|Year : 2022 | Volume
| Issue : 1 | Page : 3-11
Residual amputee limb segment lengthening: A systematic review
Anuj Sharad Chavan1, Munjed Al Muderis2, Kevin Tetsworth3, Ilkhomjon Dexter Rustamov3, Jason Shih Hoellwarth4
1 Macquarie School of Medicine Macquarie University, Queensland, Australia
2 Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Queensland, Australia
3 Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Queensland, Australia
4 Limb Salvage and Amputee Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
|Date of Submission||08-May-2022|
|Date of Decision||14-Jun-2022|
|Date of Acceptance||14-Jun-2022|
|Date of Web Publication||30-Jun-2022|
Anuj Sharad Chavan
Macquarie School of Medicine Macquarie University, Suite 305, Level 3/2 Technology Pl, Macquarie Park NSW 2109
Source of Support: None, Conflict of Interest: None
Aims: This study aimed to systematically review the indications, techniques, complications, and insights identified for lower extremity residual amputee limb segment lengthening. Methods: Searches in PubMed, Google Scholar, Ovid Medline, Ovid Embase, and the Journal of Limb Lengthening and Reconstruction were performed using terms including “amputee,” “residual limb,” and “stump” combined with “lengthening,” “distraction,” “histogenesis,” “osteogenesis,” and “Callotasis.” Included articles described lengthening amputated tibias or femurs (other segments excluded). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized. Descriptive statistics were performed. Results: Twenty-two studies reported lengthening 32 femurs and 31 tibias (63 total segments). Fifteen articles described a single segment, five described two to four (15 total segments), and two described five or more (31 total segments). Lengthening was performed to improve prosthesis fit (21/22 studies, 54/63 segments) or to optimize osseointegration (1/22 studies, 9/63 segments) and utilized an external fixator (52/63) or a motorized intramedullary nail (11/63). Femurs were lengthened an average of 7.7 ± 2.5 cm (60% ± 23%) and tibias 5.8 ± 1.8 cm (97% ± 53%) from a starting length of 12.5 ± 4.6 cm for femurs and 6.7 ± 2.3 cm for tibias. The most common minor problem was pin site infection. The most common major problem was over-lengthening bone beyond the soft tissue envelope, requiring flap coverage, bone excision, or knee disarticulation. Conclusions: Amputee lengthening can achieve measurable gains to improve prosthesis use. Over-lengthening can be difficult to manage, if not catastrophic. Osseointegration may be a further rehabilitation solution for amputees struggling with prosthesis problems and willing to consider surgical options.
Keywords: Amputee distraction osteogenesis, amputee lengthening, limb lengthening, osseointegration, short amputee, short residual limb
|How to cite this article:|
Chavan AS, Al Muderis M, Tetsworth K, Rustamov ID, Hoellwarth JS. Residual amputee limb segment lengthening: A systematic review. J Limb Lengthen Reconstr 2022;8:3-11
|How to cite this URL:|
Chavan AS, Al Muderis M, Tetsworth K, Rustamov ID, Hoellwarth JS. Residual amputee limb segment lengthening: A systematic review. J Limb Lengthen Reconstr [serial online] 2022 [cited 2022 Aug 9];8:3-11. Available from: https://www.jlimblengthrecon.org/text.asp?2022/8/1/3/349415
| Introduction|| |
The ability to comfortably and confidently wear a prosthetic limb is critical for the lower extremity amputee's rehabilitation. Some with Pirogoff or similar type ankle-level amputations can walk without a prosthesis, but amputations proximal to the ankle nearly always require a prosthesis for reasonable ambulation. A generally accepted minimum transfemoral length is 5 cm distal to the lesser trochanter or for below-knee amputees a tibial length of 12.5–17.5 cm. It is also important to not leave too long a limb, to accommodate the necessary prosthetic components including the socket, joints, pylons, and foot.
For patients whose limb is too short or bulbous to support a prosthesis, residual amputee limb segment (RALS) lengthening can be performed to create a limb which is better able to don and control a prosthesis. Sometimes, this can avoid amputation of a proximal joint simply to achieve the ability to wear a prosthesis. Lengthening can also be performed in preparation for osseointegrated prosthetic rehabilitation.
