Distraction osteogenesis
Encyclopedia
Distraction osteogenesis, also called callus distraction, callotasis and osteodistraction is a surgical
process used to reconstruct skeletal
deformities
and lengthen the long bone
s of the body. A corticotomy
is used to fracture
the bone
into two segments, and the two bone ends of the bone are gradually moved apart during the distraction phase, allowing new bone
to form in the gap. When the desired or possible length is reached, a consolidation phase follows in which the bone is allowed to keep healing. Distraction osteogenesis has the benefit of simultaneously increasing bone length and the volume of surrounding soft tissue
s.
Although distraction technology has been used mainly in the field of orthopedic
s, early results in rats and humans indicated that the process can be applied to correct deformities of the jaw
. These techniques are now utilised extensively by maxillofacial surgeons
for the correction of micrognathia, midface, and fronto-orbital hypoplasia in patients with craniofacial
deformities.
introduced surgical practices for lengthening of the lower limbs. Early techniques had a high number of complications
, particularly during healing
, and often resulted in a failure to achieve the goal of the surgery.
In 1934 the New York Hospital For Joint Disease worked on an early method developed by Ilizarov. The major item that the US team of surgeons developed was the metal frame the leg was placed in to hold it perfectly in place till the cut made in the bone was healed over.
The breakthrough came with a technique introduced by Russia
n orthopedic surgeon Gavril Ilizarov. Ilizarov developed a procedure based on the biology of the bone and on the ability of the surrounding soft-tissues to regenerate under tension; the technique involved an external fixator, the Ilizarov apparatus
, structured as a modular ring. Although the types of complications remained the same (infection
, the most common complication occurring particularly along the pin tracks, pain
, nerve
and soft tissue
irritation) the Ilizarov technique reduced the frequency and severity of the complications. The Ilizarov technique made the surgery safer, and allowed the goal of lengthening the limb to be achieved.
in a 1990 article. Paley distinguished among problems (defined as "a difficulty that arises during the distraction or fixation period that is fully resolved by the end of the treatment period by non operative means"), obstacles, and complications.
Ilizarov surgery
, developed by Gavriel Ilizarov, a Russian
orthopedic surgeon
, in 1951, is the oldest and most common method of distraction osteogenesis. It often brings complications, while some new methods have a much lower rate of complications.
The process involves the following:
Ilizarov surgery is extremely painful, uncomfortable, infection
-prone, and often causes unsightly scar
s . Frames used to be made of stainless steel
rings weighing up to 7 kilogram (kg), but newer models are made of Carbon fiber reinforced plastic, which though lighter, are equally cumbersome.
Derivative devices provide physicians better control over the bone axis and angle during elongation, such as the Taylor Spacial Frame (TSF) which is computer assisted. The downside of these developments are their relative complexity and resulting longer learning curve.
For decades, the Ilizarov procedure was the best chance for shattered bones to be restored, and crooked ones straightened. Breakthroughs in distraction osteogenesis in the 1990s, however, have resulted in less painful (albeit more expensive) alternatives, such as unilateral rails.
In 2009, Dr. Guichet patented the Guichet Nail. The Guichet Nail is an improved version of the Albizzia nail because it uses stronger steel that allows for full weight bearing activity almost immediately after surgery. Furthermore, the Guichet Nail is customizable for size to ensure maximum comfort and efficiency for patients with smaller bones. Although there is initial pain after the surgery and during the clicks, the Guichet Nail is believed to be less painful than other methods as it is less invasive. Furthermore, as the patient controls the method of “clicking,” the patient is able to reduce pain by determining the most suitable method for themselves.
The Guichet Nail is currently used exclusively at the Leg Lengthening Clinic in Marseilles, France. Founded in 2011 by Guichet and Keeper, the clinic specializes in cosmetic leg lengthening surgeries. With worldwide recognition for being the foremost knowledgeable limb reconstruction
surgeon
with respect to internal fixators in the world, Dr. Guichet has successfully completed over 350 limb lengthening procedures.
.
With ISKD, a telescopic rod that can be gradually extended by knee
or ankle
rotations is implanted into the bone. Lengthening is monitored by a hand-held external magnetic
sensor
that tracks the rotation of an internal magnet
on a daily basis.
ISKD requires a physical leg movement to "click" the device into lengthening. In this method, there is no risk of accidentally over-stretching the bone due to the lengthener being preset to the desired fully extended length. However, there is a risk of growing the bone too quickly. Bone growth is monitored by measuring changes in the magnetic field of an embedded magnet in the system. The poles of the magnet change as the device grows. However, if the motion of the leg makes the device grow too quickly, and the magnet switches poles twice between measurements, then that growth is not recorded. This leads to overly rapid growth which can cause a number of issues such as nerve damage or causing breaks in the bone.
While there is some pain associated with the immediate post-op lengthening, the initial lengthening procedure is not to begin until one week after surgery. Furthermore, there is no noticeable "click" to the patient as there is less than nine degrees of rotation of the two bone segments in relation to one another.
Regularly used at a handful of medical centers mostly in the United States, only several dozens of ISKD devices are implanted each year. An improved version is currently being developed by its manufacturer (Orthofix).
-motorised
limb-lengthening implant, called "Fitbone", is a technologically
advanced, though relatively complex, device.
