Lower-limb lengthening in short stature. An electrophysiological and clinical assessment of peripheral nerve function

Peripheral nerve injuries in the pediatric population: a review of the literature. Part I: traumatic nerve injuries

OBJECTIVE

This article reviews the clinical results that can be obtained after repair of a traumatic peripheral nerve injury in the pediatric population.

METHODS

A systematic review of the published literature has been made.

RESULTS

Functional outcome after major nerve injuries is sometimes disappointing in adults. However, children have been reported to experience much better functional results after nerve repair than adults. Moreover, recovery generally is faster in children. The superior capacity of children's central nervous system to adapt to external or internal environmental changes (neural plasticity) and the shorter recovery distance from the axon repair site to the target muscle are claimed to be crucial determinants of their favorable outcomes. Moreover, even in the pediatric population, it has been demonstrated that functional results are better the younger the patient is, including better clinical results in those injured in early childhood (< 6 years old) than in those injured in adolescence. Other favorable prognostic factors include the type of nerve injury (with complete transections doing less well than crush injuries) and the timing of surgery (with better outcomes after early repairs).

CONCLUSIONS

All efforts should be done to repair in a timely and adequate fashion traumatic peripheral nerve injuries in children, as the results are good.

Limb lengthening in achondroplasia

BACKGROUND

Stature lengthening in skeletal dysplasia is a contentious issue. Specific guidelines regarding the age and sequence of surgery, methods and extent of lengthening at each stage are not uniform around the world. Despite the need for multiple surgeries, with their attendant complications, parents demanding stature lengthening are not rare, due to the social bias and psychological effects experienced by these patients. This study describes the outcome and complications of extensive stature lengthening performed at our center.

MATERIALS AND METHODS

Eight achondroplasic and one hypochondroplasic patient underwent bilateral transverse lengthening for tibiae, humeri and femora. Tibia lengthening was carried out using a ring fixator and bifocal corticotomy, while a monolateral pediatric limb reconstruction system with unifocal corticotomy was used for the femur and humerus. Lengthening of each bone segment, height gain, healing index and complications were assessed. Subgroup analysis was carried out to assess the effect of age and bone segment on the healing index.

RESULTS

Nine patients aged five to 25 years (mean age 10.2 years) underwent limb lengthening procedures for 18 tibiae, 10 femora and 8 humeri. Four patients underwent bilateral lengthening of all three segments. The mean length gain for the tibia, femur and humerus was 15.4 cm (100.7%), 9.9 cm (52.8%) and 9.6 cm (77.9%), respectively. Healing index was 25.7, 25.6 and 20.6 days/cm, respectively, for the tibia, femur and humerus. An average of 33.3% height gain was attained. Lengthening of both tibia and femur added to projected height achieved as the 3(rd) percentile of standard height in three out of four patients. In all, 33 complications were encountered (0.9 complications per segment). Healing index was not affected by age or bone segment.

CONCLUSION

Extensive limb lengthening (more than 50% over initial length) carries significant risk and should be undertaken only after due consideration.

Bilateral double level tibial lengthening in dwarfism

PURPOSE

Outcome assessment after double level tibial lengthening in patients with dwarfism.

METHODS

Fourteen patients with dwarfism were analyzed after bilateral simultaneous double level tibial lengthening.

RESULTS

Average age was 15.1 years. Average lengthening was 13.5 cm. The two levels were lengthened by an average of 7.5 cm proximally and 6.0 cm distally. Concomitant deformities were also addressed during lengthening. External fixation treatment time averaged 8.8 months. Healing index averaged 0.7 months/cm.

CONCLUSION

Bilateral tibial lengthening for dwarfism is difficult, but the results are usually quite gratifying.