The techniques and complications of stature lengthening for cosmetic or functional reasons (such as in situations of dwarfism) have been recently reviewed. In contrast, the expectations and potential adverse outcomes following RALS lengthening are poorly understood. The available literature is mostly reports of individuals or fewer than three cases and often in journals that can be difficult to access. This can reduce the quality of care to amputees who undergo RALS.
This systematic review was performed to address the knowledge gap for amputee lengthening. The primary outcome investigated was the average amount of lengthening achieved. The secondary outcome investigated was complications encountered. The intent is to provide a convenient, consolidated summary of the indications, techniques, complications, and insights into lengthening lower extremity amputees.
| Methods|| |
In November 2021, two of the authors independently performed searches in PubMed, Google Scholar, Google search engine, and the Journal of Limb Lengthening and Reconstruction. That specific journal was included separately because its articles are not indexed in the database and search engines, but it features well-regarded literature focused on extremity and amputee reconstruction. Searches included combinations of the terms “amputee,” “residual limb,” and “stump,” combined with “lengthening,” “distraction,” “histogenesis,” “osteogenesis,” and “callotasis.” Additional articles were traced by reviewing included articles' reference lists (to identify prior articles) and the “Cited by” feature of Google Scholar (to identify later articles which referenced those identified). Article screening was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. This review was not registered, and no prior protocol was published.
Searches were performed in English, but all identified articles of any language were included if they described lengthening amputated tibias or femurs. Articles were excluded if they described lengthening bones other than femurs or tibias (such as upper extremities or metatarsals) or other procedures (such as bone transport, replantation, or using length-providing prostheses). Articles were not excluded based on patient number, indication for lengthening, or publication date.
Data extraction and presentation
Two authors independently reviewed abstracts to confirm the article presented clinical cases of lower extremity amputee lengthening (not theory, cadaver studies, or technique descriptions without patient data). These two authors then independently read each selected article in entirety and created a spreadsheet of pertinent variables: number of femurs and/or tibias lengthened, gender, amputation indication, lengthening indication, lengthening technique, weight-bearing during lengthening, length gained, fixation index, minor and major problems, and notable points. These variables were chosen because they are informative to surgeons considering such procedures and aid in assessing the benefits and risks to future patients. Data not specified (n/s) in an article were reported as n/s. Where relevant, the means and standard deviations as well as percentages of lengthening parameters were calculated. Because of inconsistency in data reporting, comparative statistical analysis was not performed. Heterogeneity effects and sensitivity analysis were not investigated. Articles in Danish and Portuguese were translated using Google Translate. Articles in Russian were translated by a co-author.
Screening of database search results (Ovid Medline/Embase, and PubMed)
A total of 401 articles were deduplicated utilizing the Bramer method; 61 duplicates were identified and removed, leaving 340 articles for screening. No automation processes were used for screening; 199 articles were excluded based on title, 88 articles were excluded based on abstract, and 23 articles were excluded based on full-text review. Of the remaining 30 articles, all successfully retrieved, 16 were deemed ineligible for the purposes of this study leaving a total of 14 articles extracted from Ovid Medline/Embase and PubMed databases.
Screening of JLLR and Google Scholar Search Results
A total of 303 articles were identified for screening by JLLR simple keyword search and the Google Scholar “Cited by” feature. No automation processes were used for screening; 290 articles were excluded based on title and abstract screening. Of the remaining 13 articles, 5 were excluded based on full-text review, leaving a total of 8 articles extracted from JLLR and Google Scholar.