Developed in Germany
by Augustin Betz and Rainer Baumgart, the first successful operations were performed in 1996 and the technique was patent
ed in 1997. Thus far, most of the surgeries using this method have been performed in Munich
, Germany
by Baumgart and Peter Thaller. The first successful surgeries in Asia have been performed since 2001 by Dr Sarbjit Singh in Tan Tock Seng Hospital
, Singapore
, and Dr Sittiporn, Bumrungrad Hospital
, Bangkok
. In December 2005 Fitbone surgery was done in Malaysia at the Mahkota Orthopaedic Reconstruction and Limb Lengthening Center, Melaka by Thirukumaran Subramaniam and Jeyaratnam T Satkunasingam. Dr. Bruce Foster of Adelaide, Australia, chairman of the "Bone Growth Foundation" — a charity established with the aim of helping children with crippling bone growth problems — is currently the only surgeon that uses the "Fitbone" device in the southern hemisphere.
Fitbone comprises a telescopic nail implant
that can extend, powered by an electric motor and controlled by a receiver with an antenna
that is buried under the skin; the receiver in turn is controlled by a hand-held radio-frequency
transmitter
. The procedure for lengthening the lower leg is as follows:
This procedure, however, comes at a price. While the Ilizarov external fixator
costs approximately USD$4,000, and the ISKD implant about USD$8,000, the Fitbone device carries a price tag of roughly USD$15,000 (all prices exclusive of surgery costs).
The Bliskunov device is currently not available.
Biotechnological advances, such as in stem cell
research, may become the next generation standard of care for limb elongation once it matures, possibly within a decade or two.
regime comprising stretching exercises and at times, they may be required to be hooked up to a "continuous passive motion" device. The purpose is to avoid stiffness and to stimulate the muscles, nerve
s and blood vessels to grow alongside the bone. Patients are often prescribed painkillers
and are unable to work while undergoing rehabilitation
.
defects, as well as some facial injuries resulting from trauma
, requires making bones longer. Distraction osteogenesis is an effective way to grow new bone, but it is much more difficult to accomplish in the face than in other areas of the body. Bones must often be moved in three dimensions, as opposed to just one, as in a limb, and scarring must be kept to a minimum.
Researchers are attempting to improve the distraction devices used in the face. Until recently, the mechanisms were external and only operated along straight lines. Now, maxillofacial surgeons can use curvilinear devices capable of moving bone in three dimensions.
These new devices still need to be improved. They depend on patient caretakers reliably turning a screw. The next goal is to create devices that will move bone continuously, not in daily increments of 1 mm. These continuously moving devices would cause less pain, wouldn’t require daily patient compliance, and might promote faster bone growth. At the moment, researchers are testing a continuously moving device in animal models, and they have found that the device’s components are durable, that its user interface works, and that it is tolerated by the body. When the position sensor in the device is perfected, the device will be ready to use in people.
In distraction osteogenesis procedures involving the face, it is critical that bone movements be carefully planned before a device is implanted. No existing device is capable of changing its trajectory
mid-course, and small skeletal changes lead to large changes in the structure of the face. Recently researchers have developed state-of-the-art software capable of simulating the entire process of distraction osteogenesis. The 3-D
planning tool uses data from CT scans to create a segmented model of the patient’s skull, and it then calculates the vector of movement required to achieve desirable bone positioning. Outcome CT scans can be overlaid on the original model to assess the effectiveness of the procedure. In the future, researchers hope that the distraction devices used in maxillofacial procedures will continue to improve, along with the corresponding software.
(which helps preserve the blood supply) and secondarly bone marrow
and the stability of the fixator.
.
Too slow of a distraction rate would result in early bone consolidation. A common distraction rate for lower limbs is 1 millimeter per day.
injuries, it is increasingly used to correct limb discrepancies caused by congenital conditions
and old injuries. A list of the possible uses of distraction osteogenesis are as follows:
lengthening for people who want to add a couple of inches to their frames because such people are:
People insistent on doing the procedure, however, are required by some doctors to undergo a thorough body image
assessment by a psychologist
to help determine how far the person's quality of life has been affected by his perceived lack of height, and if doing the surgery will make a marked difference. The entire evaluation
, which includes in-depth doctor-patient discussions, usually takes months during which time, the doctors hope that their patients will change their minds.
undergoes a limb lengthening procedure, along with other extreme methods, in order to impersonate another person and thus avoid genetic discrimination.
In Ian Fleming
's James Bond novel Dr. No, Dr. No alludes to using leg-lengthing to increase his height to roughly 7 feet tall as part of a larger scheme to mask his identity.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
process used to reconstruct skeletal
Skeleton
The skeleton is the body part that forms the supporting structure of an organism. There are two different skeletal types: the exoskeleton, which is the stable outer shell of an organism, and the endoskeleton, which forms the support structure inside the body.In a figurative sense, skeleton can...
deformities
Deformity
A deformity, dysmorphism, or dysmorphic feature is a major difference in the shape of body part or organ compared to the average shape of that part.Deformity may arise from numerous causes:*A Genetic mutation*Damage to the fetus or uterus...
and lengthen the long bone
Long bone
The long bones are those that are longer than they are wide. They are one of five types of bones: long, short, flat, irregular and sesamoid. Long bones, especially the femur and tibia, are subjected to most of the load during daily activities and they are crucial for skeletal mobility. They grow...
