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deformity surgery

Limb Reconstruction

Limb reconstruction is a term used to describe a very specialized field in orthopaedic and plastic surgery. This encompasses a process whereby a destroyed / deformed limb or limb segment is reconstructed using the body’s own tissues, implantable materials / prostheses or a combination of both. Limbs can end up requiring reconstruction as a result of trauma, infection, tumours or congenital (inborn) conditions.

Generally this is very exacting surgery, performed by a small number of dedicated surgeons (typically orthopaedic or plastic/reconstructive surgeons). As the types of problems faced in limb reconstruction surgery are quite complex, a team of health care professionals are generally involved in the patient’s treatment. Often, patients end up at a reconstruction surgeon after many previous failed attempts at correcting their problem. Obviously this makes the surgery even more challenging.

Treatment might involve techniques like tissue transfer using flaps, external fixation with distraction histiogenesis or treatment with internal devices like joint replacement techniques using implantable materials.

Tissue transfer using flaps is a technique whereby defects (i.e. ‘holes’) in bone or flesh are filled by moving living pieces of tissue (like skin, muscle, bone or combinations) from areas of the body where they are not crucial to the areas with the defects.

External fixation involves fixation of the limb or limb segment in an external frame (scaffolding). This external fixator can then be used to correct deformities, fix fractures, to stretch out soft tissue stiffness and even to lengthen bones and limbs!

Distraction histiogenesis is the term used for the process whereby the body forms new tissues under the influence of a stretching force being applied to limb. This phenomenon can be used to lengthen limbs, correct deformities and to move segments of living bone into large defects. Specialised joint replacement techniques are utilized where joints are destroyed as part of the limb needing reconstruction. Whereas standard joint replacement surgery is practiced widely, specialized replacements might need partial or complete replacement of, not only the affected joint, but indeed of parts or the whole affected bone.

A special subgroup of patients requiring limb reconstruction is the group of patients requiring limb lengthening surgery. This is surgery where a limb is lengthened, generally using an external fixation device and applying the principle of distraction histiogenesis. This can be very satisfying surgery to the patient as well as the surgeon, if done for the correct indications and if performed correctly.

Limb reconstruction surgery is difficult and requires a team effort between an experienced surgeon, his support team and the patient.

A non-union of a bone is any situation where a bone does not want to heal. A non-union can result from a previous fracture, an osteotomy (bone cut made by a surgeon) or after an attempt at stiffening a joint (arthrodesis). Generally, bones proceed to proper healing. For this to happen, they need three things: a good blood supply, stability and bone contact. The blood supply makes sure that the bone ends receive oxygen and nutrients necessary to stimulate bone healing. The blood also carries cells that help the bone to grow. The second thing that bones need to grow together is something called stability. Simply put, the bone ends shouldn't move around too much, as this disrupts the new bone growth. Lastly, bone ends need to be in contact, otherwise they simply can't grow together. Sometimes bones can heal although there might be a small gap between the bone ends. This is, however the exception rather than the rule.

Various other factors can also influence bone healing. The most important of these are smoking, general health status and nutrition. Smoking prolongs the time that bones take to heal. Full stop. Bones can take 2 to 3 times longer to heal in smokers than in non-smokers. The general health status is important, because chronic diseases like immunodeficiency and diabetes can have profound effects on bone healing. Nutrition is very important as it provides the necessary building blocks for the bones to heal.

Once a non-union is established, management will depend on the underlying cause of the non-union. If the cause is biological (i.e. poor blood supply, nutritional problems or systemic diseases), these conditions will need to be addressed and sometimes a bone graft might be performed. Bone grafting is where living bone is taken from somewhere else in the body in order to provide growth factors, cells and a scaffold to facilitate healing at the non-union site. Should a non-union be the result of a biomechanical reason (i.e. instability or poor bone contact), this will need to be addressed with proper fixation of the bone ends, either with internal devices (plates, screws, pins etc.) or with external devices (e.g. external fixators, splints, casts).

Additional measures can be taken to facilitate union. These can include the use of pulsed ultrasound or electromagnetic fields. Other modalities include the use of synthetic bone graft substitutes, growth factors etc.

Non-unions can be very challenging to treat and it is important to be managed by someone experienced in the management thereof.

The necessity for limb lengthening, for correction of congenital and acquired deformities of the upper and lower limbs or for reconstruction of a post traumatic limb defect may bring you to this page.

