Bulletin of Orthopaedics, Traumatology and Prosthetics, 2009, No. 3; P.44-47
MULTI-PAIR ELONGATION OF THE LOWER EXTREMITIES WITH THE INTRAOSTEAL DRIVE DEVICES
The technology of implantation intraosteal driven devices for femur and tibia allows to make a substantial correction parameters of undersized people’s body with social and adaptive problems with unacceptable look . Long-term stable fixation of bone fragments at the distraction site (regeneration), as well as intact muscles and tendons in the process of extension are ensured during multi-pair elongation. So, there are conditions for the simultaneous extension of the four segments of the lower extremities. Clinical examples of the developed technology multi-pair elongation of the lower extremities are provided in the article.
Absence of complete physical, mental and social well-being, that is often observed at people with the look shortcomings, this may be considered to be “not healthy”.
Obtained possibility of the intraosseous lengthening of long bones made problem of the pair lengthening of segments of extremities be actual, this lengthening is mainly accomplished to improve social adaptation of short people.
In such cases, criteria of general lengthening size becomes the most important one. Nowadays, big lengthening size (over 12 cm) with saving body proportions is possible with the multi-paired lengthening only. It is when optimum size of distraction on each pair of extremities’ segments is achieved without a great stress for patients.
The term "multi-paired lengthening" is worthy of detailed mentioning. The term "poly-segmental lengthening" used in scientific literature doesn’t reflect correctly point of the distraction process when only pair segments (tibia-tibia or femur-femur) are used for clinical result. The term “poly-segmental lengthening” is pertinent for, i.e. limb lengthening with external constructions when doctor has to distract simultaneously opposite unpaired segments (cross method “tibia – femur”) with further alternation of segments.
The lengthening programs oriented to the maximum result while simultaneous or consistent distraction is done for certain segment pairs – this process is to be called a “multi-paired lengthening”. Word “multi” means plural, i.e. plurality with homogeneity. Word “poly” is less suitable as it includes plurality with no homogeneity (e.g.: word “poly-vaccine”, i.e. vaccine against various agents).
A vivid example of the multi-paired lengthening is a clinical case (more detailed described below) when the lengthening program included two stages of paired distraction: femur-femur, tibia-tibia. Theoretically, the maximum clinical result with multi-paired lengthening is limited mainly with adaptive capabilities of patient’s body. At this point we may give more detailed description of comparative advantages allowing multi-paired lengthening with intraosseous drive apparatuses as facilities to achieve maximum result of distraction.
First of all, paired lengthening means maintenance of symmetry (reflectivity) of the distraction process, that excludes disbalance of distraction load. That’s why it is so important to avoid warps and dissymmetry of vectors of distraction loads. Firstly, one of the most important criteria of fast rehabilitation after lengthening is recovery time of the walk stereotype. Function of walk on the top of big lengthening programs get upset. The segmental and intersegmental musculo-ligamentous apparatus (near joint area) that is stretched due to distraction, therefore it resists adequate muscle traction because of patient’s attempt to do routine walk movements. Although the symmetric rigidity of the stretched musculo-ligamentous apparatus is still much more advantageous conditions for fast adaptation and return to the full-weight functions, than as it was in the above mentioned case of non-paired lengthening with external constructions when various muscle groups on all sides get stretched. It is much more difficult for the body to adjust to such situation, because the walk stereotype and routine movements are worse because of the distraction loads disbalance.