s of the body. A corticotomy
Corticotomy
In bone surgery, a corticotomy is a cutting of the bone that may or may not split it into two pieces but involves cortex only, leaving intact the medullary vessels and periosteum. Corticotomy is particularly important in distraction osteogenesis....
is used to fracture
Bone fracture
A bone fracture is a medical condition in which there is a break in the continuity of the bone...
the bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...
into two segments, and the two bone ends of the bone are gradually moved apart during the distraction phase, allowing new bone
Bone healing
Bone healing, or fracture healing, is a proliferative physiological process in which the body facilitates the repair of a bone fracture....
to form in the gap. When the desired or possible length is reached, a consolidation phase follows in which the bone is allowed to keep healing. Distraction osteogenesis has the benefit of simultaneously increasing bone length and the volume of surrounding soft tissue
Soft tissue
In anatomy, the term soft tissue refers to tissues that connect, support, or surround other structures and organs of the body, not being bone. Soft tissue includes tendons, ligaments, fascia, skin, fibrous tissues, fat, and synovial membranes , and muscles, nerves and blood vessels .It is sometimes...
s.
Although distraction technology has been used mainly in the field of orthopedic
Orthopedic surgery
Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system...
s, early results in rats and humans indicated that the process can be applied to correct deformities of the jaw
Jaw
The jaw is any opposable articulated structure at the entrance of the mouth, typically used for grasping and manipulating food. The term jaws is also broadly applied to the whole of the structures constituting the vault of the mouth and serving to open and close it and is part of the body plan of...
. These techniques are now utilised extensively by maxillofacial surgeons
Oral and maxillofacial surgery
Oral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is an internationally recognized surgical specialty...
for the correction of micrognathia, midface, and fronto-orbital hypoplasia in patients with craniofacial
Craniofacial
Craniofacial may be used to describe certain congenital malformations, injuries, surgeons who subspecialize in this area, multi-disciplinary medical-surgical teams that treat and do research on disorders affecting this region, and organizations with interest in...
deformities.
History
In 1905, Alessandro CodivillaAlessandro Codivilla
Alessandro Codivilla was an Italian surgeon.He was associated with early forms of pancreaticoduodenectomy and traction.- External links :* -References:...
introduced surgical practices for lengthening of the lower limbs. Early techniques had a high number of complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
, particularly during healing
Bone healing
Bone healing, or fracture healing, is a proliferative physiological process in which the body facilitates the repair of a bone fracture....
, and often resulted in a failure to achieve the goal of the surgery.
In 1934 the New York Hospital For Joint Disease worked on an early method developed by Ilizarov. The major item that the US team of surgeons developed was the metal frame the leg was placed in to hold it perfectly in place till the cut made in the bone was healed over.
The breakthrough came with a technique introduced by Russia
Russia
Russia or , officially known as both Russia and the Russian Federation , is a country in northern Eurasia. It is a federal semi-presidential republic, comprising 83 federal subjects...
n orthopedic surgeon Gavril Ilizarov. Ilizarov developed a procedure based on the biology of the bone and on the ability of the surrounding soft-tissues to regenerate under tension; the technique involved an external fixator, the Ilizarov apparatus
Ilizarov apparatus
The Ilizarov apparatus is named after the orthopedic surgeon Gavriil Abramovich Ilizarov from the Soviet Union, who pioneered the technique. It is used in surgical procedures to lengthen or reshape limb bones; to treat complex and/or open bone fractures; and in cases of infected non-unions of bones...
, structured as a modular ring. Although the types of complications remained the same (infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
, the most common complication occurring particularly along the pin tracks, pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
, nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
and soft tissue
Soft tissue
In anatomy, the term soft tissue refers to tissues that connect, support, or surround other structures and organs of the body, not being bone. Soft tissue includes tendons, ligaments, fascia, skin, fibrous tissues, fat, and synovial membranes , and muscles, nerves and blood vessels .It is sometimes...
irritation) the Ilizarov technique reduced the frequency and severity of the complications. The Ilizarov technique made the surgery safer, and allowed the goal of lengthening the limb to be achieved.
Difficulties arising during distraction osteogenesis
Difficulties that may arise during distraction osteogenesis are commonly classified in medical scientific literature according to the standard introduced by professor Dror PaleyDror Paley
Dror Paley , is a Canadian orthopedic surgeon, who specialises in limb lengthening procedures. He graduated from the University of Toronto Medical School...
in a 1990 article. Paley distinguished among problems (defined as "a difficulty that arises during the distraction or fixation period that is fully resolved by the end of the treatment period by non operative means"), obstacles, and complications.
Using exclusively an external fixator
The most common is the Ilizarov surgery with the Ilizarov external fixator. Other external fixators are Wagner, Orthofix and Judet. Dr. Helong Bai (8th Hospital in Chongqing, China) developed the technique "Micro-wound" with a different apparatus.Ilizarov surgery
Ilizarov surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
, developed by Gavriel Ilizarov, a Russian
Russians
The Russian people are an East Slavic ethnic group native to Russia, speaking the Russian language and primarily living in Russia and neighboring countries....
orthopedic surgeon
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
, in 1951, is the oldest and most common method of distraction osteogenesis. It often brings complications, while some new methods have a much lower rate of complications.
The process involves the following:
- Shattered bones and devascularisedBlood vesselThe blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and...
ones are removed from the patient, leaving a gap; - The healthy part of the upper bone is broken into two segments with an external sawSawA saw is a tool that uses a hard blade or wire with an abrasive edge to cut through softer materials. The cutting edge of a saw is either a serrated blade or an abrasive...
