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NEWS AND VIEWS Table of Contents   
Year : 2002  |  Volume : 36  |  Issue : 1  |  Page : 59-61
An indigenous way to prevent equinus in limb lengthening


Arora Bone and Joint Clinic, Amritsar, India

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How to cite this article:
Arora R K. An indigenous way to prevent equinus in limb lengthening. Indian J Orthop 2002;36:59-61

How to cite this URL:
Arora R K. An indigenous way to prevent equinus in limb lengthening. Indian J Orthop [serial online] 2002 [cited 2019 Dec 12];36:59-61. Available from: http://www.ijoonline.com/text.asp?2002/36/1/59/48651
Muscle contractures occur in long limb lengthening due to the tension generated on the muscles by the forces of distraction. This force tends to select out the dominant muscle group. In leg triceps surae offers the greatest resistance to lengthening. This tension or the resistance is the force which stimulates the muscle to regenerate during lengthenings, but this very tension leads to muscle contracture and development of equinus at the ankle and flexion at the knee. If the muscle lags behind in lengthening or if it gets tethered down while applying the fixator, the contractures result. This tethering of the muscle cannot be avoided because we want a stable fixation and the stability of the frame depends upon the number of pins, diameter of pins and the spread of pins in different planes. Again, the transfixion of the skin and fascia may limit the joint motion more than the transfixion of the muscles. The development of muscle contracture and of the deformities at the ankle and the knee has to be prevented.

Prophylaxis against muscle contracture is an essential part of the treatment for limb lengthening. These measures are avoidance of tethering of muscles, skin and fascia and maximizing the excursion of the muscles before transfixing them. Other measures are physiotherapy and splinting. Physiotherapy mainly revolves around passive stretching of the muscles. As triceps surae crosses two joints, both the joints have to be mobilized. The foot should be dorsiflexed maximally with the knee in flexion and then with the foot in dorsiflexion, the knee should be fully extended. This has to be repeated very often during the day and the patient must bear weight on his limb for a minimum of six hours per day. All this puts the muscle under tension which is necessary for regeneration of the muscle so that it can keep pace with the lengthening bone. It has been seen that tensioning of the muscle for less than six hours per day does not prevent development of contractures. Ilizarov used one wire in the calcaneus for tibial lengthenings. Two wires in the heel add greater stability and avoid frequent wire breakage that can occur from cyclic loading of a single wire [1] . Even the fixation of calcaneus by two wires does not prevent the development of contractures. Moreover the patient must bear weight if we want good quality regenerate. Unfortunately, majority of our patients do not follow the daily routine of physiotherapy and tensioning of the triceps surae. To maintain the normal tibiotalar relationship, an orthosis was developed.

Development of the orthosis

The various devises like ordinary bandages, elastic bandages, Hawai chappal with elastic stitched to it did prevent equinus to some extent but with the limbs being unequal, weight bearing was not possible. So as an alternative an orthosis was made. It is a synthetic sole to which four fully threaded rods are attached with the help of nuts and bolts. The two anterior rods are attached to the last ring and the posterior rods are attached to the last half ring which is used to fix the calcaneus with a single wire [Figure 1]. Another sole can be attached to this sole with the help of four more (same rods can also be used) fully threaded rods. This makes up the length of the limb so that the patient can bear weight on this limb [Figure 1]. It leads to the formation of a good quality regenerate. The distance between the two soles is decreased at the same rate at which the lengthening is progressing.

With the first sole, equinus can be corrected even if some of it has already developed. When the lengthening is complete, the two soles come in close contact [Figure 2]. This orthosis is left attached to the fixator till the bone consolidates and then it is removed along with the fixator. No equinus develops even with lengthenings of more than 20 cms.

Results are surprisingly good. Out of the fifty odd cases where this orthosis was used not even one case developed equinus.

If we have to lengthen tibia by more than 6 cm we have to guard against development of equinus. Complex type of dynamic knee and ankle splints [1] have been used but these are not available everywhere and are beyond the reach of most of our patients. Maurizio Catagni [2] recommends the placement of the foot in a rigid sole shoe. A spring (like the one used in an old fashioned toe raising device) attached to the anterior part of the shoe and the frame prevents the foot from going into equinus. This does allow ankle motion. This rigid soled shoe is worn during the night; during the day it is replaced by a tennis shoe which will allow easier ambulation while still providing dynamic positioning of the ankle [2] . This is a good idea but with it weight bearing cannot be done during the course of the lengthening. It can be used once the lengthening is over. During the lengthening, the double soled orthosis and after full lengthening single soled orthosis described above seems a better choice. It has no dynamic element in it but after the removal of the fixator the movements at the ankle are slowly regained.

 
   References Top

1.Paley D. Problems, obstacles and complications of limb lengthening. Clin Orthop India 1991; 6 : 152 - 173.  Back to cited text no. 1    
2.Catagni M, Biancchi A, Aronson J. Lengthening of the tibia. In Operative Principles of Ilizarov ASAMI group. Milan; Williams and Wilkins. 1991; 288 - 300.  Back to cited text no. 2    

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Correspondence Address:
R K Arora
Arora Bone and Joint Clinic, 36, Anand Avenue, Amritsar - 143 001.
India
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Source of Support: None, Conflict of Interest: None


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