Share this article on:

A Brief History of Limb Lengthening

Birch, John G. MD, FRCSC

Journal of Pediatric Orthopaedics: September 2017 - Volume 37 - Issue - p S1–S8
doi: 10.1097/BPO.0000000000001021
A Brief History of Limb Lengthening

In the last 35 years, orthopaedic surgeons have witnessed 3 major advances in the technique of limb lengthening: “distraction osteogenesis” facilitated by Gavriil Ilizarov method and infinitely-adaptable circular fixator with fine-wire bone fragment fixation; the introduction of the “6-strut” computer program-assisted circular fixators to effect complex deformity correction simultaneously; and the development of motorized intramedullary lengthening nails. However, the principles and associated complications of these techniques are on the basis of observations by Codivilla, Putti, and Abbott from as much as 110 years ago. This review notes the contribution of these pioneers in limb lengthening, and the contribution of Thor Heyerdahl principles of tolerance and diversity to the dissemination of Ilizarov principles to the Western world.

Texas Scottish Rite Hospital for Children, Dallas, TX

J.G.B. receives royalties distributed by Texas Scottish Rite Hospital for Children from Orthofix for sales of a circular external fixator.

Reprints: John G. Birch, MD, FRCSC, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219 (e-mail: john.birch@tsrh.org).

Although episodic anecdotal documentations of rack-like acute leg lengthening exist from time immemorial, no one can say with certainty when, where, how, or by whom the first leg lengthening was performed. This article is not intended as a comprehensive review of the history of limb lengthening and deformity correction nor, by any stretch of the imagination, all of the important contributors to the evolution of those techniques. It is rather a recognition of a few key developments over the last 120 years that have brought us to the current “state of the art” of limb lengthening. Just as limb lengthening in a patient is a process, so too has been the evolution of new surgical techniques and devices, which should continue well into the future, as many unsolved challenges remain.

Back to Top | Article Outline

ALESSANDRO CODIVILLA

The title of “Father of Modern-Day Leg Lengthening” is bestowed on Alessandro Codivilla of Bologna, Italy, for being the first to employ skeletal traction for lengthening purposes. In 1905, in the Journal of Bone Surgery,1 he described a change in his method of acute femoral lengthening after osteotomy by distraction of a sectioned plaster spica cast to replace the foot and ankle portion with a calcaneal “nail.” He stated his philosophy of lengthening thus: “I am convinced that in so far as regards the extension of the fleshy parts, and when great force is necessary, the best results are obtained from forced lengthening, practiced under narcotics; by using a sudden and intense force; and by then applying the plaster apparatus to the limb while it is still maintained in complete extension” (Fig. 1). He said “The application of the force could then be repeated as many times as was considered necessary (by separating the leg portion of the spica with a Gigli saw, repeating the acute lengthening, and closing the spica), either under narcotics, or without, according to the needs of the case.” He noted cases of delayed “reaction which occurs in the central nervous system…which shows itself…in convulsive attacks… which will necessitate the cessation of the traction.” This method, however, gave rise to what he rather euphemistically called “inconveniences,” specifically, necrosis around the instep, ankle, and heel (including tendons). This stimulated him to use a 5 to 6 mm transverse calcaneal “nail” connected by “ferrules” incorporated in the lower leg portion of the spica to replace the foot and ankle portion of the spica (Fig. 2). A screw-like mechanism attached to the nail could be used to diminish (not augment) traction, should some complication develop (Fig. 3). In one case, “to obtain a good effect from the apparatus upon the evil tendency (emphasis mine) towards rotation of the distal portion of the limb,” he used 2 nails, one in the calcaneus and the other in the upper part of the tibia. He described 26 cases in which “we obtained in all cases the constant fulfillment of our desires” (lengthening of 3 to 8 cm). He concludes with the comment “After traction on the nail has been accomplished the method has left no ill effects of any kind.”

