Limb Lengthening Using External Fixation

 

What is an external fixator?

An External Fixator is a device on the outside of a leg or arm that is used to hold the bone in place.

 
Three different types of external fixators
are used at the St. Louis Children’s and Shriners Hospital.

Your doctor will discuss the best type of device based on the needs of your child.

      ILIZAROV external fixator is a circular fixator composed of metal and carbon rings connected by metal rods and
   clickers. The Ilizarov fixator is connected to the bone with thin wires and thick pins that are used to hold the bone in   
   place.

 

The TAYLOR FRAME is a circular fixator composed of metal rings and six struts.  It is connected to the bone with thin wires and thick pins.

The computer generated ring positions are based on measurements taken from x-rays and clinical examinations.  The computer then generates a schedule of daily strut settings.  The struts are turned daily to straighten or lengthen the bone.

The Monolateral External Fixator is a bar or monolateral fixator composed of a metal bar connected to the bone by thick pins.  This device is used for lengthening or holding a bone in place after it is straightened.  When the device is used for lengthening, a metal rod is often placed in the center of the bone allowing for removal of the fixator earlier than otherwise possible.  A screw holds the rod in place as the bone is lengthened over the rod.  Once the desired length is achieved, another screw is placed at the bottom of the rod and the External Fixator can be removed.  Approximately six to twelve months later, another minor surgery can done to remove the bottom screw.

 
Why would a patient be a candidate for an eternal fixator?

Patient conditions:

  • Trauma ( fracture of extremity)
  • Limb Length Discrepancy- The differences between lengths of the upper and lower arms or the lengths of upper and lower legs are called limb length discrepancies

o   Post Traumatic Growth Arrest

o   Tumors with physeal involvement

o   Vascular

-  Perthes

-  Ischemia

o   Congenital

-  Aplasia

-  Hip Dysplasia

-  Hypoplasia

-  Club foot

  • Bowing of Extremity

o   Valgus

o   Blount’s Disease ( Tibia Vara)

  • Osteomyelitis
  • Tumors
  • Non Unions or Malunions

Consultation Visit

This visit is to examine the patient to determine the best personalized future plan of care for the patient.

Family members are strongly encouraged to be a part of the consultation visit. 

During the consultation the family will meet with Dr. Gordon, the office staff, the nurses (Jill or Kim) and physical therapy.

The lengthening and straightening process requires a great deal of commitment and responsibility from the entire family.  The consultation visit is to make sure that everyone is prepared and ready for the process.  The fact that you are given a date for the consultation visit and complete it does not mean that we have decided that a fixator is the best thing for you.  We use the consult visit to get to know you and further study the medical problem in order to be sure that an external fixator is the best solution to the problem and that this is the best timing for surgical intervention.

 

 

How does the limb lengthening work?

·  This works by slowly growing bones and muscles, and pulling (distracting) them to the desired location.

·   The growth of bone and muscle is approximately 1mm a day.

·    During the pulling (distracting) time patients are asked to “turn” the struts on the Taylor Spatial Frame.

·    After the “turning” is complete, the frame remains on so that the bone solidifies.

·    The process from start to finish is approximately 4 to 6 months.

·    The plan for each patient is individualized.

 

What happens in surgery?

·    The Frame or Device is placed on the extremity, and held into place with wires and pins.

·     A surgical procedure called an Osteotomy

is used to cut the bone so the limb can be straightened or lengthened.

 

 

Will there be scars?

·    Yes

 

·    There is a 2 inch incision made over the osteotomy site.

·    There are small percutaneous incisions over the k-wire and pin sites.

After removal of the external fixator, the pin sites are not sutured closed, but are allowed to heal.  They usually will close over within four to six days and small scars form.  Sometimes these scars are large and dimpled and other times they heal with minimal scarring.

 

Patient experience with an External Fixator:

1)   Surgery

The procedure will last several hours under general anesthesia.

2)   Hospitalization

You will be in the hospital approximately 2-3 nights.  You will work with a physical therapist twice a day while in the hospital.

You will go home when you are tolerating a regular diet, pass physical therapy, and tolerating pain on oral pain medication. You will be sent home on enough medication to last you until your follow up appointment.

