Lengthening Limbs, Walking Tall
by Mary Ann Littell

A physical deformity caused by trauma, a birth defect or disease
results in one limb being significantly longer than the other, destroying the
body’s perfect balance. The result is often a serious disability, impairing walking
and other activities of daily function.

It happened to 16-year-old Belal Moghal of Pakistan. As a 6 year old, he was riding on the back of a motorcycle when he was hit by a bus. The accident severely damaged his left leg. He underwent several surgical procedures in his native country, but doctors there were unable to help him. As he grew, the discrepancy became more and more pronounced.

Belal’s family came to New Jersey four years ago to seek medical treatment. They saw several physicians, then learned of the work being done at UMDNJ-University Hospital by Sanjeev Sabharwal, MD. When they came to see him, there was an
18-centimeter difference (approximately seven inches) in the length of Belal’s two legs. The injured leg was bowed and twisted and he walked with a limp.

Sabharwal, who is chief of pediatric orthopaedics at UMDNJ-New Jersey Medical School, is one of the few physicians in the country specializing in limb length
discrepancy (LLD) and correction of limb deformities. He says, “It gives me a great sense of purpose to straighten crooked bones and improve not only the appearance, but also the function and longevity of the limb.”

His interest in LLD was sparked early in his career. A native of Delhi, India, he went to medical school in his hometown and came to the U.S. in 1985 to study at Harvard Medical School. He then completed an orthopaedics residency in Vancouver and two fellowships in pediatric orthopaedics in California, at USC and UCLA.

“I had a job lined up in California,” he recalls. “My family was so happy. They loved it there. But then I decided to take a limb lengthening course before starting the job. I’d always been curious about it.”

The course was at the Maryland Center for Limb Lengthening, a world-renowned training site for the complex procedures. “Two of the pioneers in the field were faculty, and they were great teachers,” he states. “I became totally fascinated by it. When I finished the course they offered me a job. I couldn’t turn it down. But it wasn’t easy telling my family we weren’t staying in California — we were going to Maryland instead!”

Sabharwal came to NJMS in 1997, where he is an associate professor of orthopaedics. Both he and Fred Behrens, MD, professor and chair of orthopaedics at NJMS, perform limb lengthening procedures at UMDNJ-University Hospital. Patients come to them primarily through referrals.

LLD has many causes, including old trauma (a fracture that did not heal or healed incorrectly), growth plate injuries, congenital disorders or infection. Another cause is Blount’s disease, a disorder of morbidly obese adolescents. They literally become so heavy that their legs cannot support their weight and become severely bowed. “As pediatric obesity continues to rise, we’re seeing more and more patients with Blount’s disease,” says Sabharwal. “It’s particularly prevalent among African-American children.”

In most cases, LLD can be corrected through a slow process called distraction osteogenesis. The procedure was developed in the early 1960s by a Russian physician, Professor G.A. Ilizarov, and is sometimes called the Ilizarov
procedure. Sabharwal likens this work to “gardening, as opposed to carpentry.”

Sanjeev Sabharwal, MD, with his patient, Belal Moghal. Following a serious motorcycle accident many years ago, Belal’s left leg was seven inches shorter than his right leg. He and his family traveled to the U.S. from Pakistan to seek treatment.

“In orthopedics, there is a lot of mechanical work, or ‘carpentry,’” he explains. “With this procedure, the mechanical work is minimal. The gradual pulling apart of the cut ends of the bone is what enables us to correct these deformities. You have to nurture it along, just like a garden.”

Surgery is the first step. Using minimally invasive techniques, the bone is cut, taking care to preserve the periosteum, which promotes bone growth. A fixator, an external metal device resembling a circular cage, is placed around the limb and attached to the bone by wires and pins.

In the second phase of treatment, or distraction, the fixator is adjusted daily, while the patient is at home, to slowly pull apart the bone. Over time, new bone grows in the open space, lengthening the limb.

	Left: X-rays of Belal’s leg show the discrepancy in length. Right: X-rays taken after a fixator was attached to the leg to lengthen it.

Sabharwal states that the patient or family plays a vitally important role in the treatment. They’re responsible for turning the small wheel on the fixator precisely the right amount each day to separate the bone. He trains them how to do it properly and explains that compliance is very important. “I’m always amazed at how well patients learn to do this,” he says. “You have to take things very slowly. You can’t turn it too much or too little. But the patients and families are very, very careful.”

Patients are at risk for infection where pins and wires go through the skin, so they must keep the area scrupulously clean. Once the fixator is removed, a cast or brace is usually worn for a few days, and patients receive physical therapy to recover full range of motion.

In addition to his clinical work, Sabharwal is researching ways to refine the procedure. He’s looking at the effects of limb lengthening on the growth plate, and also investigating different ways to measure leg length difference. It’s all aimed towards improving care to patients.

Belal’s fixator was attached in October 2004. When he comes for a check-up in mid-July, he’s wearing baggy, “hip-hop” style sweatpants that snap up the sides. Still, the fixator is visible, primarily because of its bulk. He’s had it on for eight months now. “I’ve gotten used to it,” he says. “Nobody makes fun of me, and it doesn’t keep me from doing anything I like to do, except play soccer.”

Belal’s family lives in Jersey City. He comes to the Newark office with his father, who doesn’t speak much English, and a family friend, who serves as translator and chauffeur. The physician says, “In spite of transportation issues and language barriers, Belal has come very far because he and his family have done everything right.”

They’ve had a lot of help from technology. Turning to a computer on his desk, Sabharwal logs onto a Web site monitored by the manufacturer of Belal’s fixator, called the Taylor Spatial Frame.

“With new technology, you can customize the fixator for the person,” he explains. “On the Web site, you input the patient’s data and get a schedule that outlines the necessary adjustments. You give the schedule to the patient so they know exactly what to do and when to do it.”

Belal’s fixator was removed this past August. Because his knee had been previously fused during one of his many prior surgeries, he did not have full motion before his recent limb reconstruction surgery. Therefore, his left leg was purposely left approximately 3/4 inch shorter so his foot doesn’t drag. He is doing very well with little residual limp, which should improve over time.

Sabharwal finds it gratifying that a patient with a deformed leg and severely limited movement is now walking almost normally. He says, “The combination of biology, technology and medicine is what makes this kind of work possible. With the right tools and a little patience, we can make a big difference.

“Belal’s case is a good example of what can be accomplished. He can do everything he wants to do now, with no limitations. He’ll be on the soccer field before too long.”