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

Back to Top | Article Outline

VITTORIO PUTTI

In 1921, Codivilla’s protégé Vittorio Putti published in JAMA 2 (of all places) a description of both his philosophy of lengthening of the femur (the only bone he reported that he had lengthened) and an ingenious device with which to accomplish it, which he called an “osteon.” He said that “shortening of the femur which does not surpass 2 inches and is not complicated by a deviation of the static axis of the limb does not require operative treatment.” He pointed out that the “the greatest resistance (to lengthening) is naturally offered by the bones, and their elongation can be effected only by osteotomy, which, however, must be performed in such a way as to facilitate the formation of the callus (emphasis mine). But a strong resistance is also offered by the soft parts.” He stated that the traction method of Codivilla and others did not bring “about that kind of traction which is indispensable to our purpose, ie, continuous traction (emphasis mine),” and therefore “to overcome the elastic resistance of the soft parts gradually, and without excessive effort, which might be dangerous, the acting force must also be elastic and continuous.” Thus, Putti seems to be the surgeon responsible for introducing both the concept and a technique of gradual, continuous traction after osteotomy to effect lengthening, and skeletal fixation of both fragments of the femur. The “osteon” (Fig. 4) consisted of 2 large metal pins fixed bicortically in the proximal and distal femur; and a telescoping tube housing a strong spring compressed by a screw. Two metal sockets fixed the pins to the tube. The entire apparatus could be disassembled and sterilized. A scale engraved on the apparatus served to “give the operator at every moment the measure of force used and the lengthening achieved.” He used a motor saw to outline a large Z-osteotomy. After a month of distraction, bandages were removed and the patient placed in a plaster of Paris until complete consolidation of callus had occurred. He noted the advantages of the device: no pressure on the skin; the wound was available for inspection by the surgeon; and the limb could be placed in a more comfortable position of slight hip and knee flexion (rather than complete extension as advocated by Codivilla). In the published commentaries following Putti's 2-page description of his technique, Dr Wilson (Boston) recommended contralateral shortening as a safer alternative, even though “the objection may be raised that this means operating on a normal limb.” Dr Magnuson (Chicago) further described a patient who “died in shock” after acute traction on a “Hawley table.” Both were clearly skeptical of other surgeons being able to replicate Putti surgical skills and results.

FIGURE 4

FIGURE 4

Back to Top | Article Outline

LEROY ABBOTT AND JOHN SAUNDERS

In 1939, Abbott and Saunders4 described in detail their method of lengthening, which Abbott had originally described in 19275 using a bed-based, semicircular external fixator (Fig. 5). They presented detailed lower leg dissection diagrams to illustrate the soft tissues resisting leg lengthening, and case histories; many of their patients had polio. Importantly, they documented a list of complications which could be expected to be associated with limb lengthening (Table 1); ironically, the list and consequences of lengthening are unchanged in the “modern era,” including a revived opportunity for avascular necrosis (but not yet reported, to my knowledge) with the introduction of femoral antegrade-inserted intramedullary lengthening rods.

FIGURE 5

FIGURE 5

TABLE 1

TABLE 1

Back to Top | Article Outline

HEINZ WAGNER

From the early-1970s until the mid-1980s, Heinz Wagner from Nurnberg, Germany became an internationally prominent champion of leg lengthening and complex limb deformity correction. He was renowned for showing composite “before and after” photographs of projected appearance after reconstructions (Fig. 6). He introduced the Wagner external fixator for leg lengthening.7 This consisted of a telescopic tube square in cross-section, which was connected to Schanz screws (2 to 3) inserted in parallel, attached by clamp, which had swivel capability in 2 modes, parallel to the fixator, and perpendicular to it (Fig. 7). This device was both versatile and unique in allowing the patient to be ambulatory. Unfortunately, he combined the use of the fixator with an aggressive surgical approach to osteotomy and lengthening itself. Specifically, he was a proponent of vigorous soft tissue resection including circumferential incision of the periosteum at the osteotomy site (with a motorized saw), acute intraoperative distraction until “stabilization” achieved by soft tissue tensioning (typically 1 to 2 cm), with relatively rapid distraction (a full turn on the original device effected 1.5 mm distraction; the distraction could be incremental) until the lengthening goal was achieved. At this point, the distraction gap would inevitably have little or no new bone formation except in some younger children, requiring planned second stage iliac crest bone grafting and application of a special distraction plate (AO neutral plate with no holes in the center portion) to bridge the distraction gap, with removal of the fixator. The special distraction plate would be removed after solid union (if it occurred). Unfortunately, although the fixator was serviceable (which subsequent publications confirmed, using the device but corticotomy/gradual distraction methods),8 the Wagner method of lengthening was precisely the opposite, with many reports of high complication rates.

