 cas /J.C.Pouliquen, S.Gorodischer, C.Vernert, L.Richard//Rev.Chir.Orthop.-1989.-Vol.75, N 4.-P.239-251.
  9. Allongement des member inferieurs: methode d’Illizarov/J.P.Damisin, J.C.Panniset, S.Gorodischer// Rev. Chir.Orthop. – 1991 – Vol. 77 N 4. – P.31-81.
  10. Guichet J.-M. intramedullarer Verlangerungsnagel (albizzia). Technik, Anwendung und Ergebnisse nach kontinuierlichen Verlangerungen von Femur und Tibia // In: Strecker W., Keooler P., Kinzl L. (Hrsg). Posttraumatische Beindeformitaten. Analyse und Konrektur. – Berlin, Heiderlberg, New York: Springer, 1997.
  11. Guichet J.-M., Grammont P.M., Trouilloud P. Clou d’allongement progressif. Experimentation animal avec un recul de deux ans Chirurgie. – 1992. – Vol.118, No 6.-7. –P.405-410.
  12. Gradual elongation intramedullary nail for femur (Albizzia) Result of the 52 first cases in 48 patients/ J.-M.Guichet, P.Lascombes, P.M.Grammont, J.Prevot // J.Jpn.Orthop. Assoc.-1995. – Vol.69, No 3. – P.310.
  13. Lower limb-length discrepancy.An epidemiologic study / L.-M.Guichet, J.M.Spivak, P.Trouilloud, P.M.Grammont//Clin.Orthop.-1991. – Vol.272. –P.235-241.
  14. Bone lengthening in rabbits by callus distraction. The role of periosteum and endosteum / H.Kojimoto, N.Yasui, T.Goto et. Al.//Bone Jt. Surg. – 1988. – Vol.70-B, No 4. – P.543-549.
  15. Factors affecting callus distraction in limb lengthening / N.Yasui, H.Kojimoto, K.Sasaki et al.//Clin.Orthop.-1993. Vol. 293 – P.55-60.