The Experimental Study on Promoting the Ilizarov Distraction Osteogenesis by the Injection of Liquid Alg/nHAC Biocomposites

Limb lengthening is frequently utilized in treating limb length inequalities, angulation deformities, nonunions, complex fractures, and deficiencies after tumor resection in more recent year. The procedure of limb lengthening pioneered by Ilizarov is now a widely accepted method for correcting limb length inequality and short stature as well as for bridging large defects in long bones. In order to promote bone healing during distraction osteogenesis and reduce the complications caused by limb lengthening pioneered, an alginate/nanohydroxyapatite/collagen (Alg/nHAC) composite was fabricated. General observation, histologically morphological observations, X-ray examination, biomechanical test, bone density, and the percentage area of bone trabecula were used to assay the ability of Alg/nHAC composite to promote bone healing. The present study demonstrates that the injection of liquid Alg/nHAC composites can significantly promote distraction osteogenesis. Alg/nHAC composite is promising for clinical application, solving the healing problem of backbone osteotomy and the fixing problem of metaphyseal backbone.

Limb lengthening and peripheral nerve function-factors associated with deterioration of conduction

BACKGROUND

and purpose Limb lengthening is performed for a diverse range of orthopedic problems. A high rate of complications has been reported in these patients, which include motor and sensory loss as a result of nerve damage. We investigated the effect of limb lengthening on peripheral nerve function.

PATIENTS AND METHODS

36 patients underwent electrophysiological testing at 3 points: (1) preoperatively, (2) after application of external fixator/corticotomy but before lengthening, and (3) after lengthening. The limb-length discrepancy was due to a congenital etiology (n = 19), a growth disturbance (n = 9), or a traumatic etiology (n = 8).

RESULTS

2 of the traumatic etiology patients had significant changes evident on electrophysiological testing preoperatively. They both deteriorated further with lengthening. 7 of the 21 patients studied showed deterioration in nerve function after lengthening, but not postoperatively, indicating that this was due to the lengthening process and not to the surgical procedure. All of these patients had a congenital etiology for their leg-length discrepancy.

INTERPRETATION

As detailed electrophysiological tests were carried out before surgery, after surgery but before lengthening, and finally after completion of lengthening, it was possible to distinguish between the effects of the operation and the effects of lengthening on nerve function. The results indicate that the etiology, site (femur or tibia), and nerve (common peroneal or tibial) had a bearing on the risk of nerve injury and that these factors had a far greater effect than the total amount of lengthening.

The effects of botulinum toxin A on muscle histology during distraction osteogenesis

Distraction osteogenesis is a highly successful method of bone formation, yet muscle fibrosis and contractures can result in significant morbidity. In the current study, we investigate the efficacy of botulinum toxin A in preventing fibrosis and potentially increasing muscle development in distracted muscles. Fifteen New Zealand White rabbits underwent tibial distraction at 1.5 mm/day until a 20% gain was achieved. Treatment groups were divided by drug (saline or botulinum toxin) and target muscle (gastrocnemius or tibialis anterior). Two additional control animals received no treatment. Bromeodeoxyuridine was delivered continuously throughout the 8-week experiment, and following muscle harvest. Tissues were stained for BrdU, Pax-7, vimentin, and haematoxylin and eosin staining. Mitotic activity increased in all distracted animals; however, in the animals receiving botulinum toxin A injections into the gastrocnemius, the antagonist tibialis anterior suffered up to 9% less fibrosis than distraction alone (p = 0.024). Use of botulinum A toxin did not appear to promote or improve neogenesis of muscle fibers, nor did it decrease fibrosis in the injected muscles. It appears from this study, and a previously published study on the effects of this toxin on muscle function, that botulinum A toxin maybe of some benefit in decreasing morbidity in the antagonist muscle but not the muscle injected with the toxin.

The effect on the extracellular matrix of the deep fascia in response to leg lengthening

BACKGROUND

Whereas the alterations of diverse tissues in cellular and molecular levels have been investigated during leg lengthening via microscopy and biochemical studies, little is known about the response of deep fascia. This study aims to investigate the changes of the extracellular matrix in deep fascia in response to leg lengthening.