May this information and perspective empower you to be an active participant in your recovery process and may it reduce the discomfort and anxiety associated with the unexpected.

Management of the mangled extremity is one of the most challenging tasks in orthopaedic trauma care. Deciding if an amputation or reconstruction is best for an individual patient is most of the time a difficult and complex decision. Many factors including patient and injury variables must be considered in the assessment of a treatment strategy aimed at the best possible outcome. The instinctive desire on both the patient and physician’s part to save a limb at all costs must be tempered by the expected long-term functional result. Once the patient has been stabilized in the emergency setting and concomitant life threatening injuries managed, attention can be directed to the injured limb.

Your orthopaedic surgeon plays a central role in the diagnosis and individualized treatment and rehabilitation plan for your specific injury. Hereafter he involves a multidisciplinary team to put this plan into action. Besides the orthopaedic surgeon, the team consists of an anaesthesiologist, physician or intensivist, physiotherapist, nurses and occupational health worker. Each highly skilled member is dedicated to implement their specific part for a successful outcome.

Before you go to theatre the anaesthesiologist will do a preoperative examination and risk analysis with or without consultation of the attending physician. Apart from managing a patient’s pre-existing medical conditions during anaesthesia and the basic necessity of safety during the operation, the injury itself and the specific surgical procedure provide unique challenges for the anaesthesiologist. Certain special investigations and treatments may be necessary preoperatively to prepare the patient for his/her anaesthetic. Your anaesthesiologist will then discuss the intra-operative anaesthetic plan as well as the postoperative pain-control protocol that will be best suitable for your situation. Your anaesthetic will most of the time be a general anaesthetic coupled with some type of local anaesthetic technique (local infiltration, peripheral block, spinal or epidural). This multimodal pain strategy provides a more comfortable patient and staff experience, reduces the general anaesthetic requirements of the patient, improves his/her anaesthetic stability and generally improves patient morbidity and mortality. Multimodal techniques reduce the dose of each individual drug which, in turn, reduces the potential for adverse drug effects. Intervening before the pain system becomes sensitized is an absolute necessity when your goal is to attenuate the pain associated with the surgery and to give optimal patient benefit. Unfortunately every drug has the potential to cause side-effects and depending on the patient’s genetic make-up, age, pre-existing conditions and chronic medication, each patient displays an individualized susceptibility towards the multiple potential adverse effects. The most common dichotomy seen is the excellent pain relief versus the sometimes overwhelming side-effect of nausea and vomiting caused by the opiates. Side-effects may be the first sign of a need to discontinue the mode of treatment, change the dosage or switch to a different drug. Fortunately there are superb drug options on the market today that can manage most of these side-effects. For the extensive surgical interventions we prefer to send the patient to a high care facility postoperatively with a Patient Controlled Pain Pump (PCA). These devices are connected to your IV line and deliver a pre-programmed dosage of analgesic (calculated on your body weight) whenever you press the pain button. If solely handled by the patient this modality is extremely efficient and safe with a built-in lock out time to prevent overdose. This intense acute-pain-control-method is usually only necessary for the first postoperative day where after the pain protocol is continued in the ward with a combination of injections, infusions and pills till discharge.

In special situations a need for chronic pain management arises for instance for phantom limb pain after limb amputation where the classic analgesics are combined with antidepressants, anticonvulsants and/or neuroleptics.

Another special concern with limb reconstruction surgery apart from pain control, is prevention of deep venous thrombosis. This is a potential problem because multiple surgeries and limited mobilization predispose certain high risk patients to thrombosis. These patients will be identified preoperatively and pharmacological and mechanical preventative measures will be implemented. In the treatment of severely injured limbs the use of flaps may be necessary to close open parts of the wound. Flaps are simply layers of tissue with an intact pre-existing blood supply that are moved to cover an adjacent wound. In this instance a Plastic Surgeon joins the team and performs the surgery in collaboration with your Orthopaedic Surgeon. There are special anaesthetic considerations with flap surgery and more invasive monitoring methods like a central venous line and an arterial line is usually indicated. For more information about your anaesthesiologist, the green anaesthetic form to be completed with hospital admission, anaesthetic information sheets, consent forms, fees and accounts and additional interesting web links visit www.gseven.org

While most patients experience some level of anxiety about their injured limb, it is sometimes the prospect of an anaesthetic with it’s accompanying fears about awareness, not waking up, excruciating postoperative pain and extreme vomiting that overshadows all else. Please feel free to discuss any concern that you may have with your anaesthesiologist. Be assured that each member of this team has your best interest at heart and is committed to provide you with the highest quality of health care. We wish you a safe and comfortable perioperative experience and are dedicated to walk the path towards your recovery with you.