; - The leg is then fitted with the Ilizarov frame that pierces through the skinSkin-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
, muscleMuscleMuscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s, and bone; - ScrewScrewA screw, or bolt, is a type of fastener characterized by a helical ridge, known as an external thread or just thread, wrapped around a cylinder. Some screw threads are designed to mate with a complementary thread, known as an internal thread, often in the form of a nut or an object that has the...
s attached to the middle bone are turned 1 millimetre (mm) per day, so that new bone tissuesOsseous tissueOsseous tissue, or bone tissue, is the major structural and supportive connective tissue of the body. Osseous tissue forms the rigid part of the bone organs that make up the skeletal system.-Formation:Bone tissue is a mineralized connective tissue...
that are formed in the growth zone are gradually pulled apart to increase the gap (One millimetre has been found to be the optimalOptimization (mathematics)In mathematics, computational science, or management science, mathematical optimization refers to the selection of a best element from some set of available alternatives....
bone distraction rate. Lengthening too fast overstretches the soft tissues, resulting not only in pain, but also in the inability of the bone to fill up the gap; too slow, and the bone hardens before the full lengthening process is complete.); - After the gap is closed, the patient continues to wear the frame until the new bone solidifies; the waiting period is usually 120 days before the leg can be used.
Ilizarov surgery is extremely painful, uncomfortable, infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
-prone, and often causes unsightly scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
s . Frames used to be made of stainless steel
Stainless steel
In metallurgy, stainless steel, also known as inox steel or inox from French "inoxydable", is defined as a steel alloy with a minimum of 10.5 or 11% chromium content by mass....
rings weighing up to 7 kilogram (kg), but newer models are made of Carbon fiber reinforced plastic, which though lighter, are equally cumbersome.
Derivative devices provide physicians better control over the bone axis and angle during elongation, such as the Taylor Spacial Frame (TSF) which is computer assisted. The downside of these developments are their relative complexity and resulting longer learning curve.
For decades, the Ilizarov procedure was the best chance for shattered bones to be restored, and crooked ones straightened. Breakthroughs in distraction osteogenesis in the 1990s, however, have resulted in less painful (albeit more expensive) alternatives, such as unilateral rails.
Using exclusively an intramedullary nail
The techniques that use an intramedullary nail without an external fixator are: Albizzia, Bliskunov, Guichet, Fitbone and ISKD.The Guichet Method
Invented in 1987 by Dr. Jean-Marc Guichet MD, the Albizzia nail was created during his residency at the University Center (CHU) of Dijon, France. The Albizzia nail is inserted into the bone canal after it is calibrated with a reamer. The nail is then fixed to the ends of the bone fragments with screws. The nail consists of two sliding tubes that rotate in relation to the other, allowing for the nail to extend through a series of “clicks.” After insertion, the patient “clicks” the nail by turning the knee and leg (femoral nail) or foot (tibial nail) alternating inward and outward rotations to gradually lengthen. 15 clicks per day results in 1mm of gain. Expansions of up to 10cm have been reported. The Albizzia nail is used in almost 30 countries and over 3,000 nails have been implanted.In 2009, Dr. Guichet patented the Guichet Nail. The Guichet Nail is an improved version of the Albizzia nail because it uses stronger steel that allows for full weight bearing activity almost immediately after surgery. Furthermore, the Guichet Nail is customizable for size to ensure maximum comfort and efficiency for patients with smaller bones. Although there is initial pain after the surgery and during the clicks, the Guichet Nail is believed to be less painful than other methods as it is less invasive. Furthermore, as the patient controls the method of “clicking,” the patient is able to reduce pain by determining the most suitable method for themselves.
The Guichet Nail is currently used exclusively at the Leg Lengthening Clinic in Marseilles, France. Founded in 2011 by Guichet and Keeper, the clinic specializes in cosmetic leg lengthening surgeries. With worldwide recognition for being the foremost knowledgeable limb reconstruction
Reconstruction
In the history of the United States, the term "Reconstruction Era" has two senses: the first covers the entire nation in the period 1865–1877 following the Civil War; the second one, used in this article, covers the transformation of the Southern United States from 1863 to 1877, with the...
surgeon
Surgeon
In medicine, a surgeon is a specialist in surgery. Surgery is a broad category of invasive medical treatment that involves the cutting of a body, whether human or animal, for a specific reason such as the removal of diseased tissue or to repair a tear or breakage...
with respect to internal fixators in the world, Dr. Guichet has successfully completed over 350 limb lengthening procedures.
Intramedullary skeletal kinetic distractor
In 2001, the "Intramedullary skeletal kinetic distractor" (ISKD) was introduced, allowing lengthening to take place internally, thereby drastically reducing the risk of infections and scarring. The ISKD device was designed by Dr. J. Dean Cole, MD of Orlando, FloridaOrlando, Florida
Orlando is a city in the central region of the U.S. state of Florida. It is the county seat of Orange County, and the center of the Greater Orlando metropolitan area. According to the 2010 US Census, the city had a population of 238,300, making Orlando the 79th largest city in the United States...
.