METHODS

Animal model of leg lengthening was established in New Zealand white rabbits. Distraction was initiated at a rate of 1 mm/day and 2 mm/day in two steps, and preceded until increases of 10% and 20% in the initial length of tibia had been achieved. Alcian blue stain and picrosirius-polarization method were used for the study of the extracellular matrix of deep fascia samples. Leica DM LA image analysis system was used to investigate the quantitative changes of collagen type I and III.

RESULTS

Alcian blue stain showed that glycosaminoglycans of fascia of each group were composed of chondroitin sulphate and heparin sulphate, but not of keratan sulphate. Under the polarization microscopy, the fascia consisted mainly of collagen type I. After leg lengthening, the percentage of collagen type III increased. The most similar collagen composition of the fascia to that of the normal fascia was detected at a 20% increase in tibia length achieved via a distraction rate of 1 mm/d.

CONCLUSION

The changes in collagen distribution and composition occur in deep fascia during leg lengthening. Although different lengthening schemes resulted in varied matrix changes, the most comparable collagen composition to be demonstrated under the scheme of a distraction rate of 1 mm/day and 20% increase in tibia length. Efficient fascia regeneration is initiated only in certain combinations of the leg load parameters including appropriate intensity and duration time, e.g., either low density distraction that persist a relatively short time or high distraction rates.

Effects of botulinum toxin A on functional outcome during distraction osteogenesis

Distraction osteogenesis is useful for correcting limb length inequality, deformities, or short stature. Despite success with bone formation, soft tissue maladaptations including muscle and joint contracture may lead to undesirable results. Botulinum toxin A has been useful in treating spasticity in cerebral palsy, and has been used clinically in select cases to allay contracture in distraction osteogenesis. This study examines the toxin's efficacy in preventing distraction-induced loss of muscle strength and range of motion. The left tibias of 15 New Zealand White rabbits were distracted 1.5 mm/day until approximately a 20% gain was achieved. Each treatment group was divided into animals injected with saline or botulinum toxin in either the gastrocnemius or tibialis anterior muscles. A control group of two additional animals underwent no surgical procedure. Strength and range of motion were assessed prior to, and following, the experiment. At the study's end, animals were euthanized and muscles were harvested, when lengths and weights were recorded. All muscles injected with botulinum toxin showed decreased wet weight and persistent weakness upon completion of the study. Range of motion decreased in all distracted animals. When the gastrocnemius was injected, its strength was reduced but the tibialis anterior strength was preserved, and the limb achieved 22% greater dorsiflexion than saline controls (p = 0.016). When the tibialis anterior received the toxin, plantarflexion was increased by 23% (p = 0.049). Botulinum toxin injection prior to limb distraction increases the "post-lengthened" excursion of the injected muscle and this increased length may have a protective effect on its antagonist. In toxin-injected gastrocnemius muscles, the level of equinus contracture is reduced due to length gains in the Achilles tendon while the anterior tibialis maintains its ability to generate torque. Injection of botulinum toxin in the gastrocnemius may minimize equinus contracture and protect the anterior tibialis from damage during human tibial lengthening. Longer follow-up studies are needed to ensure that toxin-induced muscle weakness resolves with time.

Induction of tumor necrosis factor-alpha in Schwann cells after gradual elongation of rat sciatic nerve

BACKGROUND

Although limb lengthening has become a common treatment, the biochemical responses underlying the adaptation of elongated nerves are unclear. The purpose of this study was to clarify whether expression of cytokines and neurotrophins is altered in gradually elongated peripheral nerves.

METHODS

Left sciatic nerves of adult rats were elongated by lengthening the femur up to 20 mm at a rate of 1, 2, or 20 mm/day. The ipsilateral and contralateral sciatic nerves of each group were resected 1, 4, 8, and 16 days after 20 mm of lengthening. mRNAs for interleukin-1beta, interleukin-6, tumor necrosis factor-alpha (TNFalpha), nerve growth factor, brain-derived neurotrophic factor, neurotrophin-3, and neurotrophin-4/5 were semiquantified by reverse transcription-polymerase chain reaction. Histological changes were assessed by immunoperoxidase and immunofluorescence staining.

