Limb Lengthening & Reconstruction Service
Yerevan Center of Reconstruction and Extremity Lengthening (YCLLR) was established in 2000. Acknowledged as a regional leader in this field of orthopedics, the Center presents technologically advanced methods in the treatment of children and adults with congenital and acquired orthopedic problems. More than 40 years we have been intensively working in this field of medicine. Two doctors of the Center worked and studied the Ilizarov’s method under the direct supervision of professor Gavriil Ilizarov in Kurgan. The percentage of treatments’ successful results is high. The level of our qualification allowed us to present Ilizarov’s method on different international symposiums, and also on the extension courses with lectures and demonstrative operations in Australia, Denmark, Norway and the USA.
Besides the successful solution of various problems in orthopedics and traumatology, we also manage a cosmetic lengthening of the height, correction of form and proportions of lower extremities of the people, who psychologically suffer because of their legs ’unattractiveness. At the present time we are also specializing on aesthetic reconstructive surgery of lower extremities. We have a considerable experience. The first operation for exactly aesthetic purpose on legs form correction and shin lengthening was performed in 1989. Today we are famous as one of the few centers, where patients from many countries of the world come for the treatment. The practical experience allowed us to develop our own classification of lower extremities types, which helps us to clarify the target and tasks of treatment during each particular case. Our approach in the solution of this problem was repeatedly presented and discussed on the most prestigious international congresses.
Our Center is located at “Nairi” Medical Center, which is equipped and furnished on the level of contemporary medicine’s international demands. Wide spectrum of diagnostic equipment includes MRI, CT and other modern technologies. Surgical unit and ICU Department are equipped according to the highest standards.
Out-patient settings of our Center have gained multiple positive opinions from the patients. We try to create homely and warm atmosphere. We offer to our patients a dietary pattern, considering their individual preferences. We follow the principle - “To treat the patient and not a disease” and provide multilateral spectrum of services, including a psychological support.
In our Center we provide the following services:
- cross lengthening of hips and shins,
- lengthening by system device /nail,
- correction of legs form (treatment of “O” or “X” bowlegs),
- exercise therapy,
- rendering of additional services,
Indications to Surgical Lengthening of Legs
Aesthetic lengthening of lower extremities is indicated for the people, whose length and/or the form of the legs are the reason for psychological sufferings, which creates difficulties in their private or professional life.
Natural development of the patient must be accomplished. However, in some cases, when growth zones are almost fully closed physiologically, the lengthening may stimulate their functioning within short period of time through stimulation of growth hormone (somatotropin) during lengthening process.
The final goal of the lengthening must be the correct proportion between shin and hip, body and extremities. Besides aesthetic demands, it’s very important from the biomechanical point of view. That’s why we recommend to our foreign patients to send us photographs for the preliminary analysis, and also for the verification of surgical indications and treatment targets. The patients must be in undergarment or analogic wear in following positions (if patient desire, the face may be covered).
This information can be very useful for preliminary definition of surgical indications, targets and technical details of treatment, and also for estimation of the length and cost of the treatment.
Patients, who plan an aesthetic surgery on height increase, must be somatically healthy and non-smokers. Also, without fail, we perform psychological expertise to be sure in psychological adequacy and high motivation of the patient.
Only after the definition of indications, treatment target and patient’s direct examination the doctor makes the final decision regarding operation.
Correction of legs form (treatment of “O” – type bowlegs)
It is necessary to differentiate the real and false “O”-type bowlegs. In both cases the inner outline of the shin is not enough expressed. But if it is the real “O” bow-type shin, then the reason for the legs unattractiveness is the curvature of tibia, and that’s why the correcting osteotomy of the bone is indicated with creation of open cuneiform regenerator with a little displacement inside. As a rule, this technique leads to patient’s height increase up to 2.5cm. During false “O” Bow-type deformation the axis of tibia is correct, and the cosmetic defect is due to soft tissues. In these cases, for the increase of internal shin outline it is indicated to use silicone implants.
Correction of legs form (treatment of “X” –type bowlegs)
Correction method of “X” –type bowlegs is very much similar to correction of “O” –type bowlegs. The difference is in wedge position, which is open internally (medially) for correction.
Simultaneous lengthening from one zone is the most frequent procedure in our practice. The indication to use this method is a hip/shin disproportion (short shins and relatively long hips). It is one of the less uncomfortable procedures for the patients: with less percentage of complications and broadcasted good result. Because of appropriate demands regarding proportions between hip and shin, this method usually is not used during hip lengthening for more than 6 cm.