With ISKD, a telescopic rod that can be gradually extended by knee
Knee
The knee joint joins the thigh with the leg and consists of two articulations: one between the fibula and tibia, and one between the femur and patella. It is the largest joint in the human body and is very complicated. The knee is a mobile trocho-ginglymus , which permits flexion and extension as...
or ankle
Ankle
The ankle joint is formed where the foot and the leg meet. The ankle, or talocrural joint, is a synovial hinge joint that connects the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus bone in the foot...
rotations is implanted into the bone. Lengthening is monitored by a hand-held external magnetic
Magnetism
Magnetism is a property of materials that respond at an atomic or subatomic level to an applied magnetic field. Ferromagnetism is the strongest and most familiar type of magnetism. It is responsible for the behavior of permanent magnets, which produce their own persistent magnetic fields, as well...
sensor
Sensor
A sensor is a device that measures a physical quantity and converts it into a signal which can be read by an observer or by an instrument. For example, a mercury-in-glass thermometer converts the measured temperature into expansion and contraction of a liquid which can be read on a calibrated...
that tracks the rotation of an internal magnet
Magnet
A magnet is a material or object that produces a magnetic field. This magnetic field is invisible but is responsible for the most notable property of a magnet: a force that pulls on other ferromagnetic materials, such as iron, and attracts or repels other magnets.A permanent magnet is an object...
on a daily basis.
ISKD requires a physical leg movement to "click" the device into lengthening. In this method, there is no risk of accidentally over-stretching the bone due to the lengthener being preset to the desired fully extended length. However, there is a risk of growing the bone too quickly. Bone growth is monitored by measuring changes in the magnetic field of an embedded magnet in the system. The poles of the magnet change as the device grows. However, if the motion of the leg makes the device grow too quickly, and the magnet switches poles twice between measurements, then that growth is not recorded. This leads to overly rapid growth which can cause a number of issues such as nerve damage or causing breaks in the bone.
While there is some pain associated with the immediate post-op lengthening, the initial lengthening procedure is not to begin until one week after surgery. Furthermore, there is no noticeable "click" to the patient as there is less than nine degrees of rotation of the two bone segments in relation to one another.
Regularly used at a handful of medical centers mostly in the United States, only several dozens of ISKD devices are implanted each year. An improved version is currently being developed by its manufacturer (Orthofix).
Fitbone surgery
A form of surgery involving an intramedullar, fully implantable, electronicallyElectronics
Electronics is the branch of science, engineering and technology that deals with electrical circuits involving active electrical components such as vacuum tubes, transistors, diodes and integrated circuits, and associated passive interconnection technologies...
-motorised
Electric motor
An electric motor converts electrical energy into mechanical energy.Most electric motors operate through the interaction of magnetic fields and current-carrying conductors to generate force...
limb-lengthening implant, called "Fitbone", is a technologically
Technology
Technology is the making, usage, and knowledge of tools, machines, techniques, crafts, systems or methods of organization in order to solve a problem or perform a specific function. It can also refer to the collection of such tools, machinery, and procedures. The word technology comes ;...
advanced, though relatively complex, device.
Developed in Germany
Germany
Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate...
by Augustin Betz and Rainer Baumgart, the first successful operations were performed in 1996 and the technique was patent
Patent
A patent is a form of intellectual property. It consists of a set of exclusive rights granted by a sovereign state to an inventor or their assignee for a limited period of time in exchange for the public disclosure of an invention....
ed in 1997. Thus far, most of the surgeries using this method have been performed in Munich
Munich
Munich The city's motto is "" . Before 2006, it was "Weltstadt mit Herz" . Its native name, , is derived from the Old High German Munichen, meaning "by the monks' place". The city's name derives from the monks of the Benedictine order who founded the city; hence the monk depicted on the city's coat...
, Germany
Germany
Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate...
by Baumgart and Peter Thaller. The first successful surgeries in Asia have been performed since 2001 by Dr Sarbjit Singh in Tan Tock Seng Hospital
Tan Tock Seng Hospital
The Tan Tock Seng Hospital is the second-largest hospital in Singapore after the Singapore General Hospital, but its accident and emergency department is the busiest in the country largely due to its geographically centralised location...
, Singapore
Singapore
Singapore , officially the Republic of Singapore, is a Southeast Asian city-state off the southern tip of the Malay Peninsula, north of the equator. An island country made up of 63 islands, it is separated from Malaysia by the Straits of Johor to its north and from Indonesia's Riau Islands by the...
, and Dr Sittiporn, Bumrungrad Hospital
Bumrungrad Hospital
Bumrungrad International Hospital is a multiple-specialty medical center located in Bangkok, Thailand...
, Bangkok
Bangkok
Bangkok is the capital and largest urban area city in Thailand. It is known in Thai as Krung Thep Maha Nakhon or simply Krung Thep , meaning "city of angels." The full name of Bangkok is Krung Thep Mahanakhon Amon Rattanakosin Mahintharayutthaya Mahadilok Phop Noppharat Ratchathani Burirom...
. In December 2005 Fitbone surgery was done in Malaysia at the Mahkota Orthopaedic Reconstruction and Limb Lengthening Center, Melaka by Thirukumaran Subramaniam and Jeyaratnam T Satkunasingam. Dr. Bruce Foster of Adelaide, Australia, chairman of the "Bone Growth Foundation" — a charity established with the aim of helping children with crippling bone growth problems — is currently the only surgeon that uses the "Fitbone" device in the southern hemisphere.