RESULTS

Expression of TNFalpha mRNA was markedly induced in the ipsilateral sciatic nerves of the gradually elongated, 1 mm/day and 2 mm/day groups, although to a lesser extent than in the acutely elongated, 20 mm/day group. In contrast, mRNAs for other factors remained undetectable. The mRNA level for TNFalpha in each group was highest 1 day after 20 mm of lengthening. The highly up-regulated level in the acute group declined rapidly within 4 days and slowly thereafter; in contrast, the decrease in the gradual groups was always slow. Even 16 days later, the levels in all groups remained significantly elevated. Unexpectedly, TNFalpha mRNA expression was also induced in the contralateral side of all groups. Immunohistochemical staining showed that TNFalpha-immunoreactive cells in gradually elongated nerves were also positive for S-100 protein but negative for proliferating nuclear cell antigen, indicating that TNFalpha was produced by nonproliferating Schwann cells.

CONCLUSIONS

Gradual nerve elongation by limb lengthening induces production of TNFalpha in Schwann cells. Presumably, TNFalpha plays a critical role in the adaptation of peripheral nerves to elongation.

Nerve lesions associated with limb-lengthening

BACKGROUND

Nerve injury is one of the most serious complications associated with limb-lengthening. We examined the risk, assessment, and treatment of nerve lesions associated with limb-lengthening.

METHODS

We retrospectively studied the records on 814 limb-lengthening procedures. Nerve lesions were defined by clinical signs and symptoms of motor function impairment, sensory alterations, referred pain in the distribution of an affected nerve, and/or positive results of quantitative sensory testing with use of a pressure specified sensory device.

RESULTS

Seventy-six (9.3%) of the limbs had a nerve lesion. Eighty-four percent of the nerve lesions occurred during gradual distraction, and 16% occurred immediately following surgery. The pressure specified sensory device showed 100% sensitivity and 86% specificity in the detection of nerve injuries. The patients in whom the lesion was diagnosed with this method, or with this method as well as with nerve conduction studies, had significantly faster recovery than did those diagnosed on the basis of clinical symptoms or nerve conduction studies alone (p = 0.02). Patients undergoing double-level tibial lengthening and those with skeletal dysplasia were at higher risk for nerve lesions (77% and 48%, respectively). Nerve decompression was performed in fifty-three cases (70%). The time between the diagnosis and the surgical decompression was strongly associated with the time to recovery (p = 0.0005). Complete clinical recovery was achieved in seventy-four of the seventy-six cases.

CONCLUSIONS

Early detection based on signs and symptoms or testing with a pressure specified sensory device improves the prognosis for nerve injury that occurs during limb-lengthening. Of the methods that we used to identify neurologic compromise, testing with the pressure specified sensory device was the most sensitive. Aggressive early treatment (slowing the rate of lengthening and/or performing decompression) allows continued lengthening without incurring permanent nerve injury. When indicated, decompression of the affected nerve should be performed as soon as possible, thereby improving the chances of and shortening the time to complete recovery.

Effects of mandibular distraction osteogenesis on the inferior alveolar nerve: an experimental study in monkeys

