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New Straits Times » Focus

COVER STORY: To grow a bone
JESSICA LIM

Oct 9
A fully internal, remote-controlled limb-lengthening device heralds a breakthrough in reconstructive surgery, whether it be for accident victims, people with natural limb discrepancies or those who simply feel they’re too short. JESSICA LIM reports.

NstKiosk Spanner in hand, Ari poised over the chunky metal brace caging his right leg. With four careful tweaks, he forced the rods piercing his skin, muscle and bone to move a fraction, bringing him a quarter of a millimetre closer to walking normally again.

When his shin bone became badly infected while recovering from a nasty car accident two months ago, the 35-year-old lorry driver refused even to ponder the possibility of amputation.

He opted for Ilizarov surgery — a painful procedure where 7cm of infected bone in his leg was removed, and new bone stimulated to grow.

This is done by breaking the healthy part of the bone and pushing the two pieces apart every six hours over six months (a process called "distraction osteogenesis") until the 7cm gap is closed.

"It was the worst pain I’ve ever experienced, especially the first week. I’ll never forget it till the day I die.

"At that time, I thought ‘dying is better than this.’ Now I’ve got used to it, it’s not too bad."

"I feel like a rotting kayu (wood)... Can’t work, can’t go out because people stare at my leg.

"But as long as my leg is saved, I don’t mind. I want to get back to work and play football again."

For decades, the painful and encumbering Ilizarov procedure was the best chance for shattered bones to be restored, short limbs to be lengthened and crooked ones straightened.

Breakthroughs in distraction osteogenesis in the past 10 years, however, have resulted in hassle-free and less painful (albeit more expensive) alternatives.

The most technologically advanced option so far is a fully implantable, electronically-motorised limb-lengthening device called "Fitbone".

Developed in Germany, Fitbone consists of an antenna which is buried under the skin, a telescopic nail implant and a handheld radio-frequency transmitter.

The patient controls the lengthening process. Push a button on the transmitter when it is placed against the antenna and the built-in motor extends the nail approximately 1mm per day.

Dr Thirukumaran Subramaniam, who has practised orthopaedic surgery in Malaysia, Germany and Singapore since 1994, said the leap forward came when optimal bone distraction rate was determined to be 1mm per day.

"Lengthening too fast will overstretch soft tissues, causing pain," he said.

"Also, bone gaps which are too big will never fill up. Too slow and the bone hardens before you complete the full lengthening process.

"Ilizarov is infection-prone. It’s itchy, uncomfortable, you get stared at, and often have to deal with unsightly scars after the whole ordeal."

Ilizarov surgery was developed in Russia in the 1950s. Frames were made of stainless steel rings, which weighed up to 7kg. Newer models are made of carbon, which, though lighter, are equally cumbersome.

With the introduction in 2001 of the Intramedullary Skeletal Kinetic Distractor (ISKD), lengthening could take place internally, drastically reducing the risk of infections and scarring.

With ISKD, a pin which could be gradually extended by knee or ankle rotations is implanted into the bone.

Lengthening is monitored by a handheld external magnetic sensor that tracks the rotation of an internal magnet on a daily basis.

Dr Thiru’s teammate and fellow orthopaedic surgeon, Dr Jeyaratnam T. Satkunasingam, said that Fitbone improved on several weaknesses of the ISKD method.

ISKD required a physical leg movement to "crick" the device into lengthening, which was quite painful, especially right after surgery, he explained.

"Patients also risk accidentally ‘over-lengthening’ their bones, which might prevent proper bone formation," said Dr Jeya, who was trained in Fitbone surgery at the University of Munich, Germany, last year after eight years of experience as an orthopaedic surgeon.

The convenient, scar-free procedure, however, comes at a price.

While the Ilizarov external fixator costs RM15,000 and the ISKD implant about 7,000 euros (RM32,000), the Fitbone device alone carries a price tag of 10,000 euros (RM45,000).

Including surgery costs, the Fitbone procedure would come to RM80,000 — per bone.

Often, especially in congenital conditions, both the tibia and femur need to be operated on to ensure proportionate lengthening of the leg.

Sometimes, all four leg bones must undergo surgery, quadrupling the cost of the procedure.

Following the lengthening procedure, the patient is confined to a wheelchair or crutches for a period to allow the bone to gain mass.

"Growing 60mm takes 60 days," said Dr Jeya. "Thereafter, the patient must wait another 120 days before using the leg normally.

"If a person has both legs operated on, it takes significantly longer because it’s not wise to operate on both legs at once."

In the days following initial surgery, patients must undergo a demanding physiotherapy regime — stretching exercises and sometimes be hooked up to a "continuous passive motion" device.

This is to avoid stiffness and to stimulate the muscles, nerves and blood vessels to grow alongside the bone.

Patients are often prescribed painkillers and are unable to work.

The surgeons recommend that bones be grown to a maximum of about 7cm per bone, which means the individual can gain up to 14cm in total limb length.

"Some doctors claim that they can grow each bone by up to 12cm, but that will place great strain on the body," said Dr Thiru.

"Besides, if your legs are too long, you’ll look like a lemon on toothpicks."

Factors that influence an individual’s bone growth rate include age, discipline and lifestyle. The bones of a smoker, for example, grow more slowly than that of a non-smoker.

Although the procedure most often deals with post traumatic injuries, it is increasingly used to correct limb discrepancies caused by congenital conditions and old injuries.

Dr Thiru and Dr Jeya both find it very satisfying, as orthopaedic surgeons, to see patients — whose limbs were deemed unsalvageable — walking tall and straight again.

Some were accident victims whose shattered legs were considered a lost cause.

Some were people who have lived for years with congenital deformities so severe that their doctors recommended amputation and a prosthetic fitting.

Others were resigned to living with their awkward gaits and misaligned postures, with no hope of correcting them.

But now many of these conditions can be remedied, if money is not a big issue.

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