Fitbone comprises a telescopic nail implant
Implant (medicine)
An implant is a medical device manufactured to replace a missing biological structure, support a damaged biological structure, or enhance an existing biological structure. Medical implants are man-made devices, in contrast to a transplant, which is a transplanted biomedical tissue...
that can extend, powered by an electric motor and controlled by a receiver with an antenna
Antenna (radio)
An antenna is an electrical device which converts electric currents into radio waves, and vice versa. It is usually used with a radio transmitter or radio receiver...
that is buried under the skin; the receiver in turn is controlled by a hand-held radio-frequency
Radio frequency
Radio frequency is a rate of oscillation in the range of about 3 kHz to 300 GHz, which corresponds to the frequency of radio waves, and the alternating currents which carry radio signals...
transmitter
Transmitter
In electronics and telecommunications a transmitter or radio transmitter is an electronic device which, with the aid of an antenna, produces radio waves. The transmitter itself generates a radio frequency alternating current, which is applied to the antenna. When excited by this alternating...
. The procedure for lengthening the lower leg is as follows:
- A two-centimetre incision is made at the patient's knee, and a reamer is used to create enough space in the bone for a stainless steel nail.
- The bone is cut about 14 cm below the knee from the inside with an internal saw.
- The stainless steel nail is held in place by two screws. The top of the nail is attached to a tiny, plasticPlasticA plastic material is any of a wide range of synthetic or semi-synthetic organic solids used in the manufacture of industrial products. Plastics are typically polymers of high molecular mass, and may contain other substances to improve performance and/or reduce production costs...
-encased receiverReceiver (radio)A radio receiver converts signals from a radio antenna to a usable form. It uses electronic filters to separate a wanted radio frequency signal from all other signals, the electronic amplifier increases the level suitable for further processing, and finally recovers the desired information through...
that is placed under the skin. - The patient controls the lengthening process. By pushing a button on the transmitter when it is placed against the antenna, the built-in motor extends the nail one millimetre per day. When the leg has grown to the desired length, lengthening stops, and the bone is allowed to solidify.
- The device can be removed about two years after the initial surgery.
This procedure, however, comes at a price. While the Ilizarov external fixator
External Fixation
External fixation is a surgical treatment used to set bone fractures in which a cast would not allow proper alignment of the fracture.-Method:...
costs approximately USD$4,000, and the ISKD implant about USD$8,000, the Fitbone device carries a price tag of roughly USD$15,000 (all prices exclusive of surgery costs).
The Bliskunov device is currently not available.
Future technology
Due to shortcomings of current external and internal devices and the evident market potential of cosmetic limb elongation, a growing number of companies are researching potential intramedullary technologies. These include:- Concepts based on electromagnetic actuation
- Concepts based on smart material integration
- Concepts based on manual actuation
- Concepts based on electronic actuation
Biotechnological advances, such as in stem cell
Stem cell
This article is about the cell type. For the medical therapy, see Stem Cell TreatmentsStem cells are biological cells found in all multicellular organisms, that can divide and differentiate into diverse specialized cell types and can self-renew to produce more stem cells...
research, may become the next generation standard of care for limb elongation once it matures, possibly within a decade or two.
Post-surgical care
Following the initial surgery, patients must undergo a demanding physiotherapyPhysical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
regime comprising stretching exercises and at times, they may be required to be hooked up to a "continuous passive motion" device. The purpose is to avoid stiffness and to stimulate the muscles, nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
s and blood vessels to grow alongside the bone. Patients are often prescribed painkillers
Analgesic
An analgesic is any member of the group of drugs used to relieve pain . The word analgesic derives from Greek an- and algos ....
and are unable to work while undergoing rehabilitation
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
.
Maxillofacial Distraction Osteogenesis
Correcting the majority of congenital craniofacialCraniofacial
Craniofacial may be used to describe certain congenital malformations, injuries, surgeons who subspecialize in this area, multi-disciplinary medical-surgical teams that treat and do research on disorders affecting this region, and organizations with interest in...
defects, as well as some facial injuries resulting from trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
, requires making bones longer. Distraction osteogenesis is an effective way to grow new bone, but it is much more difficult to accomplish in the face than in other areas of the body. Bones must often be moved in three dimensions, as opposed to just one, as in a limb, and scarring must be kept to a minimum.
Researchers are attempting to improve the distraction devices used in the face. Until recently, the mechanisms were external and only operated along straight lines. Now, maxillofacial surgeons can use curvilinear devices capable of moving bone in three dimensions.
These new devices still need to be improved. They depend on patient caretakers reliably turning a screw. The next goal is to create devices that will move bone continuously, not in daily increments of 1 mm. These continuously moving devices would cause less pain, wouldn’t require daily patient compliance, and might promote faster bone growth. At the moment, researchers are testing a continuously moving device in animal models, and they have found that the device’s components are durable, that its user interface works, and that it is tolerated by the body. When the position sensor in the device is perfected, the device will be ready to use in people.
