Recovery of Muscle Strength and Power After Limb-Lengthening Surgery

doi:10.1016/j.apmr.2009.11.014

Archives of Physical Medicine and Rehabilitation

Volume 91, Issue 3, March 2010, Pages 384-388

https://doi.org/10.1016/j.apmr.2009.11.014 Get rights and content

Abstract

Barker KL, Lamb SE, Simpson HRW. Recovery of muscle strength and power after limb-lengthening surgery.

Objective

To report muscle strength, power, and function after limb-lengthening surgery performed by using the Ilizarov technique.

Design

Prospective, longitudinal observational study of a cohort of consecutive patients who underwent limb-lengthening distraction followed up for 2 years after surgery.

Setting

National Health Service hospital specializing in orthopedic surgery.

Participants

Patients (N=16) who had undergone limb-lengthening surgery performed by using the Ilizarov method (11 men, 5 women; mean age=27y; range, 13–56y).

Interventions

None.

Main Outcome Measures

Muscle strength and power were assessed by using 2 validated measures: isokinetic concentric strength of the quadriceps and hamstrings measured by using a dynamometer and leg extensor power. Measures were recorded preoperatively and at 6, 12, and 24 months after the completion of lengthening. Function was measured by 2 timed tests of functional performance: stair climbing and sit-to-stand.

Results

Overall results were good with high reports of function and satisfactory clinical examination. Both concentric muscle strength and leg power showed a clear pattern of decreased muscle strength at 6 months after frame removal, improving throughout the study period until it was within 3% of the preoperative value at 2 years. By 2 years, self-reported function and ability to complete timed functional tests had returned to or improved on the preoperative values. Muscle strength remained slightly below the preoperative value; this was more pronounced in the quadriceps than the hamstrings. There was no association between muscle strength and the amount of lengthening that had been undertaken.

Conclusions

This study suggests that there is a small residual decrease in muscle strength and power after limb-lengthening surgery but that these do not adversely impact on a patients' ability to perform everyday functional activities.

Section snippets

Participants

Sixteen consecutive patients undergoing limb-lengthening surgery performed by using the Ilizarov method of distraction osteogenesis were studied prospectively over a minimum period of 2 years. All patients undergoing limb lengthening during the study period were invited to participate in the study; ethical committee approval had been obtained. The etiology of the limb-length discrepancy is described in table 1. There were 11 men and 5 women, with a mean age of 27 years 4 months (13–56,

Isokinetic Dynamometry-Concentric Muscle Strength

There was a significant difference between the operated and unoperated limbs in the mean isokinetic torque for both the quadriceps and hamstrings at all times. Preoperatively, the difference between the limbs was significant at the P<.01 level. Thereafter, the differences between the limbs were greater, with the differences being significant at the P<.005 level for both the quadriceps and hamstrings at 6 months and 1 year and for the quadriceps at 2 years. The difference for hamstrings at 2

Discussion

A relative deficit in the strength of the quadriceps and hamstrings was observed in the index limb preoperatively. This is attributed to a decreased use of the shorter, or injured, limb before surgery and by the patients compensating and favoring their unaffected limb.

The changes in muscle strength over time were interesting. Quadriceps strength decreased more than hamstrings strength at 6 months, and at 1 year the quadriceps torque ratio was still decreased. At the final measure, 2 years after

Conclusions

In terms of time to recover, our results would endorse the view that clinically significant improvements in strength, power, and function are unlikely to be detected after 2 years and that any residual deficit in muscle strength that is detected is likely to be permanent. The fact that the operated limbs remained weaker than the unoperated side suggests that despite good recovery from surgery, limitations are likely to persist in performing high-demand functional activities and sport.

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Cited by (21)