FIGURE 6

FIGURE 6

FIGURE 7

FIGURE 7

Back to Top | Article Outline

DE BASTIANI AND COLLEAGUES

De Bastiani et al9 from Verona, Italy, noting a high rate of complications and revision surgery associated with lengthening by the Wagner technique and apparatus, and clearly familiar with Ilizarov work (Ilizarov publications in Russian are included in his bibliography), sought a better way of lengthening. They significantly improved Western techniques of limb lengthening with the introduction of more serviceable external fixators and, more importantly, a better appreciation of gentler osteotomy and distraction techniques. The fixator (“dynamic axial fixation system” Orthofix S.r.l.) was originally described for external fixation of long bone fractures, but then adapted to allow linear distraction (or controlled compression); a similar modular device with ball-joints between components to allow greater adaptability to deformities was subsequently introduced (Fig. 8).

FIGURE 8

FIGURE 8

Of greater importance was their introduction of several key advances in technique: “corticotomy” (osteotomy by small incision, limited periosteal stripping, outlined by multiple drill-holes); and “callotasis” (distraction delayed (10 to 15 d), with 1 mm/day (in ¼ mm increments) distraction. They also coined the term “healing index” (the total time in fixator/centimeter of length achieved), which they noted to be approximately 38 days in their patients.

Back to Top | Article Outline

GAVRIIL ILIZAROV

Unequivocally, the trumpet announcing the revolution of limb lengthening and deformity correction codified by Professor Gavriil A. Ilizarov (Fig. 9A) to most of the Western Hemisphere sounded first in Italy. De Bastiani and colleagues recommendations of low-energy corticotomy (Ilizarov preferred “compactotomy” to imply an effort to preserve the medullary canal and its arterial blood supply) and callotasis are clearly founded in Ilizarov’s work. It was the orthopaedic surgical unit of the Oespedale Generale di Lecco in Lecco, Italy led by Professor Roberto Cattaneo with department members Alessandro Villa and Maurizio Catagni, however, who learned, embraced, modified, and taught to many eager young orthopaedic surgeons (such as myself) both Ilizarovs method and his apparatus, before Ilizarov himself published in English, gave lectures, and less restricted travel to his Institute in Kurgan, USSR became possible. The fixator itself was adaptable to any deformity, as illustrated by the “Ilizarov Man” model, where variations of his tensioned, fine-wire circular fixator are secured to a skeleton, from skull to toes (Fig. 9B). In addition to caring for patients by the tens of thousands, he supervised elegant and detailed animal work using primarily dogs to confirm bony and soft tissue neogenesis effect of tension-stress.10,11 These publications, and Ilizarov textbook,12 edited by Stuart Green, are must-reads for all students and practitioners of limb lengthening.

FIGURE 9

FIGURE 9

The most important advancement in the evolution of Ilizarov’s original apparatus to date has been the introduction of the 6-strut (hexapod) circular fixators, of which the Taylor Spatial frame is the most recognized (Fig. 10). These devices with adjustable struts and associated computer software, on the basis of “platform with 6 degrees of freedom” concept introduced by Stewart,13 allow simultaneous correction of complex, multiplanar deformities.

FIGURE 10

FIGURE 10

Back to Top | Article Outline

THE THOR HEYERDAHL-LECCO CONNECTION

How the Ilizarov method and apparatus came to be known and adopted in northern Italy embodies important social lessons for us all. Thor Heyerdahl (1917 to 2002) was a self-educated Norwegian anthropologist, adventurer, and “diffusionist,” that is, he adhered to the belief of migration of cultures from central Asia to Africa, South America and thence the South Pacific. One of Heyerdahl’s unique characteristics was to prove by unsupported, hands-on reenactments, just how a culture could have migrated, first, from South America by balsa log raft (Kon-Tiki, 1947), cross the Atlantic on papyrus reed vessels (RA I and II, 1969 and 1970) (RA Expeditions),14 and finally from the “cradle of civilization” (the confluence of the Tigris and the Euphrates in modern-day Iraq) on the berdi-reed vessel Tigris (1977/1978).15

Heyerdahl was also a staunch protagonist of embracing cultural diversity. He states his thoughts clearly in the RA Expeditions.15 “On the Kon-Tiki we had been six Scandinavians. This time I felt tempted to assemble on the little reed boat as many nations as space would allow. If we crowded together we might manage seven men. Seven men from seven nations. Since I myself came from the northernmost country in Europe, the southernmost part of Europe should provide a contrast, so Italy would be the obvious answer. Since we Europeans were ‘white’ we ought to have a ‘coloured’ man with us, and the blackest Negroes I had ever seen were in Chad, so it would be logical to take one of the papyrus experts with us. Since the experiment was meant to demonstrate the possibility of contact between the ancient civilization of Africa and America, it would be symbolic to take an Egyptian and a Mexican on the voyage. And, in order to have contrasting ideologies in this international group, it was an appealing idea to take 1 representative from the United States and 1 from the Soviet Union. All the other nations, excluded solely for want of space, could be symbolized by the flag of the United Nations, if we could get permission to fly it.” As it happened, this crew was also as religiously diverse as possible, including Christian, Jew, Muslim, and atheist.

