Stature Lengthening Complications
No one wants unexpected problems, complications, and cost. For these reasons, we are very conservative regarding many aspects of the limb lengthening process. Dr. Paley is vigilant about anticipating problems and preventing complications. Many complications lead to additional surgery and therefore to additional costs. For more information on the complications of limb lengthening, see here. The following is a list of some of the potential complications for the stature patient:
This is a complication that is very rare and which can be prevented by venting the bone during the reaming (drilling) of the medullar canal of the bone. Dr. Paley vents the canal by drilling holes at the planned level of the osteotomy prior to the reaming process. As the pressure builds up in the canal the reamings eject out of the holes preventing fat embolism. Fat embolism can make a patient very sick requiring stay in the ICU. Patients can even die from fat embolism. Dr. Paley has only seen fat embolism twice in his career. Both occurred more than 10 years ago before he developed a special venting method to prevent this complication. Fortunately both patients recovered uneventfully. Dr. Paley has never had a patient die from fat embolism complications.
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
Deep vein thrombosis (DVT) can occur after any orthopedic surgery or after any fracture. Fortunately we have a very low rate of this complication. Prevention is key. We use anticoagulants after surgery in the hospital and each patient is sent home with a prescription for an anticoagulation drug to be taken until the end of the distraction phase. The cost of this medicine must be borne by the patient and is not included in our cost estimate. Dr. Paley has seen very few cases of DVT and fortunately none of them resulted in pulmonary embolism (PE). PE occurs if the clot dislodges and wanders to the lungs. It can cause shortness of breath, chest pain and even death. This is why we are careful to protect against this. Taking oral contraceptives and smoking increases the risk of DVT. All of our patients are placed on an anticoagulant, usually Xaralto, a new, low-risk medication. This cost is not included in the cost estimate and is the patient’s responsibility.
Premature consolidation is when the patient’s bone heals prematurely, bridging the gap, and preventing further lengthening. Premature consolidation (PC) can occur with any method if the patient is a rapid bone healer. The patient, in these cases, is able to make bone faster than the speed at which the bone is being lengthened. The only way to prevent this is to speed up the lengthening intentionally for a week or two. The PRECICE nail, with its rate control, allows the surgeon to do this. If premature consolidation does occur, it requires a small outpatient surgery to re-break the bone through a tiny incision. With the ISKD and Albizzia internal nails, premature consolidation was a well-recognized complication due to the lack of rate control. Since lengthening in both of these devices occurred by movement through the osteotomy site and since movement through the osteotomy site can cause pain and muscle spasm, the patient’s muscles sometimes would prevent the movement and therefore the lengthening would not occur. In other cases, both the ISKD and the Albizzia have had broken mechanisms that fail to lengthen during the distraction phase leading to premature consolidation. The treatment in these cases was to not only re-break the bone but also to change the device to a new one. Although in each case the company provided a new device at no additional cost, the patient still had to bear the cost of an additional outpatient surgery. With the PRECICE and the PRECICE 2, this complication almost never occurs.
Delayed or Failure of Consolidation
Slow or failed bone healing can occur with any lengthening surgery and can result in delayed consolidation or a failure to consolidate. The best treatment is prevention. We start by identifying factors that may slow healing prior to surgery: low Vitamin D level, smoking (including exposure to secondhand smoke), menopause, and the use of certain medications including anti-inflammatory medicine, anticonvulsant medication, and other medications such as Accutane. We also recommend supplements to help the bone heal faster (e.g. Silical, Silical 2, and Boost from Bone Health Now). If a patient’s blood work shows low Vitamin D levels, we recommend taking Vitamin D supplements. We try and identify these factors in advance of surgery. In surgery there are several steps that help maximize bone healing. Dr. Paley uses a technique he originally developed in 1990 to allow bone marrow to surround the area of the bone cut. This is done by making drill holes at the level of the planned osteotomy before reaming the bone. Stable fixation is also important so the choice of nail length and diameter are important as well as the level of the osteotomy. Even the type of osteotomy affects the rate of bone healing. Cutting the bone with multiple drill holes and an osteotome is the most minimally invasive way, while using an intramedullary saw or performing an open osteotomy has higher failure rates. All of these are surgeon-controlled parameters and are based on surgeon knowledge and experience. Choosing the wrong level or method of osteotomy or the wrong diameter or length of implant can significantly impact the result.
The next most important factor is the rate of distraction. Lengthening too quickly can lead to delayed or complete or partial failure of bone formation. Rapid distraction was the most common cause of poor bone formation with the ISKD. This is not a problem with the PRECICE nail since it has complete rate control. Poor bone healing can be recognized during the lengthening process. Once it is recognized, the rate of distraction can be slowed. With the PRECICE the lengthening can be reduced to any level or even stopped. If, despite these changes, the bone healing remains poor, the lengthening can be reversed until better bone formation is seen. The bone can then be re-lengthened. This can only be done with the PRECICE. Going in reverse is not possible with the ISKD, Albizzia, or the Fitbone. This is a huge advantage that is possible with external fixation and now with the PRECICE.