Lengthening of both shins from two zones — on each shin (two mm per day):
Lengthening of two zones can be offered to the patients who have not enough time to spare. This method may decrease the duration of entire procedure up to 30%. The lacks of this method are: 1) relatively large volume of surgical intervention: 2) big loading on soft tissues, because the lengthening is carried out for 2mm per 24-hours, hence, the patient needs more intensive course of intensive exercise therapy.
Cross lengthening of hips and shins:
This method is indicated due to the lengthening of the height for more than 6-7cm. Cross lengthening of hips and shins is a two-steps procedure. It is conditioned by the reason that because of relative crockitude of Ilizarov’s device, the simultaneous lengthening of both hips is very uncomfortable procedure for the patient. That’s why we lengthen shin and crossing (contralateral) hip during first stage. After the first period the length of the legs is equal, but knee joints are on the different levels. Between two stages of lengthening the patient passes the period of rehabilitation, which usually lasts one-three months. After mobility restoration in adjacent joints (bending knee at least for 90 degrees and 90 degrees of foot dorsal flexion), the analogous stage of opposite hip and shin is performed, as it is shown on diagram.
Lengthening by the system device/ nail:
This approach is relatively new. Intramedullar nail is fixed with two outboard locators. Distruction starts usually on the 5th day after the surgery. When the necessary length of segment is obtained and X-Ray control shows adequate osteogenesis (bone formation), the second surgery is performed to fix blocking screws and to remove outboard locators. The advantage of this method is a cutting of necessary time for wearing a device of external fixation. The lack of this method could be considered some technical difficulties and the danger of submercible construction’s (nail) infection, and also the necessity of three operations under the general anesthesia.
Qualified exercise therapy not only helps to recover the volume of mobility in the joints and the full value of walking, but also decreases the duration of treatment and rehabilitation. Large value for the effectiveness of physical therapy has constructive collaboration of the patient with instructor of exercise therapy. The patient needs to have a high motivation and must work out daily to maintain the results. It is an important basis for successful achievement of the final goal at the earliest possible date.
There are three stages of exercise therapy, and each one is significant in its own way:
1. muscle and tendons stretching for preparation of the extremity to the lengthening,
2. therapy during the process of lengthening and during fixation period,
3. exercise therapy after the device removal.
1. For better understanding the target of exercise therapy, it is important to know some peculiarities of anatomy and biomechanics of human being’s hip and shin. It’s obvious that the muscle distribution around the shin is unequal. On anterior and internal surfaces of tibia there are practically no muscles, but on the other hand they are developed very much on posterior and lateral surfaces of the shin. The strongest muscle of our organism is – a gastrocnemius muscle. It’s attached to the heel bone through the Achilles tendon. Mechanically resisting, especially in the end of the lengthening, this muscle leads to the bending of knee joint and plantar position of foot.
Please, watch our first video about how to prepare muscles for aesthetic lengthening of the lower extremities to prevent the possible limitations of joints mobility.
2. The most important period for extremities function starts on the next day after the surgery. One of the advantages of Ilizarov’s method is that the device ensures a necessary hardness and safe fixation of bone fragments. This gives an opportunity to get on the feet and start the exercises on the very next day of the surgery. The target of physical therapy - is the achievement of joints’ maximum mobility and, if it’s possible, the loading of operated extremities. Intensive course of therapy with exercise therapy instructor – is the pledge of treatment’s good result. To make exercises more interesting for the patient, we often organize an events, make trips to the various places in the city and out of the city. Watch our video about a therapy during the lengthening process.
3. After device removal, the exercise therapy must be carried out very carefully, especially in the first days, when the newly grown bone is not so strong to resist the powers of flexure. Excessive loadings in the process of exercise therapy may lead to deformation of bone tissue and negatively effect on joint surface of osteoporotic bones. As a rule, we recommend an intensive therapy in one month after the device removal. Usually it demands from one month to three months to fully recover the mobility volume in the joints and to reach the ideal gait (video).
Pins’ care (Infection prophylaxis)
One of the most frequent complications, described in the special literature about transosseous osteosynthesis, is the inflammation of soft tissues around pins and nails. This complication may lead to the necessity of surgical intervention and to affect the treatment terms. In most cases, with only external fixator, it is not a big problem and doesn’t affect the final result. During method device/nail – infection is much more dangerous and may lead to the most unpleasant consequences.
There are two fundamentally different approaches in infection prophylaxis around pins: tying the entrance space of pins and nails by gauze bandage with antiseptic and open treatment, using oral antibiotics. In spite of the fact that the first approach is very labor –intensive and demands more expenses, we definitely prefer this method, especially when the implant is used (device/nail method). According to our protocol, we treat the wound after each shower or other water procedure of the patient. Due to this, the percentage of infectious complications in our clinic is very low (video).
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