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An operation is performed to create an osteotomy (see below) in the affected limb. Then the fixator is put on the limb with wires or pins above and below the osteotomy, with other wires to support the limb. Changes to the frame over time lengthen the bone and also correct the deformity. As a general rule, lengthening is carried out at about 1mm per day, in three or four steps. It tends to be faster in younger patients and slower in older ones.
The limb lengthening procedure is done to lengthen the bones of the legs or arms for those patients who require an adjustment to limb length. It may also be done in combination with gradual or acute bone correction. To understand more about the limb correction procedure, look here.
When a bone needs to be corrected, there are several orthopedic non-surgical and surgical treatments available, depending on the severity of the issue and the patient’s medical history. Your doctor or orthopedic surgeon will carefully evaluate what is appropriate for the case considering patient’s age, medical history, the physical examination, imaging, and blood and/or nerve tests. For details look here.
An osteotomy is when a bone is cut by the surgeon to adjust or correct the deformity or to create fresh bone ends in order to form new bone growth as the healing process re-starts. The new bone growth can be guided to fix the limb in many ways, such as making it longer or changing the angle.
Human skeletal development starts during pregnancy and continues until bones have reached their full shape and structure in late puberty. Some bone deformities are evident at birth, such as clubfoot, while others generally occur between 10 and 18 years old, such as scoliosis where the spine has a side-to-side curve with an S or a C shape. After the child’s birth, their pediatrician would begin the process of performing regular check-ups during routine appointments to look out for any signs of orthopedic deformities (as some are present since birth). The child’s parent may also notice characteristic signs of underlying orthopedic conditions. To know more about these signs, look here. If the parent feels that there is something “just not right,” it is advisable to consult an orthopedic doctor as soon as possible to alleviate any doubts.
Depending on the surgical procedure that you’re scheduled to receive, the duration of your stay at the hospital shall be decided and conveyed to you in advance. However, going home the day of surgery may not be warranted if you’re to receive an external or internal fixator device. Nurses and other medical professionals in the hospital will assess your health status before surgery and guide you through each phase of your treatment until you are able to go home. The nursing staff will help control your pain and teach you about caring for yourself after surgery. Don’t be afraid to ask your nurses questions about the surgery process or to express your concerns before or after surgery; nurses can help you with and advise you on a range of issues.
Some pain is normal and pain may increase a little after frame adjustments. Methods for managing pain after surgery include pills, suppositories, capsules, nerve blocks and pain pumps. Pain pumps let you control the amount of pain-killer you receive, as you need it. These methods will be discussed with and explained to you before your operation. If pain does not go away or becomes acute, contact your surgeon or family doctor.
It is not advisable to shower for 1 or 2 days after surgery. When you do it, keep your incisions and dressing dry. If you have a cast, tape a sheet of plastic to cover it so it does not get wet. Your health care team will provide you all necessary guidance on self-care instructions on your shower routine prior to leaving the hospital.
Yes. The amount of weight that you can exert on the affected limb is explained to you by your doctor and physical therapist; their guidance is to be strictly followed. Usually any weight-bearing should be avoided immediately after the surgery. However, after a few days the physical therapist will teach you the essential exercises as gradual weight-bearing is initiated. Weight-bearing is an essential component of healing as it allows the formation of new bone. For more information look here. Bear in mind that excessive exercise may also be harmful. Always follow the physical therapist’s instructions
This will depend on several factors: the type of work you do, the severity of your condition, how you get to work and the treatment plan after surgery. You should discuss returning to work with both your surgeon and your employer.
Children should mobilize as much as possible and should return to school as soon as safely possible, depending on the severity of the child’s condition and the treatment plan after surgery. Discuss a timeline with your child’s surgeon. In addition, it will be helpful to discuss the child’s after-surgery needs with the school so that any necessary arrangements can be made. Pictures of the external fixator may be useful to bring along to this meeting.
This depends on the type of treatment you are having and whether you will be flying. Speak to your surgeon’s office for advice. Be sure to get a letter from your surgeon to pass through security at the airport with the fixator in place and any prescription medications.