In distraction osteogenesis procedures involving the face, it is critical that bone movements be carefully planned before a device is implanted. No existing device is capable of changing its trajectory
Trajectory
A trajectory is the path that a moving object follows through space as a function of time. The object might be a projectile or a satellite, for example. It thus includes the meaning of orbit—the path of a planet, an asteroid or a comet as it travels around a central mass...
mid-course, and small skeletal changes lead to large changes in the structure of the face. Recently researchers have developed state-of-the-art software capable of simulating the entire process of distraction osteogenesis. The 3-D
3D computer graphics
3D computer graphics are graphics that use a three-dimensional representation of geometric data that is stored in the computer for the purposes of performing calculations and rendering 2D images...
planning tool uses data from CT scans to create a segmented model of the patient’s skull, and it then calculates the vector of movement required to achieve desirable bone positioning. Outcome CT scans can be overlaid on the original model to assess the effectiveness of the procedure. In the future, researchers hope that the distraction devices used in maxillofacial procedures will continue to improve, along with the corresponding software.
General solid bone regeneration
The most important aspects for the success of bone distraction are an intact medullary blood supply, preservation of soft-tissue envelope, primarily the periosteumPeriosteum
Periosteum is a membrane that lines the outer surface of all bones, except at the joints of long bones. Endosteum lines the inner surface of all bones....
(which helps preserve the blood supply) and secondarly bone marrow
Bone marrow
Bone marrow is the flexible tissue found in the interior of bones. In humans, bone marrow in large bones produces new blood cells. On average, bone marrow constitutes 4% of the total body mass of humans; in adults weighing 65 kg , bone marrow accounts for approximately 2.6 kg...
and the stability of the fixator.
Distraction rate
The distraction rate must be gradual, as a rapid rate of distraction will result in a fibrous union in which the bone pieces are joined by fibrous, rather than osseous tissueOsseous tissue
Osseous tissue, or bone tissue, is the major structural and supportive connective tissue of the body. Osseous tissue forms the rigid part of the bone organs that make up the skeletal system.-Formation:Bone tissue is a mineralized connective tissue...
.
Too slow of a distraction rate would result in early bone consolidation. A common distraction rate for lower limbs is 1 millimeter per day.
Complications
In a 2004 study lengthening with an exclusively intramedullary nail (Albizzia) had a "significant lower rate" of complications respect to exclusively external methods (Judet, Orthofix, Ilizarov and Wagner fixators).Possible uses of distraction osteogenesis
Although distraction osteogenesis is most often used in the treatment of post-traumaticPhysical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
injuries, it is increasingly used to correct limb discrepancies caused by congenital conditions
Congenital disorder
A congenital disorder, or congenital disease, is a condition existing at birth and often before birth, or that develops during the first month of life , regardless of causation...
and old injuries. A list of the possible uses of distraction osteogenesis are as follows:
- Congenital deformities (birth defects):
- Congenital short femurFemurThe femur , or thigh bone, is the most proximal bone of the leg in tetrapod vertebrates capable of walking or jumping, such as most land mammals, birds, many reptiles such as lizards, and amphibians such as frogs. In vertebrates with four legs such as dogs and horses, the femur is found only in...
; - Fibular hemimelia (absence of the fibula, which is one of the two bones between the knee and the ankle);
- Hemiatrophy (atrophyAtrophyAtrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations , poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply to the target organ, disuse or lack of exercise or disease intrinsic to the tissue itself...
of half of the body); and - Ollier's disease.
- Congenital short femur
- Developmental deformities
- NeurofibromatosisNeurofibromatosisNeurofibromatosis is a genetically-inherited disorder in which the nerve tissue grows tumors that may be benign or may cause serious damage by compressing nerves and other tissues...
(a rare condition which causes overgrowth in one leg); and - Bow legs, resulting from ricketsRicketsRickets is a softening of bones in children due to deficiency or impaired metabolism of vitamin D, magnesium , phosphorus or calcium, potentially leading to fractures and deformity. Rickets is among the most frequent childhood diseases in many developing countries...
or secondary arthritisArthritisArthritis is a form of joint disorder that involves inflammation of one or more joints....
.
- Neurofibromatosis
- Post-traumatic injuries
- Growth plates fractures;
- Malunion or non-union (when bones do not completely join, or join in a faulty position after a fracture);
- Shortening and deformity; and
- Bone defects.
- Infections and diseaseDiseaseA disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
s- OsteomyelitisOsteomyelitisOsteomyelitis simply means an infection of the bone or bone marrow...
(a bone infection, usually caused by bacteriaBacteriaBacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
); - Septic arthritisSeptic arthritisSeptic arthritis is the purulent invasion of a joint by an infectious agent which produces arthritis. People with artificial joints are more at risk than the general population but have slightly different symptoms, are infected with different organisms and require different treatment. Septic...
(infections or bacterial arthritis); and - PoliomyelitisPoliomyelitisPoliomyelitis, often called polio or infantile paralysis, is an acute viral infectious disease spread from person to person, primarily via the fecal-oral route...
(a viralVirusA virus is a small infectious agent that can replicate only inside the living cells of organisms. Viruses infect all types of organisms, from animals and plants to bacteria and archaea...
disease which may result in the atrophy of muscles, causing permanent deformity).
- Osteomyelitis
- After tumorTumorA tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
s - Short statureShort statureShort stature refers to a height of a human being which is below expected. Shortness is a vague term without a precise definition and with significant relativity to context...
- AchondroplasiaAchondroplasiaAchondroplasia dwarfism occurs as a sporadic mutation in approximately 85% of cases or may be inherited in an autosomal dominant genetic disorder that is a common cause of dwarfism...
