Introduction
Limb length inequality is a common problem in children and adults, with the causes ranging from congenital to post traumatic to idiopathic. Since there can be serious long term effects to living with a shortened or deformed extremity, Connecticut Children's Medical Center has established a Limb Lengthening and Deformity Correction Service, where patients with such problems can be evaluated and treated. Here, the llizarov circular external fixator, a revolutionary corrective device, is generating excellent outcomes.

Indications
There are a multitude of problems that are well suited for correction with the llizarov technique. Among them are:

• Limb lengthening
• Correction of angular deformities, both post traumatic and developmental
• Correction of contractures
• Treatment of fractures
• Non unions, including infected, atrophic and hypertrophic non unions
• Trauma victims with segmental bone loss
• Acute pylon or tibial plateau fractures
• Lengthening in achondroplasia
• Knee and ankle arthrodesis

The Team
The evaluation and treatment of patients with limb length inequality and deformities is accomplished by a highly trained team of medical professionals under the close supervision of Orthopaedic surgeons. This team includes:

• Attending Orthopaedic Surgeons
• Orthopaedic Physician Assistant
• Orthopaedic Residents/Fellow
• Registered Nurses
• Physical Therapists
• Occupational Therapists

Initial Assessment
The initial assessment involves a complete history and physical examination, appropriate x rays, and laboratory studies as indicated. Each patient has his/her case discussed by the Attending Orthopaedic Surgeon.

Children's Special Needs
In children, carefully calculated predictions are made of ultimate limb length discrepancies. Based on the results of these calculations, recommendations can be made regarding equalization of limb lengths and deformity correction. As a result, children may require multiple visits with x rays over time in order to obtain enough data to allow for the calculation of their predicted length discrepancy at maturity.

Those In whom the ultimate discrepancy is not excessive may be candidates for an appropriately timed growth arrest on the long leg in order to equalize the leg lengths at maturity. In those patients where it is felt that treatment is best facilitated by lengthening, a conference would be scheduled, where the lengthening technique, risks involved, and changes in activities of daily living would all be reviewed.

The Ilizarov Apparatus
Dr. Gavril Abramovich llizarov is credited with much of the new methodology used for lengthening and deformity correction. He devised a system of modular, circular, external fixation devices which now bears his name. In addition, he advanced a new biological principle which he called "tension stress."

The essence of this biologic principle is that bone and soft tissue will regenerate under tension. He demonstrated that under appropriate conditions of stable skeletal fixation, blood supply preservation, and controlled mechanical distraction, new bone would predictably form within an osteotomy site.

Bones are usually lengthened at the rate of one millimeter per day, with adjustments made to the frame four times daily during the correction phase to allow for gradual correction or lengthening. This is followed by a consolidation phase where the new bone matures to the point that the frame can be removed without the need for additional casting or bracing.

In most circumstances, patients are allowed to weight bear as tolerated, may swim in chlorinated water, and may shower with these devices. Depending on the type of deformity and treatment, various amounts of physical and occupational therapy may be needed.

Improved Outcomes
Treatment of these deformities in the past was often considered both dangerous and impractical. However, with recent advances in the understanding of bone regeneration and external fixation, treatment remains complicated, but with a lower morbidity rate and much improved outcomes. In many conditions the use of the llizarov technique has revolutionized treatment options.

For More Information
Contact Bruce E. Bowman, M.H.S., P.A.-C.
Clinical Coordinator, llizarov Service
Connecticut Children's Medical Center
Department of Pediatric Orthopaedics
282 Washington Street
Hartford, CT 06106-3316
(Voice) 860.545.8640
(FAX) 860.545.8650