Four men sailed all 3 reed vessel expeditions: Yuri Senkevitch (a Russian pulmonologist); Carlo Mauri (alpinist, photo-journalist, and dear friend of the Lecco surgeons); Norman Baker (USN, ret.), second in command; and Thor Heyerdahl himself. Carlo Mauri had some time before the reed expeditions sustained multiple injuries including an open right tibial fracture, which had been recalcitrant to multiple traditional surgeries in Europe; a persistent draining sinus and deformity are well documented in The Tigris Expedition. Senkevitch, familiar with Ilizarov’s remarkable work, gently encouraged Mauri during the Tigris expedition to seek treatment for his leg by Ilizarov at his Institute in Kurgan. Mauri shrugged off the suggestion [Baker, Norman (Captain, USNR, ret.), personal communication], but when on return to Lecco was informed by his surgeon friends that their next recommendation was an amputation, took Senkevitch up on his offer, and under the latter’s guidance, travelled to Kurgan in 1980. Using his apparatus and method, Ilizarov corrected Mauri’s residual tibial deformity and rid him of infection. Mauri then made it is mission to convince his surgical colleagues to learn about Ilizarov’s apparatus and method. They first invited Ilizarov to speak at a conference in Bellagio, Italy in June 1981. This was followed by a second trip to Lecco, where Ilizarov, arriving by train and bringing sets of tibial frames with him, performed the first Ilizarov apparatus application in the West. The Lecco surgeons subsequently traveled to Kurgan to learn more, and then in turn, began to practice his methods and teach other young surgeons (including myself).

In 2012, the Kon-Tiki Museet in Oslo (which houses the Kon-Tiki and RA II) constructed a temporary exhibit in the Museet honoring the direct role Norwegian favored-son Thor Heyerdahl and his philosophies played in introducing Ilizarov apparatus and method to the West (Fig. 11).

FIGURE 11

FIGURE 11

Back to Top | Article Outline

INTRAMEDULLARY LENGTHENING NAILS

An inescapable bane of external fixation, particularly when circular and used for limb lengthening, is soft tissue scarring, muscle tethering, and pin-track inflammation and infection caused by the wires and half-pins. Intramedullary lengthening devices have thus long been the dream of any who have such dreams. The first true intramedullary lengthening device is attributed to Bliskunov (published in Russian in 1983, although no publications exist in English), followed by the Albizzia,16 and the “Intramedullary Skeletal Kinetic Distractor”17 (ISKD). Each worked in a similar manner, which was distraction by ratchet-like telescopic nails, with distraction effected by either the patient or surgeon rotating the leg (and the rod components). Although effective in avoiding external fixation, patient intolerance of the rotations and mechanical failures17 doomed these devices (rightly) to transient existence; none are currently available.

The most significant advance in limb lengthening in our time is the development of effective motorized nails18,19 which not only avoided external fixation elements, but are activated transcutaneously without rotation or other manipulations required of the patient or the surgeon. Unequivocally, these devices represent a major advance in limb lengthening by significantly reducing the patient’s pain and discomfort while facilitating more rapid and effective rehabilitation (Figs. 12A and B). At the same time, the major complications of limb lengthening remain, as in the end, we are still trying to overcome the resistance of the soft tissues to lengthening.20,21 The wise young surgeon will do well to evaluate, counsel, treat prospective limb lengthening patients as if it were to be accomplished by external fixation, rather than fall into the trap of proceeding with this challenging procedure because it is “easier.”

FIGURE 12

FIGURE 12

Back to Top | Article Outline

CONCLUSIONS

One thing that becomes clear when reviewing available literature (in English, I confess) addressing limb lengthening is a sense of a perpetual circle of “discovery” of things previously described. We do well to remember that it was Codivilla1 who pointed out the resistance of the soft tissues to lengthening (although he sought to overcome it with violence); Putti2 who introduced an external fixator and continuous traction for lengthening, and pointed out that the osteotomy should be performed in such a way as to promote the formation of callus; Abbott and Saunders4 who neatly summarized still-valid complications of limb lengthening; and Bost and Larsen22 who first described lengthening over an intramedullary (Rush) rod in 1956.

