The Journal of Bone and Joint Surgery (American) 85:1502-1510 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.
Nerve Lesions Associated with Limb-Lengthening
Monica Paschoal Nogueira, MD,
Dror Paley, MD, FRCSC,
Anil Bhave, PT,
Andrew Herbert, MD,
Catherine Nocente, PhD and
John E. Herzenberg, MD, FRCSC
Investigation performed at the International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
Monica Paschoal Nogueira, MD
Universidade de São Paulo, Av Ministro Gabriele de Rezende Passos, 555-21, 04521-022 São Paulo-SP, Brazil
Dror Paley, MD, FRCSC
Anil Bhave, PT
Catherine Nocente, PhD
John E. Herzenberg, MD, FRCSC
International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215-5271. E-mail address for D. Paley: dpaley{at}lifebridgehealth.org
Andrew Herbert, MD
Whangeri Hospital, P.O. Box 742, Maunu Road, Whangeri, New Zealand
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Background: Nerve injury is one of the most serious complications associated with limb-lengthening. We examined the risk, assessment, and treatment of nerve lesions associated with limb-lengthening.
Methods: We retrospectively studied the records on 814 limb-lengthening procedures. Nerve lesions were defined by clinical signs and symptoms of motor function impairment, sensory alterations, referred pain in the distribution of an affected nerve, and/or positive results of quantitative sensory testing with use of a pressure specified sensory device.
Results: Seventy-six (9.3%) of the limbs had a nerve lesion. Eighty-four percent of the nerve lesions occurred during gradual distraction, and 16% occurred immediately following surgery. The pressure specified sensory device showed 100% sensitivity and 86% specificity in the detection of nerve injuries. The patients in whom the lesion was diagnosed with this method, or with this method as well as with nerve conduction studies, had significantly faster recovery than did those diagnosed on the basis of clinical symptoms or nerve conduction studies alone (p = 0.02). Patients undergoing double-level tibial lengthening and those with skeletal dysplasia were at higher risk for nerve lesions (77% and 48%, respectively). Nerve decompression was performed in fifty-three cases (70%). The time between the diagnosis and the surgical decompression was strongly associated with the time to recovery (p = 0.0005). Complete clinical recovery was achieved in seventy-four of the seventy-six cases.
Conclusions: Early detection based on signs and symptoms or testing with a pressure specified sensory device improves the prognosis for nerve injury that occurs during limb-lengthening. Of the methods that we used to identify neurologic compromise, testing with the pressure specified sensory device was the most sensitive. Aggressive early treatment (slowing the rate of lengthening and/or performing decompression) allows continued lengthening without incurring permanent nerve injury. When indicated, decompression of the affected nerve should be performed as soon as possible, thereby improving the chances of and shortening the time to complete recovery.
Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.
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