Sure, "ideal" multi-paired lengthening seams to be the simultaneous distraction of two pairs program (femur-femur, tibia-tibia). In this case, we may see a slightly noticeable advantage: reduction of the whole time for lengthening and rehabilitation. Although, we can’t talk about a mono-semantic benefit of choosing that way. Experience of done multi-paired lengthening programs allows to claim, that it is currently relevant to choose the “step-by-step” lengthening program (i.e. pair after pair). Prima facie, “loss” of time spent for lengthening is noticed. I.e. the lengthening periods per each pair of segments are not laid on each other, that increases total duration of lengthening. But, if recall the main goal of the multi-paired lengthening meaning obtaining the maximum result of distraction, than we may state, that the simultaneous lengthening of both segments’ pairs loses against of the “pair-after-pair” program by the “stress for the body” criteria. Of course, that does not mean the simultaneous lengthening of both segments’ pairs is a “result at all hazards”. Possibility of such option is based on the level of patient’s preparedness to stress caused by the simultaneous lengthening of four segments. But still the “pair-after-pair” program has more chance to get a “record” result of lengthening with a pretty “gentle” rehabilitation. After the devices of the first pair of the already lengthened segments are disconnected, the intraosseous constructions fulfill a function of the loads fixing stabilizer for bones that are being fused. At this point, favourable conditions for recuperation of the musculo-ligamentous apparatus are worthy of mentioning: intactness of soft tissues with constructive elements of the distraction apparatus and also equability and reflectivity of distraction loads on the pair segments. In case of the “pair-after-pair” program the time economizing is achieved by means of laying period of the second pair lengthening on period of recovery of already lengthened first pair. It is important to note, that lengthening of the second pair of segments is a pronounced stimulating factor for recovery of the already lengthened first pair. Regeneration of bone tissue of the first pair will be increased because of implanting the apparatuses in the second pair segments and because of the distraction process. We may also talk about mutual stimulation of the regeneration and adaptation processes for segments of first and second pair that are in different phases of rehabilitation. Also, the fact is worthy of mentioning, that the multi-paired lengthening “pair-after-pair” is more favourable for joints. Especially remarkable is the knee joints case, when loads on the joint apparatus are mostly determined with a united resistance as separate intersegmental muscles groups as well loads that occur in adjoining segments as a respond to distraction. The joint stays in a peculiar “lock”. Therefore, the time distribution of the top loads on the joint – is a very important element of correct rehabilitation. In the “pair-after-pair” program, the top loads on the joint are distributed in a time. While the distraction loads are increased when lengthening of the second pair of segments, load on the joint caused by the already lengthened first pair, reduces more day after day as a result of adaptation. In other words, curve of the joint loads has no dramatic rises and is characterized with smooth gradients. It is also important to note, that the lengthening method with intraosseous drive apparatuses allows patient and the rehabilitation doctor to start active rehabilitation activities sooner, that helps joints to have an easier overcoming through stress of the distraction loads.
Multi-paired lengthening of lower extremities (two femurs + two tibias) were done for the four patients in our clinic. The lengthening size was at average 12.5 cm. One patient undergone lengthening within three phases of pair distraction: femur-femur (7.5ñm) + tibia-tibia 1 (5.0 ñm) + tibia-tibia 2 (4.0 ñm). Lengthening size was – 16.5 ñm.
Patient Ê., 32 years old applied to the clinic complaining about own height, that caused him a emotional trauma. (174 cm). It is one of cases of “being not healthy”, i.e. social-adaptive problem when patient had personal intersex problems in spite of his height that is not considered to be short. On first phase there were done alternating (with a 14 days brake) surgeries on implantation of the intraosseous drive apparatuses inside of both femurs. The distraction was started on the seventh day after the implantation. Rate of distraction on average – 1,0±0,25 mm per 24 hours. The lengthening size - 7,5 cm ( Pic. 1). Duration of lengthening – 88 days.
X-rays of both femurs. Condition after implanting the gear distraction apparatuses
inside of both femurs (one year later after implanting). The lengthening size – 7.5 cm.
In two months after completion the lengthening program of both femurs and the recovery treatment, the second phase was done – alternate implantation of the drive distraction apparatuses inside of both tibias. The distraction was started on the 7th day after implanting. Rate of distraction on average – 0.75 – 1.0 mm per 24 hours. Size of lengthening is 5.0 cm (Picture 2). Duration of lengthening was 65 days.
Size of the multi-paired lengthening of lower extremities was 12.5 cm.
X-ray of both tibias. Condition after implanting the drive distraction apparatuses
inside of the both tibia bones (one year later after implanting). The lengthening size – 5.0 cm.
Height after lengthening is 186.5 cm (Picture 3). Function in contiguous joints of lower extremities is completely recovered (Picture 4 à, b). After the program the patient solved all of his personal intersex problems (got married).
Patient Ê., 32 years old. Condition after multi-paired lengthening of lower
extremities for 12.5 cm within one month after completion of the lengthening
program. The patient’s height became 186.5 ñm.
Patient Ê., 32 years old. Condition after multi-paired lengthening of lower extremities for 12.5 cm within six month after completion of the lengthening program. Functional results of the right lower extremity (à) and the left lower extremity (b).
Currently, the multi-paired lengthening of lower extremities with intra-osseous drive apparatuses is one of the most efficient ways to gain over 12 cm length, with provided comparatively comfortable distraction and rehabilitation and also with possibility of saving harmonious proportions.
Search of optimum ways of combination the lengthening and recovery periods within the multi-paired lengthening program will allow providing even better results of distraction and rehabilitation under the conditions of limited personal patient’s time.
One of the priorities of development the multi-paired lengthening of the lower extremities with the intra-osseous drive apparatuses is the increased patient’s activity during distraction and recovery together with the reduced necessary period of patient’s contact with his/her doctor (self-sustained lengthening and recovery), that significantly improves quality of patient’s life.