We have witnessed extraordinary advances in modern times, specifically Ilizarov apparatus and method incorporating low-energy osteotomy, delayed distraction, gradual distraction, fine-wire fixation of small or poor bone, and a near-universally adaptable circular fixator; sophisticated 6-strut (hexapod) circular fixators and software programs to gradually correct complex deformity; and the introduction of reliable “motorized” intramedullary lengthening rods which clearly provide greater comfort and easier rehabilitation for patients undergoing this arduous procedure. However, it is still those soft tissues providing resistance to lengthening that we must overcome without harm to our patients. We must also continue to ask (and answer) the “why are we having to do this anyway?” for at least congenital limb deficiencies, determine what goes awry during embryonic development of the limbs, and how to correct that biologically.

Back to Top | Article Outline

ACKNOWLEDGEMENTS

Author thanks Ms Mary Peters, MLS, AHIP, Manager of the Texas Scottish Rite Hospital for Children’s Medical Library for her diligent efforts to obtain copies of the historical publications cited in this article.

Back to Top | Article Outline

REFERENCES

1. Codivilla A. On the means of lengthening, in the lower limbs, the muscles and tissues which are shortened through deformity. J Bone Joint Surg Am. 1905;s2–2:353–369.
2. Putti V. The operative lengthening of the femur. 1921. Clin Orthop Relat Res. 1990;250:4–7.
3. Paterson D. Leg-lengthening procedures. a historical review. Clin Orthop. 1990;250:27–33.
4. Abbott LC, Saunders JB. The operative lengthening of the tibia and fibula: a preliminary report on the further development of the principles and technic. Ann Surg. 1939;110:961–991.
5. Abbott LC. The operative lengthening of the tibia and fibula. J Bone Joint Surg. 1927;9:128–152.
6. Compere EL. Indications for and against the leg lengthening operation. J Bone Joint Surg. 1936;18:692–705.
7. Wagner H. Operative lengthening of the femur. Clin Orthop Relat Res. 1978;136:125–142.
8. Aaron AD, Eilert RE. Results of the Wagner and Ilizarov methods of limb-lengthening. J Bone Joint Surg Am. 1996;1:20–29.
9. De Bastiani G, Aldegheri R, Renzi-Brivio L, et al. Limb lengthening by callus distraction (callotasis). J Pediatr Orthop. 1987;7:129–134.
10. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;239:263–285.
11. Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res. 1990;250:8–26.
12. Ilizarov GAGreen SA. Transosseous Osteosynthesis. Berlin Heidelberg: Spinger-Verlag; 1992.
13. Stewart D. A platform with six degrees of freedom. Proc Inst Mech Eng. 1965;180:371–378.
14. Heyerdahl T. The Ra Expeditions (translated by Patricia Crampton). Garden City, NY: Doubleday and Company; 1971.
15. Heyerdahl T. The Tigris Expedition: In Search of Our Beginnings. Garden City, NY: Doubleday and Company; 1981.
16. Guichet JM, Deromedis B, Donnan LT, et al. Gradual femoral lengthening with the Albizzia intramedullary nail. J Bone Joint Surg Am. 2003;85-A:838–848.
17. Cole JD, Justin D, Kasparis T, et al. The Intramedullary Skeletal Kinetic Distractor (ISKD): first clinical results of a new intramedullary nail for lengthening of the femur and tibia. Injury. 2001;32(suppl 4):SD129–SD139.
18. Baumgart R, Betz A, Schweiberer L. A fully implantable motorized intramedullary nail for limb lengthening and bone transport. Clin Orthop Relat Res. 1997;343:135–143.
19. Shabtai L, Specht SC, Standard SC, et al. Internal lengthening device for congenital femoral deficiency and fibular hemimelia. Clin Orthop Relat Res. 2014;472:3860–3868.
20. Black SR, Kwon MS, Cherkashin AM, et al. Lengthening in congenital femoral deficiency: a comparison of circular external fixation and a motorized intramedullary nail. J Bone Joint Surg (Am). 2015;97:1432–1440.
21. Burghardt RD, Herzenberg JE, Specht SC, et al. Mechanical failure of the intramedullary skeletal kinetic distractor in limb lengthening. J Bone Joint Surg (Br). 2011;93:639–643.
22. Bost FC, Larsen LJ. Experiences with lengthening of the femur over an intramedullary rod. J Bone Joint Surg. 1956;38A:567–584.
Keywords:

leg lengthening history; external fixators; Thor Heyerdahl

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.