(a form of dwarfismDwarfismDwarfism is short stature resulting from a medical condition. It is sometimes defined as an adult height of less than 4 feet 10 inches , although this definition is problematic because short stature in itself is not a disorder....
where arms and legs are very short, but torsoTorsoTrunk or torso is an anatomical term for the central part of the many animal bodies from which extend the neck and limbs. The trunk includes the thorax and abdomen.-Major organs:...
is more normal in size); and - Constitutional short stature.
- Achondroplasia
Cosmetic lengthening of limbs
Generally, doctors tend to discourage cosmeticBeauty
Beauty is a characteristic of a person, animal, place, object, or idea that provides a perceptual experience of pleasure, meaning, or satisfaction. Beauty is studied as part of aesthetics, sociology, social psychology, and culture...
lengthening for people who want to add a couple of inches to their frames because such people are:
- breaking perfectly functional limbs;
- confining themselves unnecessarily to crutchCrutchCrutches are mobility aids used to counter a mobility impairment or an injury that limits walking ability.- Types :There are several different types of crutches:...
es or a wheelchairWheelchairA wheelchair is a chair with wheels, designed to be a replacement for walking. The device comes in variations where it is propelled by motors or by the seated occupant turning the rear wheels by hand. Often there are handles behind the seat for someone else to do the pushing...
for over a year; - voluntarily subjecting themselves to pain and discomfort;
- exposing themselves to unnecessary risk of infections, of damaged nerves and blood vessels, and fat embolismEmbolismIn medicine, an embolism is the event of lodging of an embolus into a narrow capillary vessel of an arterial bed which causes a blockage in a distant part of the body.Embolization is...
that can result in death; and - incurring unnecessary expenses as the procedure is relatively expensive.
People insistent on doing the procedure, however, are required by some doctors to undergo a thorough body image
Body image
Body image refers to a person's perception of the aesthetics and sexual attractiveness of their own body. The phrase body image was first coined by the Austrian neurologist and psychoanalyst Paul Schilder in his masterpiece The Image and Appearance of the Human Body...
assessment by a psychologist
Psychologist
Psychologist is a professional or academic title used by individuals who are either:* Clinical professionals who work with patients in a variety of therapeutic contexts .* Scientists conducting psychological research or teaching psychology in a college...
to help determine how far the person's quality of life has been affected by his perceived lack of height, and if doing the surgery will make a marked difference. The entire evaluation
Evaluation
Evaluation is systematic determination of merit, worth, and significance of something or someone using criteria against a set of standards.Evaluation often is used to characterize and appraise subjects of interest in a wide range of human enterprises, including the arts, criminal justice,...
, which includes in-depth doctor-patient discussions, usually takes months during which time, the doctors hope that their patients will change their minds.
In popular culture
The protagonist of the movie GattacaGattaca
Gattaca is a 1997 science fiction film written and directed by Andrew Niccol. It stars Ethan Hawke, Uma Thurman and Jude Law with supporting roles played by Loren Dean, Ernest Borgnine, Gore Vidal and Alan Arkin....
undergoes a limb lengthening procedure, along with other extreme methods, in order to impersonate another person and thus avoid genetic discrimination.
In Ian Fleming
Ian Fleming
Ian Lancaster Fleming was a British author, journalist and Naval Intelligence Officer.Fleming is best known for creating the fictional British spy James Bond and for a series of twelve novels and nine short stories about the character, one of the biggest-selling series of fictional books of...
's James Bond novel Dr. No, Dr. No alludes to using leg-lengthing to increase his height to roughly 7 feet tall as part of a larger scheme to mask his identity.
See also
- Bone graftingBone graftingBone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly....
- Bone healingBone healingBone healing, or fracture healing, is a proliferative physiological process in which the body facilitates the repair of a bone fracture....
- Fibrocartilage callusFibrocartilage callusA fibrocartilage callus is a temporary formation of fibroblasts and chondroblasts which forms at the area of a bone fracture as the bone attempts to heal itself...
- NonunionNonunionNonunion is permanent failure of healing following a broken bone.Nonunion is a serious complication of a fracture and may occur when the fracture moves too much, has a poor blood supply or gets infected. Patients who smoke have a higher incidence of nonunion. The normal process of bone healing is...
- Orthopedic surgeryOrthopedic surgeryOrthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system...
- Tissue expansionTissue expansionTissue expansion is a technique used by plastic and restorative surgeons to cause the body to grow additional skin, bone or other tissues.-Skin expansion:...
- Valgus deformityValgus deformityIn orthopedics, a valgus deformity is a term for outward angulation of the distal segment of a bone or joint. The opposite deformation, medial deviation of the distal bone, is called varus....
Conference References
- Leonard B. Kaban, “Bone Lengthening by Distraction Osteogenesis,” CIMIT Forum, October 2, 2007
External links
- Distraction Osteogenesis information from Seattle Children's Hospital Craniofacial Center
- Dr. Dror Paley LIMB LENGTHENING INTRODUCTION
- Limb Lengthening - ISKD Documents by Dr. Cole - includes additional information leg lengthening and case studies
- Dr. Guichet Leg Lengthening Clinic
- The Leg Lengthening Clinic's official forum and support group for those who have done or are considering Limb Lengthening
- Introduction to Distraction Osteogenesis by Dr. Martin Chin, D.D.S.
- Previous history of Prof. Betz’s Fitbone-Surgery
- Information on Fitbone procedure
- Cosmetic Leg Lengthening
- LL Community Support group for those who have done or are considering Limb Lengthening.