| Results|| |
[Figure 1] and [Table 1] depict the search and selection process; 22 studies reporting on the lengthening of 32 femurs and 31 tibias (63 total segments) were included, written in English (16), Russian (4), Danish (1), and Portuguese (1). Articles which were excluded included those describing bone transport, replantation, or increasing functional residual limb length by using prosthetic implants. [Table 2] and [Table 3] identify the primary and secondary outcomes identified in each study. Of the 22 included articles, 15 described lengthening of one limb segment (single case report), another 5 described two to four segments each (small case series, 15 segments total), and the remaining 2 described five or more segments (relatively large cohorts, 31 total segments). Lengthening was performed to improve prosthesis fit (21/22 studies, 54/63 segments), of which 52/54 had had improved fitment/mobility, or to optimize prior to planned osseointegration (1/22 studies, 9/63 segments), of which all 9 proceeded successfully. Lengthening was performed using either an external fixator (52/63) or a motorized intramedullary nail (11/63). All patients who received osseointegration were lengthened using a motorized lengthening nail.
|Figure 1: This flowchart outlines the PRISMA systematic review process employed to identify and screen articles. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses|
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The primary outcome investigated was the average amount of lengthening achieved. For femurs, this was 7.7 ± 2.5 cm (60% ± 23%) and for tibias was 5.8 ± 1.8 cm (97% ± 53%). Some additional metrics pertinent to lengthening were also reviewed. Weight-bearing status varied for external fixator patients in different studies; in seven studies unrestricted weight-bearing was allowed throughout treatment, while in 24 studies it was only allowed after lengthening was completed to encourage consolidation. In 10 studies weight-bearing was restricted, while in 12 studies it was unspecified.
The secondary outcome investigated was complications encountered. The most common minor complication was pin site infection, as it is for any situation that involves prolonged external fixation. None of the articles described pin site infections as a major complication or deterrent to lengthening and management is often not described. When described they are managed with simple oral antibiotics. The most common major complication was lengthening beyond the limit of the available soft tissue envelope, prompting surgical intervention. The next most common major complications were nonunion and premature consolidation, both of which were managed surgically by applying bone graft or repeating the corticotomy, respectively. There were two catastrophic complications, both knee disarticulations performed to manage lengthening beyond the limit of the available soft tissue envelope [Figure 2].
|Figure 2: View of the amputation stump from the distal vantage point at the end of the distraction period showing a rupture of the overlying scarred soft tissue envelope. Figure reproduced with permission from Springer Nature. van Roermund P. M. (2015) Case 57: An Initially Successful Lengthening of a Traumatic Below Knee Amputation Stump by Ilizarov Technique with Subsequent Failure Due to Soft Tissue Conditions. In: Rozbruch S., Hamdy R. (eds) Limb Lengthening and Reconstruction Surgery Case Atlas More Details. Springer, Cham. https://doi.org/10.1007/978-3-319-18020-5_197|
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| Discussion|| |
This systematic review of 22 articles presenting 63 limb segment lengthenings (32 – femur, 31 – tibia) reveals that residual lower limb lengthening for amputees can often achieve the intended purpose: to improve (or enable) the use or fit of socket prostheses. As is common for patients with intact lower extremities undergoing lengthening, lengthening technology included circular frames, monolateral rails, and motorized intramedullary nails. On average, femurs achieved 7.7 ± 2.5 cm (60% ± 23%) and tibias achieved 5.8 ± 1.8 cm (97% ± 53%). 52/54 (94%) segments exhibited improved fitment or mobility after lengthening with poor postoperative fitment associated with complications rather than the lengthening itself. These two segments had knee disarticulation due to over-lengthening, hence inhibiting the use of their prosthesis. The nine osseointegration patients proceeded successfully. As with any external fixation-based surgery, superficial pin site infection is common and well addressed with oral antibiotics.
Perhaps, the most important lesson from this review is that diligent, periodic monitoring of patients and their entire extremity is mandatory. Lengthening beyond the available soft tissues would appear to be very avoidable. Skin does not withstand sustained pressure, as is known from pressure ulcer literature (which probably was not as widely known in past decades). Some surgeons successfully managed this complication by shortening the bone to reduce the pressure on the skin. Unfortunately, two patients had knee disarticulation to manage over-lengthening of their residual tibia. One patient was lengthened 5 cm (62%) and the other 7 cm (175%). The authors did not report the amount of lengthening when the skin limit was reached or exceeded, only the total amount that was done. Such situations emphasize the importance of careful, frequent clinical inspection of amputees undergoing lengthening. The residual skin envelope for amputees is often fragile and can quickly change from tense but safe, to irrecoverably ruptured. Losing a functioning knee is a catastrophic event, leaving a patient most likely worse than prior to lengthening. While extenuating circumstances may always arise, it is important to anticipate problems and address them as early as possible to limit the probability of permanent sequelae of treatment. Furthermore, it is always prudent to consult the relevant literature and to seek the counsel of knowledgeable colleagues at other specialist centers whenever undertaking elective complex reconstructive procedures. Precedents were available to guide these surgeons.