Speak to your surgeon’s office for advice and to get a letter from your surgeon to pass through a metal detector with the orthopedic device in place.
The goal of the surgical correction is to allow you to regain maximum normalcy to lead an active life. Many patients can return to a normal routine after healing is complete. To learn more about life after an orthopedic surgery, you may read about the experiences of patients who have undergone them. Here is a link to patient stories.
It is crucial to precisely follow all post-operative instructions provided by your surgeon and their team. These will include instructions on when to start applying your body weight to the corrected limb and the post-operative exercises. Exercise exactly at the rate and intensity prescribed by your physical therapist. It is also most important to go to all follow up visits so that the surgeon may observe the progress of the healing and look for any potential signs of complications. To learn more about care after surgery, you may look here.
Like all surgeries, orthopedic surgeries also have some level of risk involved. To learn more about potential complications you may look here.
The bone deformity must be corrected and/or the bone lengthened. The new bone that grows is then allowed to strengthen and harden in the new shape/length. This second step is called “consolidation.” Depending on the severity of the bone deformity, the total amount of time is predicted case by case. Your surgeon will be able to give you an estimate of how long these two stages will take. An external fixator device can be left in place for 4 to 12 months and then removed. However, even after the removal of the external fixator device, the healing process continues and complete healing can take up to 18 months from the day of surgery. For an internal fixator device, the healing may also take up to 12-18 months depending on the severity of the condition. This doesn’t mean that you can’t resume an active lifestyle sooner. Your doctor and their team will ensure you’re able to continue your daily activities as soon as possible.
An external fixator device is kept in place for 4 to 12 months depending on the severity of the bone deformity. After the new bone has fully solidified, the external fixator is removed during an outpatient surgical procedure (the patient does not have to stay in the hospital overnight for this).
Internal fixator devices may or may not be removed depending on the case. It is kept in place at least until all new bone has formed and complete healing has taken place.
Follow up visits with your surgeon are an essential part of the healing process. They are spread out over the entire healing process (12 to 18 months) and may begin from a few weeks after your surgery and gradually get spaced apart with more time between consecutive visits. Your surgeon shall let you know how often the follow up visits are required for your case. All visits are crucial, however the first few ones more so as the surgeon will take X-rays of the healing limb to observe formation of new bone. Depending on the speed on this new bone formation, the surgeon will decide the next follow up visit and advise on any change in daily routine or device adjustments. Follow up visits are extremely important to the healing process and must be adhered to by the patient.
External fixators are devices used for limb correction orthopedic surgeries. They are metal devices attached directly to the bone that requires correction. A majority of the device is visible outside the body (hence the name external fixators) and is attached to the affected bone using surgical pins and wires.
The deformity that has occurred in the leg – whether you were born with it or it happened later – requires correcting. It could be that the deformity is too severe for non-surgical treatments to work or that non-surgical treatments have failed. The advantage of external fixation, whether with circular fixation or a rail, is that the treatment can be changed as needed over time. An external fixator is easier on the muscles and other soft tissues than internal fixation. It gives the surgeon the ability to change the angle of the leg, rotate the leg, and also to make the bone longer if needed in a way that is not possible with other treatments.
There are two broad types of external fixators used for bone deformity correction: 1) Monolateral Fixators and 2) Circular Fixators. You may learn more about these two types of external fixators in the sections hereafter and may also look here.
These are stainless steel wires that go through the bone and soft tissues (such as muscle) of the limb. These wires are attached on each side of the external rings of the circular fixator and held in place.
These are special pins that are put into one side of the bone. These pins are thicker than the wire pins and are attached only on one side of the frame. They are used only when stronger fixation is required.
You may need to buy clothing a few sizes bigger than usual or track pants with buttons or zips on the outside of the leg to accommodate the external fixation device. Long skirts may be useful. To help keep warm, you may want to purchase or make a tube of material (for example, from an old sweatshirt or sweatpants) as a “leg-warmer.” For ankle frames, there are special “boots” that are adjusted to fit the frame and allow walking. You may also use material to create foot-warmers in these cases.