Comparative study of the results of compound tibial shaft fractures treated by Ilizarov ring fixators and limb reconstruction system fixators
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Citation Excerpt :
Detailed distribution of complications is shown in Table 4. The outcome after rail and ring fixator treatment was evaluated according to the Association for the Study and Application of the Methods of Ilizarov (ASAMI) scoring system.14 All the factors like age, sex, physical condition of the patient, other associated injuries, medical diseases, etc were taken into consideration and found they were almost the same and will not affect the results.
Ilizarov ring fixator and limb reconstruction system (LRS) fixators have been used in the management of complex tibial fractures with severe soft tissue injuries, compound tibial fractures, and infected tibial nonunion for which conventional internal fixation cannot be contemplated. Fracture union and distraction osteogenesis can be done simultaneously with these external fixators, allowing early weight bearing. Several previous studies have shown almost equal results of rail and ring fixators for the compound tibial shaft fractures. Thus we performed a prospective study to evaluate the union rate, functional outcome and amount of limb lengthening after the treatment of compound tibial shaft fractures with or without infected nonunion by ring or LRS fixators.
This prospective study was done at Sarojini Naidu Medical College and Hospital, Agra, India and included 32 patients of compound tibial shaft fractures with or without infected nonunion. There were 26 males and 6 females and the average age was 40 years. Patients were randomly divided into two groups (n = 16 for each): one underwent Ilizarov fixation and the other received LRS fixation. Cases were followed up for 3–24 months, 6 months on average from September 2012 to October 2014. Functional and radiological outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria for both rail and ring fixators.
Union was achieved in all cases. Radiological outcome was found excellent in 68.75%, good in 18.75% and fair in 12.50% of cases treated by rail fixators whereas it was excellent in 56.25%, good in 18.75%, fair in 12.50% and poor in 12.50% of cases treated by ring fixators. Functional result was satisfactory in 75.00% of cases treated by rail fixator and 68.75% of cases treated by ring fixators whereas the corresponding rate of unsatisfactory was 25.00% vs. 31.25%.
In our short-term assessment, LRS fixators show a better result than Ilizarov fixators in terms of fracture union and functional outcome with soft tissue care and limb length.
Impact of physiotherapy in the surgical treatment of bone lengthening. A case report
2010, Revista Iberoamericana de Fisioterapia y Kinesiologia
La incidencia de las complicaciones derivadas de los alargamientos óseos cada vez supone menos en la recuperación íntegra de estos pacientes gracias al abordaje multidisciplinar que reciben, siendo la fisioterapia un elemento clave.
El objetivo del estudio es conocer los efectos beneficiosos que logra la fisioterapia en procesos de alargamientos óseos en relación con la amplitud articular y al tono muscular, así como en la prevención de complicaciones a propósito de un caso.
Nuestra paciente, diagnosticada de dismetría de miembros inferiores, se somete a elongación tibial mediante una distracción progresiva a partir de fijadores externos distractores. El seguimiento realizado valoró la amplitud articular mediante goniometría manual, tono muscular mediante la escala de Daniels, existencia de linfedema y longitud del miembro mediante cinta métrica y el dolor percibido mediante escala visual analógica. Como resultados, destacamos la ganancia completa del rango articular y la prevención del equinismo y linfedema secundario.
The incidence of complications of bone lengthening is increasingly less in the full recovery of these patients thanks to the multidisciplinary approach received, physiotherapy being a key element.
This study has aimed to determine the beneficial effects achieved by physiotherapy in bone lengthening procedures in relationship to range of motion and muscle tone and in the prevention of complications based on a case report.
Our patient who was diagnosed with lower limb dysmetria underwent tibial lengthening by gradual distraction from distracting external fixator. The monitoring performed evaluated joint range by means of manual goniometry, muscle tone scale by the Daniels scale, existence of lymphedema and limb length by measuring tape and perceived pain by the Visual Analog Scale. Standing out among the results are the full gain of joint range and prevention of equinus and secondary lymphedema.
Restoring femoral offset and leg length; the potential of a short curved stem in total hip arthroplasty
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However, to what values increases in FO are beneficial, is unknown. A study of Barker et al. reported that in muscles of patients who underwent leg-lengthening, a process comparable to enlargement of FO, a small decrease in muscle strength and power was seen eventually.30 A too large increase of FO could cause thus weakness of the abductors and lateral trochanteric pain.
Total hip arthroplasty (THA) is a very successful procedure in orthopedics. Still polyethylene wear and gait deficits are limiting the clinical success.
It is important to reconstruct leg length (LL) and femoral offset (FO) anatomically in order to have the best possible result of a THA. Gait deficits can arise due to leg length discrepancy as well as changes in the abductor moment arm. In THA, LL and FO are strongly determined by the orientation, size and geometry of the femoral stem.
This radio-anatomical study used the data of a prospective cases series of 112 patients who underwent 126 primary THAs and had completed a 1-year follow-up examination. FO and LL were compared between the conventional straight stem in vivo and a computed simulated implantation of a short curved stem, using the pre- and postoperative pelvic radiographs of the same patients.
In this simulation of the short curved stem statistically significantly restored native FO (p = 0.010) and LL (p = 0.000) better, compared to the conventional straight stem.
Thus, the short curved stem restores FO and LL better, and could potentially prevent gait deficits.
What's new in limb lengthening and deformity correction
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Khakharia et al. reported that a limited distal quadricepsplasty was effective for restoring knee flexion in patients who developed extension contractures following femoral lengthening86. Barker et al. prospectively studied the effect of limb lengthening on muscle function and noted a decrease in concentric muscle strength and leg power in patients undergoing lower limb lengthening six months following frame removal, with return to preoperative status by two years and with no adverse effect on functional activities87. Hamdy et al., in a randomized controlled trial, reported that the use botulinum toxin type A reduced pain and improved mobility in children undergoing limb lengthening and deformity correction88.
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: Supported by Smith & Nephew Ltd. and the NIHR Musculoskeletal Biomedical Research Unit, Oxford (Barker).

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

: Reprints are not available from the author.

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Original articleRecovery of Muscle Strength and Power After Limb-Lengthening Surgery

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Isokinetic Dynamometry-Concentric Muscle Strength

Discussion

Conclusions

Orthop Clin North Am

Arch Phys Med Rehabil

Problems, obstacles and complications of limb lengthening by the Ilizarov technique

Clin Orthop

Current techniques of limb lengthening

J Pediatr Orthop

Electromyographic and nerve conduction changes after tibial lengthening by the Ilizarov method

J Pediatr Orthop

Muscular strength after callostasis limb lengthening

J Pedriat Orthop

The effect of lengthening of the femur on the extensors of the knee—an electromyographic study

J Bone Joint Surg Am

Limb lengthening by means of percutaneous osteotomyExperimental and clinical studies

J Bone Joint Surg Am

Leg lengthening–a personal follow-up of forty patients some twenty years after the operation

J Bone Joint Surg Am

Unchanged muscle function after bilateral femoral lengthening

Acta Orthop Scand

Effect on knee flexion of a modification to the surgical technique of pin placement during femoral lengthening

J Paediatr Orthop B

Original article
Recovery of Muscle Strength and Power After Limb-Lengthening Surgery