There are myriad challenges lower extremity amputees face, many centered around trouble with the prosthesis interface (skin-compressing socket). Most amputees using a socket prosthesis have periodic intolerance due to subjective instability related to impaired proprioception,, trouble maintaining a good fit due to fluctuating residuum size requiring frequent socket refitting, or skin ulceration or intolerable perspiration., Some amputees, such as those profiled in this review, are unable to be fit with a prosthesis due to a residual extremity that is too short or otherwise has morphology impairing a good fit. For transtibial amputees, a knee disarticulation or transfemoral amputation can be performed to provide a longer lever arm for the socket than the short tibia. Alternatively, the knee joint can be fused and a socket worn on the entire residual limb, although this can be biomechanically awkward. For transfemoral amputees with too short a residuum that cannot suspend a socket, there is no proximal amputation that improves their prosthesis use with a socket prosthesis; they are already functionally a hip disarticulation amputee.
For limb reconstruction surgeons, RALS lengthening is likely the most intuitive intervention to improve prosthesis wear and use. The traditional technique for limb lengthening uses an Ilizarov apparatus, featuring external rings fixed to the bone with thin bicortical through-and-through wires or single-sided bicortical half-pins, and was the most common technique used in the articles summarized in this review. Hexapod frames are a more sophisticated type of external circular fixator, and unilateral or bilateral rail systems are noncircumferential external fixation devices which were also reported. The most modern lengthening technique uses a motorized telescopic intramedullary nail (with designs featuring a transcutaneous wire or an external magnetic drive to power the nail), employed in two of the reviewed articles. A sophisticated review of the techniques, benefits, and limitations of each option is beyond the scope of this study (and other reviews have been recently published),,, but some concepts warrant specific mention. Very short bones require unique osteotomy or apparatus linkage techniques. Intramedullary nails offer the convenience of avoiding a bulky fixator and eliminate pin site infections but require custom techniques to connect the bone segments to the nail. When lengthening very short tibias, care must be taken not to lengthen the tubercle which disrupts the extensor mechanism, necessitating creative osteotomy patterns. None of the tibiae in this review underwent motorized nail lengthening. All studies which utilized nails were transfemoral amputees. In patients with femurs too short to accommodate the market standard nail, they were distally linked utilizing either a cable or plate and screw technique. No custom nails were utilized as they limit intraoperative options to accommodate for unexpected anatomy, offer less quality control, and are more expensive. Multiple articles reported that for transtibial lengthening, having a long frame and/or prosthesis attached to the frame may prevent knee flexion contractures by allowing patients to weight bear or at least use the construct as a lever to assist with physical therapy during the lengthening process [Figure 3].