You may need to adjust your sleeping position while the fixator is in place. Ask your surgeon’s office or your physical therapist for advice on accommodating the fixator in bed.
The amount of time the external fixator will be in place depends on the severity of the deformity and how much correction will be required, as well as your general health and medical history. Factors such as age, smoking status, nutrition status, mobility levels and more can influence healing. Your surgeon will provide expected time frames according to your specific situation.
Your surgeon or physical therapist will be able to answer this question for you, based on your specific situation.
Follow the instructions that your surgeon or hospital staff gives you.
Your surgeon will be able to guide you on medications. Be sure to disclose all prescription and over-the-counter medications that you take.
Potential complications include pin-site infection, joint stiffness or muscle contractures, and wire or pin breakage. Your surgeon will give you information on these occurrences, including the symptoms that should prompt you to seek treatment, as well as the appropriate healthcare professional to contact. For more details, look here.
Infections are one of the most common types of complication post-surgery, including either soft tissue infection at the site of bandage or pin site infections (if you have an external fixator device). Symptoms of infection are: redness and/or swelling at the pin-site, thick or colored discharge from the pin-site, loosening or movement of the pin, and persistent pain or soreness at the pin-site. Even with excellent pin-site care, there is a chance that pin-sites could become infected or cause complications. If you experience any symptoms of infection, contact your surgeon’s office immediately.
Internal fixation is when the device corrects the bone by being completely inserted inside the bone. The advantages of internal fixation include a shorter hospital stay and a faster recovery as compared with other methods. During the surgery, the doctor implants the internal fixator device to keep the bone in the corrected position as it heals.
Depending on your orthopedic condition, your surgeon may advise you to undergo an internal fixation procedure. Internal fixation is recommended in cases where external fixation is not optimal. Internal fixation could be a safer alternative to external fixation with regards to complications, shorter hospital stay and quicker rehabilitation. Some internal fixator devices, such as the lengthening nail, have been developed to replace the function of external fixators with far lesser chances of complications.
The main types of internal fixator devices used for surgical limb correction treatment are plates, nails/rods and screws. For more information on these individual devices, look here.
An internal fixator may or may not be left in place permanently depending on the condition it is treating and the type of device used for correction. Complete healing may take up to 12-18 months, and the device is only removed (if required) after new bone formation is complete.
Internal fixation devices are designed to be inserted completely within the body. However, whether or not it is to remain permanently implanted is up to the surgeon. Once complete healing has taken place, the surgeon will decide if there is a need to explant it.
A cast may or may not be required after you receive your internal fixator device depending on the condition being treated. If you have a cast, then special precautions are to be taken during showers so it does not get wet.
Complications of internal fixation include breaking of the plate, loosening, bending, or breaking of the bone screws, and metal sensitivity. Your surgeon will give you information on these possibilities, including the symptoms that should prompt you to seek treatment and the appropriate health care professional to contact. For other possible complications and more details, look here.
A nail is an internal fixation device that is inserted into the center of the bone. It is attached to the bone with locking screws. A nail has small holes drilled at both ends through which screws or pins are inserted that help stabilize it to the bone.
For the correction of long bones (such as the femur or tibia), one of the most efficient ways to hold separate segments of bone together post-surgery is by inserting a rod or nail within the affected bone. The doctor uses an orthopedic drill to create a canal in the hollow center of the bone known as the intramedullary canal (that contains bone marrow). This canal will be large enough for the nail or rod device to be inserted. Screws present at both ends of the nail help keep the bones stable until complete healing occurs.
Plates are splint-like internal fixator devices that hold the separated segments of bone together. They are fixed to the bone using screws. Plates may either be left in place after healing is complete or they may be removed.
After you have received an orthopedic plate, you should return home and follow all necessary instructions provided by your doctor and their team. This includes resting when you feel tired, propping up your healing limb as you lie down, getting enough sleep for a faster recovery, following all physical exercises at the correct time as instructed by your physical therapist/doctor, keeping your incision clean as instructed by your doctor and eating a healthy diet. It is advised not to put too much weight on the healing limb at first and to follow the instructions by your doctor. Do not take a shower for 1-2 days after surgery and keep the incision and dressing dry as per instruction from your doctor.