 3)   Going Home

  Day 3 after Surgery = First Dressing Change

 

Family and Child’s responsibility:

            Turning

  • Start day 3 after surgery
  • You will have a dressing change, and we will go over with patient and caregiver  how to “turn”
  • You will be given a time period of how long to “turn”
  • ***Premedicate 30 minutes prior to turning with pain medication
        How Do I Care For the Fixator?

1)      The Steri-Strips should remain on 7-10 days. If they fall off, it is OK! It is best not to pull them off the incision.

2)      After the 1st dressing change, Shower with a Gentle/Mild Soap (ie Dove, Aveeno, Dial etc ) ; Let soap and water run down over pin sites to keep them clean.

3)      Sponges and Clips are placed around pin sites to help soak up excess drainage if patient so desires.

 

       Do I have to cover the fixator?

       After the 1st dressing change, the pin sites do not have to be covered. This is decided by each patient for
       their personal preference. Many patients choose to cover with an ace wrap or fabric.

 

    Physical Therapy

    The patient will initially begin walking on level surfaces; weight-bearing as tolerated on the involved
 extremity with the use of the walker or an alternate assistive device until eventually they can progress to  
 crutches.  The patient will be instructed in ambulation up and down stairs.  As strength and endurance
 improve,  the patient will gradually be weaned off the use of the assistive device.

 

 

 

 

          
     How often are the visits with the doctor?

         Weekly for an exam and x-rays

 

     How long will my child be out of school?

  • Typically children miss a few weeks of school after the initial surgery
  • Forms from the child's school can be filled out for homebound instruction by the       
      doctor's office.

      How long will parents have to take off of work?

  • The first few weeks are the hardest time period.
  • Therapy can be arranged for early morning or late afternoons to avoid missing
      work and school.
  • FMLA forms can be filled out by the doctor’s office.

 

      When will External fixator removed?

  • Removed after 4 to 6 months once desired outcome is achieved.
  • Removed in the operating room
  • This is a same day surgery. Patient is able to leave that day after surgery when child 
    is eating, drinking and tolerating pain with medication.

  Complications that May Occur

 

 

 INFECTION – It is not unusual to get a minor pin tract infection that is treated with oral antibiotics.

 

DAMAGE TO NERVES AND BLOOD VESSELSThis complication is very rare due to the close monitoring or 
                                                             circulation, sensation, and motion.

 

 BONE NOT HEALING – This may result in not getting as much length or correction as desired.

 

TEMPORARY LOSS OF MOTION IN THE AFFECTED JOINT – May require that the lengthening process be
                                                                                     slowed and more intensive physical therapy.

 

DESIRED LENGTH MAY NOT BE ACHIEVED (for whatever reason) – An operation may be required 
                                                                                                    (epiphysiodesis) to slow the growth
                                                                                                    of the affected extremity.

 

You will have your first shower five days after surgery.  The nurses will teach you how to care for your pin sites.  Despite this, it is very common to get a slight pin tract infection, which is usually treated with oral antibiotics.

 Pin tract releases may be needed a few times while the external fixator is in place.  A pin release is when the skin around the pin or wire is released to relieve some of the pressure.

 

IMPORTANT THINGS TO REMEMBER

 

* Therapy is a must, twice a day at home & three times a week with a therapist.

 

* Shower every day to care for pin sites

 

* Weight bearing is “A MUST”

 

* Avoid all nonsteroidal medications such as: Ibuprofen,Motrin, Advil, Aleve, & Naproxen.

 

* May swim in a chlorinated pool

 

*Weekly clinic visits are necessary to check on your progress

 

 When Do I call doctor?

  •           Fever

  •           Redness around incision and or pin sites

  •           Drainage around pin sites

  •           Increased pain not relieved by pain medication

  •           You are running low on Pain Medication

 

Who do I call?

During Business Hours Monday thru Friday 8-4:30:

           St. Louis Children’s Hospital Patients:

            Lisa Boerm, Dr. Gordon’s Medical Assistant (314)454-4191

            Kim Cordia, Nurse Educator (314) 454-5221

 

After hours:

            Medical Exchange (314)388-5550

 

            Shriner’s Hospital Patients:

            Jill Hahn (314)872-6400 ext 1300

 

 

 

 

 

 

 

 

 

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