Melissa, standing on a 1 1/4 inch lift under the right foot to equalize her leg length discrepancy.

Limb lengthening and reconstruction techniques can correct deformities caused by birth defects, trauma, or disease. Drawing on the body's ability to generate new bone, distraction osteogenesis and the Ilizarov method provide a minimally invasive solution.

When Melissa Trivino was a child, getting ready to have her picture taken involved more than styling her hair or saying “cheese.” She would stand with her left leg positioned in front of her shorter, crooked right leg. “No one really teased me about it, but I was self conscious about my legs,” she says. “I wore pants all the time.”

Today, at 23, Ms. Trivino has plenty to smile about. In 2002, she began a limb lengthening and straightening procedure at University Hospital known as the Ilizarov method. Unlike other surgical solutions that were suggested to Ms. Trivino and her parents as she was growing up, the Ilizarov method relies on the body’s natural ability to form new bone.

There are a number of reasons why people have length differences in their legs or arms. In some children, one leg grows faster than the other. Birth defects, such as a congenital short femur, and acquired problems such as those following injury to the growth plate—a specialized area at each end of the bone from which a growth occurs—can result in limb length discrepancies (LLDs). While developmental or congenital limb differences typically are identified during childhood, bone infection or bones that do not heal properly after trauma or following surgery can leave adults with LLDs.

Preoperative x ray of both legs confirming the right sided knock-kneed deformity (genu valgum) related to altered growth of the thigh bone (femur).
Following completion of the "distraction phase" of lengthening. The external fixator was used to gradually correct both length and malalignment of the right femur.

Ms. Trivino’s LLD was detected during childhood, and by the time she stopped growing, there was over a one-inch difference between her right leg and her left leg. Her right leg was also “knock kneed.” The Trivinos were advised by one doctor to let her sleep with a pillow between her legs to straighten the right one, a recommendation they did not follow. Until she was a teenager, Ms. Trivino wore a lift in her right shoe. “The lift didn’t feel great. It was awkward to walk with, and I definitely couldn’t run,” she recalls. One specialist wanted to remove bone from Ms. Trivino’s longer left leg, but the family was reluctant to have the shortening surgery done, which would not have helped the crooked right leg at all.

After meeting with several doctors, the Trivinos could not find a satisfactory solution and Ms. Trivino went on to college. Then, while searching on the Internet, she read about the Ilizarov method and “started calling every orthopaedic surgeon in New York, New Jersey, and the Philadelphia area.” She decided on Dr. Sanjeev Sabharwal, chief of pediatric orthopaedic surgery at University Hospital and an assistant professor of orthopaedics and pediatrics at New Jersey Medical School. He completed special training in the Ilizarov method at the Maryland Center for Limb Lengthening and Reconstruction, which is world-renowned for the correction of short and crooked limbs. While Dr. Sabharwal’s credentials were impressive, Ms. Trivino also found him to be “one of those doctors who stands by your side.”

Dr. Sabharwal and Dr. Fred Behrens, professor and chairman of the department of orthopaedics at New Jersey Medical School, both perform the Ilizarov method at University Hospital. Dr. Sabharwal primarily treats children and young adults, and Dr. Behrens, an internationally recognized expert in orthopaedic trauma, specializes in correcting post-trauma or post-surgical limb length discrepancies in adults, but they often work together. Drs. Sabharwal and Behrens are among the few orthopaedic surgeons in the area with expertise in the Ilizarov method.

	Dr. Sanjeev Sabharwal

Distraction = Pulling Apart
Osteogenesis = New Bone Formation

The Ilizarov method is based on a principle called distraction osteogenesis: gradually pulling apart a bone that’s been surgically cut causes new bone to grow. The multi-phase Ilizarov method blends distraction osteogenesis with high technology to lengthen bone or stretch soft tissue. Compared with other orthopaedic procedures, the method is slow, requiring dedication from the medical team and the patient.

“Orthopaedics is often compared to carpentry. There’s a lot of cutting and straightening. Limb lengthening using the Ilizarov method is more like gardening. Slowly, over time, new bone is grown and nurtured,” says Dr. Sabharwal. “Although the technique is a little more labor intensive for the patient and the doctor, the results are fulfilling.”

Clinical picture in the early "consolidation phase" of treatment. Following a computer generated schedule, Melissa and her family performed gradual correction of the deformity by turning the knobs on the struts connecting the two rings of the external fixator.
Soon after removal of the external fixator, following consolidation of the "new bone". Equal leg lengths and symmetric alignment of both limbs has been achieved.

In the first phase of the Ilizarov method, the surgeon performs a minimally invasive procedure, an osteotomy, in which the bone that is to be lengthened is cut. The surgeon then attaches a customized apparatus - a fixator - around the limb with wires or pins. The patient goes home after a day or two in the hospital.

It takes between five and 10 days for the body’s natural inflammatory response to occur. Then, in the next phase, the actual lengthening or straightening of the bone begins. The patient or a family member adjusts the small wheel on the fixator (the device that pulls the bone apart) at designated times during the day; some specially designed fixators equipped with computer software make this very simple. Typically, the bone is pulled apart at a rate of 1 millimeter a day (about 1/25th of an inch); the body’s response is to grow new bone to fill the gap.

It’s during the distraction phase of the Ilizarov method that patient compliance is especially critical. A physical therapy program helps maintain strength and mobility, so the patient needs to keep those appointments as well as do the prescribed exercises at home. Then there are regular visits to the surgeon’s office to track bone growth and check for any complications, such as infection around the pin site. “It takes a lot of dedication,” says Dr. Sabharwal. “We had one patient who didn’t live nearby and who didn’t speak much English. But he and his mother took two buses and a cab to see me once a week for three months. That’s how important it was to them.”

Length isn’t the only goal of the Ilizarov method. “We never sacrifice function for length,” says Dr. Behrens. “A patient can compensate with a slight discrepancy, but once function is lost, it can’t be regained.”

When the desired length or straightening is achieved, the consolidation, or bone hardening, phase begins. “The new bone needs time to mature,” explains Dr. Behrens. “The general rule of thumb is that the consolidation phase is twice as long as the distraction phase.” The fixator remains in place until the bone is sufficiently mature and is then removed, after which the patient wears a cast for about a month.

	Dr. Fred F. Behrens, Professor and Chairman

Other Options

The Ilizarov method isn’t the only answer for people with LLD. Some people with mild differences do very well with shoe lifts. For a child with one leg longer than the other, an operation called an epiphysiodesis can stop the growth in the longer leg until the shorter one is of the same length. It is also possible for a piece of bone to be removed from a longer leg or to implant a rod to lengthen a shorter leg. While these options can be good choices for certain patients, says Dr. Sabharwal, he notes that they do not always provide a comprehensive solution for short, crooked limbs. Another benefit of the Ilizarov method is that as the bone grows, so do the corresponding nerves and soft tissue.

For Ms. Trivino, the Ilizarov method was well worth the time. She began the first phase -the osteotomy - in November 2002, and by the end of January 2003, she was able to stop turning the fixator. The device was removed in May, and she wore a cast for another month, followed by three more months of physical therapy. “I still don’t have my full range of motion, but walking is easier and more comfortable,” she says. “It’s amazing how much difference one inch can make.”

To learn more about limb lengthening and deformity correction, visit our website at www.theuniversityhospital.com/limblength/. To arrange for a consultation with Dr. Sabharwal, please call (973) 972-0246. To arrange for a consultation with Dr. Behrens, please call (973) 972-5279.