A series of experimental studies were performed in monkeys to study the effect of mandibular distraction osteogenesis on the inferior alveolar nerve at different times before and after distraction. A mandible osteotomy was performed and distraction was carried out unilaterally in 10 young rhesus monkeys and bilaterally in six. The intact nerves on the contralateral side of the 10 monkeys were used for the control. Care was taken to avoid destroying the integrity of the inferior alveolar nerve during the surgical procedure. After a 5-day latency period, the distraction device was activated at a rate of 0.5 mm twice each day for 15 days. Sensory nerve action potential testing was applied before and 1 day after the operation, at completion of distraction, and at 2, 4, 6, 9, and 12 weeks of fixation. Necropsy was performed at the completion of distraction and 2, 4, 6, and 12 weeks of fixation. The mental nerves were taken, sectioned, and stained with lead citrate and uranyl acetate, and examined with a transmission electron microscope. The inferior alveolar nerves in the distraction gap were obtained, and paraffin slides were made and stained with hematoxylin and eosin, Luxol fast blue, and Bodian methods. The authors found that immediately after the mandible osteotomy, most nerves showed signs of slight acute injury; the latency was increased by 5.553 percent, and the amplitude was decreased to 1808 microV. This might be caused by the surgical procedure or by compressions produced by swelling tissues around the nerves. When distraction was completed, the latency was prolonged for an average of 22.18 percent, and the amplitude average had attenuated to 28.54 percent (804 microV) of the preoperative value on the distracted side. Most nerve fibers exhibited signs of degeneration, such as myelin disruption, swelling of cell organs greatly increased in axoplasm, axon tearing, and myelin fragments engulfed by macrophages. These were nerve reactions to the tensions produced by mandible lengthening. As time elapsed, the nerve's action potential recovered gradually because of its repairing ability, the latency shortened, amplitude increased, Schwann cells proliferated and formed new myelin sheaths, and the tearing axons reconnected. After 12 weeks of consolidation, there was still a latency of 12.384 percent prolongation because of the prolonged conduction distance, and the average amplitude was restored to 2786 microV, the approximate preoperative value. The nerve seemed to be repaired completely; its myelin thickness, axon diameter, and ultrastructure were all similar to those of the control. It was concluded that mandibular distraction osteogenesis can produce some degree of harmful effects on the function and structure of inferior alveolar nerves, but it is reversible and relatively slight. Along with the regeneration of the nerve's myelin and axon, the nerve function can gradually rehabilitate to a normal level.

Vulnerability of the gradually elongated nerve to compression injury

The purpose of this study is to clarify the vulnerability of the gradually elongated peripheral nerve. Rabbit's sciatic nerves were gradually elongated to 30 mm at the rate of 2.0 mm/day and 4.0 mm/day. Immediately after elongation, the sciatic nerve was exposed and compressed for 30 minutes at various forces, 15, 30 and 60 g/0.1 cm(2). Immediately after elongation and compression, 2, 4 and 8 weeks after compression, each group was electrophysiologically and histologically estimated--15 g/0.1 cm(2) caused no damage to the control group, neurapraxia to the 2.0 mm/day group, and axonotmesis to the 4.0 mm/day group; 30 g/0.1 cm(2) caused neurapraxia to the control group and axonotmesis to the 2.0 mm/day group; 60 g/0.1 cm(2) caused axonotmesis to the control group and slowly recovered axonotmesis to the 2.0 mm/day group. This study shows that though mild compression, does not cause nerve injury to the intact nerve, it can sometimes cause severe damage to the gradual elongated nerve.

Peripheral nerve lengthening by controlled isolated distraction: a new animal model

We have developed a simple and effective animal model to study the distraction neurogenesis utilizing the sciatic nerve-lengthening technique in rats. The model allows macroscopic, physiological, and histological evaluation of the distraction site. Fourteen adult Harlan Sprague Dawley rats (300-350 g) were used in this study. A 10 mm segment of the right sciatic nerve of each animal in the nerve-lengthening group was resected. Gradual nerve lengthening was performed by advancing the proximal nerve stump at a rate of 1 mm/day. The proximal stump neuroma was then resected and a direct nerve anastomosis was performed. On the left side a standard autogenous nerve-grafting procedure was performed with a 10 mm segment of sciatic nerve used as an in situ nerve graft. Three months after the second surgery, the sciatic nerves were exposed and investigated by gross observation and EMG followed by histological processing and tissue analysis. Neomicrovascularization was observed surrounding the sciatic nerve anastomosis in all five specimens of the nerve-lengthening group as compared to the more white-colored scar tissue that was observed in the nerve-grafting group. The EMG results were similar for both groups. Histological studies of the lengthened nerves showed axon morphology equivalent to the grafted nerves. This study demonstrated a clear evidence of the successful nerve regeneration within a segmental nerve gap by nerve lengthening.