An odor from the affected site is an immediate indicator of a problem, as well as a fever developing in the days immediately after the surgery. Pay attention to any redness or inflammation around the surgical site. Call your doctor immediately if any signs of infection develop post-surgery.
An intramedullary lengthening nail is a fully implantable limb lengthening system, which treats leg length discrepancies or one-sided abnormal or impaired growth. It requires a minimally invasive surgery, which provides great results with minimal scarring and a shorter hospital stay as compared to other surgical modalities for limb correction surgeries.
The lengthening nail is one of the components of a complete limb lengthening system. A handy transmitter (control system) is provided to the patient, who presses a button to activate the device motor that carefully lengthens the nail (1mm per day).
This system is like an implantable version of an external fixator device with the benefit of a minimally invasive surgery, minimal scarring and the absence of a large external metal frame that has to be manually adjusted to correct the bone. In contrast to external fixators, this system causes significantly less pain throughout the distraction phase. Another advantage of the system is the relatively shorter return to normalcy during the treatment period.
One session of distraction includes 9 impulses that are delivered from the device when the patient presses the “Patient” button. Each session lasts for about 90 seconds. On average, 27 impulses equal to 1mm of lengthening. The number of impulses required and their frequency will be set by your surgeon.
You would be required to adjust the length of the nail at the frequency prescribed by your doctor. Distraction begins on about the fifth postoperative day or at the instruction of the surgeon. The rate of distraction depends on the expected or radiologically detectable bone regeneration and the soft tissue conditions and can be varied, starting from 1 mm/day. The method is straight forward and you would be required to press a button once on the control set that will automatically carry out the lengthening.
The device has an inbuilt system that automatically stops after every 9 impulses. If your surgeon asks you to perform more than 9 impulses, you may reset the control set after the first round and initiate the process again. 27 impulses will equal 1mm of bone lengthening.
It is crucial to follow the frequency of adjustment as specified by your doctor. Do not perform more adjustments in hope of speeding up the lengthening process. This will do more harm than good. As for the frequency of impulses delivered in one adjustment session, the device is designed to not allow over-correction of the deformity.
Typically, 80mm of maximum limb lengthening is possible.
Bone lengthening may be performed on both legs, however not simultaneously. After one lengthening adjustment session has been completed on one leg, the other may be performed.
The bone lengthening process using a lengthening nail system is a minimally invasive process with very little scar formation.
Diabetic foot is a complication of uncontrolled or chronic diabetes. Diabetic neuropathy (i.e nerve damage) and peripheral vascular disease (i.e. poor circulation) are two of the main foot problems that occur, and both can have serious complications. If left untreated, this condition leads to deformity, ulcers and infection and – in the worst case – to amputation.
Diabetic foot ulcer is a sore or open wound that occurs in people with diabetes. Diabetic foot ulcer presents most commonly at the base of the foot, but it can occur also on the dorsal part of the toes and on the side of the foot. It may be avoided by following proper self-care instructions (for more information, look here). It is important for diabetic patients to know that due to nerve damage and poor circulation to the feet (as a result of diabetes), the signs of an ulcer can be missed as pain is not felt in diabetic feet as strongly as compared to other parts of the body. Therefore, self-inspection is crucial and an immediate visit to the doctor is warranted to avoid any potential infections occurring in the affected feet (which may even reach the bone, leading to serious complications requiring surgical intervention).
According to the American Diabetes Association, 34.2 million Americans, or 10.5% of the population, had diabetes in 2018. Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. Among patients with diabetes, there is a 25% likelihood that they will develop a foot ulcer. Nearly half of them will become infected, and about 20% of those with moderate to severe infection will require some degree of amputation. Diabetes is the leading cause of nontraumatic lower extremity amputations, as it accounts for 85% of these procedures.