An external fixator is essentially a type of a scaffolding which is constructed outside a limb or limb segment. It is then attached to the bone(s) in the limb by way of pins or wires. These pass through the skin and soft tissues into the bone.

The aim of an external fixator is to stabilize a bone or limb from the outside. This is sometimes necessary in fracture treatment, limb lengthening and other limb reconstruction applications like bone transport.

Fixators are generally of two types, namely circular and monolateral. Circular fixators (like the Ilizarov / Taylor Spatial Frame / Orthofix Sheffield Ring Fixator / Truelok / TL-Hex) surround the bone and are a bit more cumbersome, but are generally a lot stronger and more versatile than the monolateral fixators. Monolateral fixators (like the Orthofix Pro-Callus and LRS and Smith & Nephew Jet-Ex fixators) are generally simpler to construct and easier to wear, but tend to be less stable and less versatile.

A deformity in bone is the result of growth abnormalities, trauma, or previous surgery. This results in a crooked bone. The effect of such a deformity is that it causes abnormal loading of the joints in the affected limb, possibly resulting in osteoarthritis. The correction is usually achieved by making an osteotomy (bone cut) and then straightening the limb. The straightening is often achieved with the use of an external fixator device. The procedure is similar to a limb lengthening and the potential risks and recovery are very similar.

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This is a procedure where one or both legs can be lengthened by a predetermined amount. This is normally done to correct a difference in the lengths of the legs due to growth abnormalities, infection or trauma. Occasionally and in highly selected cases it is performed to increase a patient’s stature. Leg lengthening surgery entails breaking the bone that needs to be lengthened, and then gradually stretching the newly formed callus (bone) until the desired length is achieved. The bone lengthening is achieved either with the use of an external fixator device or an implantable lengthening nail device. Lengthening proceeds at a rate of 1mm per day i.e. it takes about 10 days to achieve 1cm of lengthening. Once this length is achieved, the bone needs to strengthen up sufficiently to function without the fixation device. Unfortunately this takes quite long and can be another month to month-and-a-half for every centimetre of lengthening achieved. This is a procedure that is performed regularly in our practicefor a variety of indications.

Potential Risks

  • Anaesthetic risk
  • Scar formation
  • Numbness on the skin of a small area around the scars or pins
  • Wound infection
  • Pin tract infection related to the external fixator
  • Inadequate lengthening achieved (usually when the lengthening has to be stopped due to slow bone growth or joint stiffness)
  • Slight deformity of the bone after lengthening
  • Pain related to the bone cut (osteotomy) and/or the lengthening itself (tissue stretching)
  • Non-union of the osteotomy site (the bone cuts struggle to heal)
  • Joint stiffness, especially in the knee and ankle because the muscles shorten relative to the bone

Recovery

Patients normally go to the high care facility for the first 24 hours after surgery to ensure proper pain control. Pin site dressings are applied to the external fixator pins. The nursing sisters will demonstrate the pin site care whilst in hospital. An intensive physiotherapy programme is instituted with a focus on early weight-bearing, as well as the maintenance of joint movement. Crutches are provided. The orthotists will bring a special foot splint to maintain a normal foot position throughout. Depending on pain control and mobility, the patient is discharged between day 3 and day 5 after surgery. The first follow-up visit is about 10 days after the surgery. At this visit the lengthening adjustments and pin care protocol will be demonstrated again. Lengthening adjustments (on the external fixator) commence and are continued by the patient at home. The patient is seen every 2 weeks during the lengthening phase for a clinical evaluation and x-rays. Once the desired length is achieved, adjustments stop and bone healing is awaited. During this phase, the patient is seen every 4 weeks for an x-ray. Physiotherapy continues. The patient is encouraged to bear weight as soon as possible after surgery, as this improves bone healing. Once the bone is deemed strong enough, the external fixator can be removed.

Osteomyelitis treatment

– infection in bone is a very severe condition that requires prolonged and specialized treatment. All the different techniques in reconstructive surgery arein employed in an attempt to provide an aligned drainage free limb. Once again a structured team approach is required to provide the best care.

Please visit orthoinfo.aaos.org for further information on post traumatic osteomyelitis.