|Figure 3: Patient able to bear weight on the end of the external fixator during the lengthening procedure. Note that the threaded rods between the two rings allow bone lengthening to be imparted, while the threaded rods between the “floor ring” and the distal tibia ring allow the length of the walking frame to accommodate the patient's tibial adjustments. Figure reproduced with permission from Springer Nature. Park HW, Jahng JS, Hahn SB, Shin DE. Lengthening of an amputation stump by the Ilizarov technique. A case report. Int Orthop. 1997;21 (4):274-6. doi: 10.1007/s002640050166|
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There are other techniques to provide better prosthesis wear by creating a longer functional limb, which were not reviewed because they are not methods of limb lengthening. One option includes endoprosthetic implants which can acutely provide a longer lever arm for patients with sufficient skin and soft tissue coverage.,,, Bone flap augmentation can also be considered.,,
One reviewed article was particularly compelling because the authors provided femoral lengthening for patients who had difficulty with socket prosthesis wear but with the goal of providing a longer residual femur for osseointegration instead of a socket prosthesis. Osseointegration is a relatively recent reconstruction technique which places a metal implant (usually a titanium alloy) into the intramedullary canal of the residual bone [Figure 4]. The implant has a permanent transcutaneous portion which allows a standard limb prosthesis to be connected, achieving a skeletally anchored prosthetic limb. It has proven to provide superior quality of life and mobility for transfemoral and transtibial amputees,, and may be a particularly effective option for amputees with very short residual bone segments who may continue to struggle with prosthesis rehabilitation even after investing the time and money for lengthening. While it is clear that titanium surfaces can achieve osseointegration supporting full weight-bearing,, it is not at all clear how much area or length of implant surface is required to achieve this. Very few studies have investigated how to consider short segment osseointegration (jllr_20_22 currently under revision and jllr_22_22 just submitted). Therefore, clinical experience and judgment remain the best available guide when deciding how best to manage patients with short residual bone and a resultant lower area for integration. As another alternative, osseointegration could be provided even without lengthening for some of these patients.
|Figure 4: This series of anteroposterior radiographs illustrate the care of a patient with traumatic bilateral transfemoral amputation. (a) The right femur has 19 cm of length from the piriformis fossa to the end, which is long enough for a full-length osseointegration implant without further preparation (shown in the final frame of this figure). (b) The left femur has only 9.5 cm, which is too short for a standard osseointegration implant. (c) A telescopic motorized lengthening nail was inserted into the femur after performing a transverse corticotomy. Note that the lengthening nail is still longer than the residual femur, so the distal linkage was achieved using a locking plate which was bent to allow some screws to fixate the bone and one screw to cross-lock the distal nail hole. There are other screws in the proximal bone segment to help maintain bone alignment during lengthening. (d) The nail has lengthened 6 cm, which is the limit of this patient's soft tissue envelope. This radiograph was taken after 2 months of consolidation at that length. Note the rather robust appearance of the regenerate bone. (e) The lengthening nail was exchanged for an osseointegration implant. (f) Full-length standing radiograph of both legs, taken 6 months following the left femur osseointegration, identifies the patient has full weight-bearing of both legs, each featuring osseointegrated connection of a prosthetic leg. The right femur had immediate osseointegration without intermediate preparation. The mechanical axis alignment of each leg is nearly perfectly straight|
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Several limitations are important to consider. Fifteen of the 22 articles were a single patient case report, and 20 were reports of four or fewer patients, likely resulting in over-representation of abecedarian experience. The patients' age, amputation etiology, time period of care, and other demographics were heterogeneous or not reported. There was also very little description of quantitative clinical outcomes of lengthening, such as prosthesis wear frequency or duration, or distance able to be walked. The article featuring osseointegration achieved successful implantation with prosthesis attachment and wear for all patients, which may be a relatively objective definition of success (although such patients may still experience setbacks in rehabilitation); every other article defined “success” with a brief statement that a patient wore the prosthesis more or better but did not provide any metrics of assessment, making it hard for readers to thoroughly consider the risks and benefits of amputee lengthening. Unfortunately, the articles also did not report a goal length which was adequate for prosthesis wear but generally lengthened until patients either had a complication or exceeded their tolerance of the lengthening experience. Finally, although Google Scholar identified several articles in other languages, all searches were performed in English, so results were likely biased in underreporting non-English data. Relative strengths of this study include the inclusion of studies as historic as 1970, soon after Ilizarov's recognition of distraction osteogenesis, and as recent as 2021. Furthermore, articles in several foreign languages were included, successfully incorporating some of the non-English knowledge.
| Conclusions|| |
Although very limited evidence exists, most of very low quality, it seems apparent that surgeons experienced in limb lengthening can offer lengthening procedures to patients with short residual limbs with reasonable confidence that their prosthesis fit should improve. Customizing lengthening techniques and goals to specific patient anatomy may be necessary. As with all reconstruction surgeries, avoiding major complications is important, in particular exceeding the available soft tissue coverage.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]