Eighty-five percent of leg amputations worldwide are a result of a diabetic foot ulcer. Up to 80% of diabetic patients are more likely to die within 5 years of having a limb amputation. However, 4 out of 5 amputations can be prevented. Timely diagnosis facilitates treatment and decreases long-term disability. Therefore, it is essential for diabetic patients to be aware of the early detection signs for diabetes related foot problems.
The patient’s role is key in preventing and reducing diabetic ulcer related complications. For more information, look here.
There are different ways one can treat a foot ulcer. The first way is known as “off-loading,” where pressure is taken off the area of the foot with the ulcer. In this method, patients will be asked to use special footgear, crutches or a wheelchair to reduce the irritation and pressure to the ulcer area. The second method is known as “debridement,” where the dead skin and tissue is removed. The third method is to apply dressings and topically-applied medications such as skin substitutes, growth factors and ulcer dressings. As proper blood circulation is needed to heal a foot ulcer, your podiatrist might order an evaluation test such as non-invasive studies. Managing blood glucose is another crucial aspect of treating a diabetic foot ulcer. Sometimes surgery is also used to treat a foot ulcer.
Timely diagnosis facilitates treatment and decreases long-term disability. The best safeguard is a high index of suspicion. For more info on the most common signs of diabetic foot, look here.
Your doctor may suggest some medications alongside foot care guidelines in the treatment of diabetic foot ulcers such as hemorheological agents and antiplatelet agents for the management of underlying atherosclerotic disease.
Limb amputation is the last resort treatment for serious diabetic foot complications. It is not indicated for everyone who develops diabetic foot problems. If the healing is not occurring in a diabetic foot due to presence of necrotic tissue or poor circulation, surgical intervention is required to restore the function of the foot. Sometimes, the surgeon may have to amputate the toe to avoid further spread of infection; however, if the infection has spread beyond the midfoot, then amputation below the knee is required. Educating the patient on proper diabetic foot care is crucial to avoid any serious complication. Most of the conditions are reversible if addressed in a timely manner.
Charcot Neuroarthropathy is a condition causing weakening of the bones and ligaments in the foot and the ankle that can occur in people who have significant nerve damage (neuropathy), most often related to diabetes. The bones are weakened enough to fracture and/or dislocate and with continued walking and weight-bearing, the foot eventually changes shape. As the disorder progresses, the joints collapse and the foot takes on an abnormal rocker bottom shape. For more information, look here.
0.3% to 7.5% of diabetic patients may develop a Charcot foot and ankle (also called Charcot neuroarthropathy). The hallmark deformity associated with this condition is midfoot collapse, described as a “rocker-bottom” foot, although the condition appears in other joints and with other presentations. Pain or discomfort may be a feature of this disorder at the active (acute) stage, but the level of pain may be significantly diminished when compared with individuals with normal sensation and equivalent degrees of injury. For more information, you may look here.
Treatment of Charcot foot is best performed by a multidisciplinary team composed of your doctor, surgeon, nurses and physical therapists who will ensure that all treatment measures are well planned and implemented.
Peripheral neuropathy is nerve damage caused by chronically high blood sugar and diabetes. It leads to numbness, loss of sensation, and sometimes pain in your feet, legs, or hands. It is the most common complication of diabetes.
Signs of peripheral neuropathy include loss of vibratory and position sense, loss of deep tendon reflexes (especially loss of the ankle jerk), foot drop, muscle atrophy, and excessive callous formation, especially overlying pressure points such as the heel. The nylon monofilament test helps diagnose the presence of sensory neuropathy. A 10-gauge monofilament nylon is pressed against each specific site of the foot just enough to bend the wire. If the patient does not feel the wire at 4 or more of these 10 sites, the test is positive for neuropathy.
The doctor examines the feet for signs of diabetic foot complications, such as ulcers, vascular insufficiency, and peripheral neuropathy.
The goal in the treatment of a Charcot foot is to create a stable plantigrade foot, heal relevant ulcers, prevent amputation and restore a normal life for the patient as much as possible.
Charcot foot may sometimes return within a year or so of treatment, however this may be because it did not properly heal in the first place. On the other hand, the process may affect the other foot, and is thought to do in about 30% of cases.
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