If delayed healing occurs despite all of the above steps, we start using the “accordion technique.” Using an ERC device, the bone is compressed 1mm per day and distracted 1mm per day. This cycle is repeated several times a day. This stimulates bone healing and avoids the need for surgery. Delay or failure of bone formation can delay weight-bearing and increase the period of disability and recovery. Furthermore, it can lead to the need for surgery to induce the bone to heal. Such surgery requires a bone graft and is not a small operation and can be quite costly. Therefore, having a device like the PRECICE, that can prevent or treat the problem without the need for surgery, is a major advantage.
Nerve injury can occur with any lengthening surgery but is usually uncommon if the rate of distraction does not exceed 1mm per day and if the amount of lengthening is restricted. Rate control is the most important factor to prevent nerve damage. Recognition of nerve symptoms is important. The lengthening should be stopped or slowed in such cases. If any motor symptoms (weakness or muscle paralysis) occur, a nerve decompression should be done as soon as possible. This is a small outpatient surgery. In most cases, it is the peroneal nerve that is in the most danger of injury. It is important that the surgeon know how to decompress this nerve to prevent foot drop. Delay in decompression can lead to permanent foot drop. With the PRECICE and its complete rate control, nerve injury is very rare, and greater lengthening can be performed safely.
Muscles normally get tight with lengthening. A muscle contracture occurs when a muscle gets so tight that it prevents the joint from moving through its entire range-of-motion. To prevent muscle contractures, physical therapy (PT) is essential. The patient should do daily stretches of the muscles and joints most at risk (e.g. knee joint and quadriceps muscles for femoral lengthening and ankle joint and Achilles tendon for tibial lengthening). In addition to professional PT, the patient should do their own stretches at home several times per day. Physical therapy is essential to the lengthening process. It is, however, expensive. Dr. Paley will not consider doing a lengthening if the patient is not willing to do PT. This is not an option for reducing cost. The controlled rate of lengthening with the PRECICE minimizes the risk of muscle contractures and muscle spasm but it does not obviate the need for PT. Maintaining range-of-motion and preventing contractures during lengthening decreases the rehabilitation time required to return to normal function after the lengthening is finished. A fixed contracture of the knee or ankle can lead to disability and the need for more prolonged PT along with associated expenses. If, despite additional PT, the contracture does not resolve, additional surgery to lengthen muscles, tendons, and fascia may be required. Dr. Paley tries to anticipate this by prophylactically lengthening certain soft tissue structures to prevent contractures (e.g. iliotibial band). If this is done at the initial surgery, the additional cost is small. If soft tissue lengthening surgery is required at a later date, the cost is much higher since one also has to pay for the hospital and anesthesia costs. Dr. Paley has a rehabilitation department on-site. All of the physical therapists have been specially trained to treat lengthening patients and know how to identify contractures and other complications as they arise. Furthermore, the physical therapy staff communicates with Dr. Paley during every follow up and can keep him alerted to any potential complications. PT is included in the cost estimate for the duration of the lengthening period. For more information, see Rehabilitation & Physical Therapy.
During tibial lengthening the fibula has to be lengthened as well. The implantable lengthening device only lengthens the tibia. The fibula has to be fixed to the tibia so that the two bones lengthen together. If the fibula is not fixed or not fixed adequately, it will not lengthen as much as the tibia which will lead to severe consequences including subluxation (partial dislocation), arthritis of the ankle, and flexion contractures of the knee. The method of fixation is critical. Many surgeons only fix the lower end of the fibula to the tibia. This can lead the fibula to prematurely consolidate and to pull down and dislocate from the tibia at its upper end. It is important to fix the fibula at both ends. With external fixation, the fibula can be fixed with the wires of the external fixator. With implantable lengthening, the fibula must be fixed with screws to the tibia; one screw at the upper end and one at the lower end. The angle, level, position, diameter, and type of screw are all important. A common mistake is to put the screw in horizontally between the two bones; this is not strong enough to prevent the fibula from pulling away from the tibia at the ankle. This distinction is very subtle and even a few millimeters of difference in length of the fibula at the ankle can lead to short term and/or long term consequences for the patient. Removing a segment of the fibula to prevent the fibula from not separating is another common method that should be abandoned. It leads to a nonunion of the fibula which can lead to a stress fracture of the tibia at a later date. Furthermore, it usually does not prevent the fibula from pulling away from the tibia. Therefore, fibular complications have nothing to do with the type of implantable lengthening device but rather with the method the surgeon chooses to fix the fibula to the tibia and the method of cutting the fibula bone.
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