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Medical Policy

Policy Num:       07.001.017
Policy Name:    Ilizarov Bone-Lengthening Procedure
Policy ID:          [07.001.017]  [Ar / B / M+ / P ]    [7.01.11]

Last Review:       February 3, 2021
Next Review:      
Issue:                   2:2021

Related Policies: None

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Ilizarov Bone-Lengthening Procedure  

Summary

The Ilizarov bone-lengthening procedure uses a circular external fixator device that attaches to the bone via transfixion wires. A corticotomy (percutaneous osteotomy) is performed, permitting attachment of the wires. Periodic adjustment of the external fixator produces a distractive lengthening force, which gradually
stimulates new bone growth.

Objective

The objective of this review is to demostrate the value of the Ilizarov External Fixators in the management of conmminuted  fractures, deformities and non union in fractures of the lower extremity.

Policy Statements

These services are considered for payment in the treatment of the following conditions:

• Treatment of post-traumatic osteomyelitis.
• Correction of bone defects with deformities.
• Bone lengthening necessary to match a discrepancy greater than 6 cm.
• Correction of post traumatic deformities or deformities that include limb rotation.
• To lengthen a stump after the amputation to facilitate the process of using the prosthesis.
• For correction of defective union of bone accompanied by bone loss or post-infection.

• In those cases in which the correction of the bone defect is not accompanied by deformity, we recommend evaluation by advisor.
• The use of the upper limb procedure is not considered for payment.
• The use of the technique for the sole purpose of increasing height is not considered for payment.

Policy Guidelines

N/A

Benefit Application

BlueCard/National Account Issues

The Ilizarov technique is a specialized procedure that may require out of network referral.

Background

The technique was brought to the US in 1987 by Victor Frankel, president of Hospital for Joint Diseases,^[ and Dr. Stuart Green who, in 1992, edited the first English translation of Ilizarov's book.

The Ilizarov external fixators can be used to correct angular deformity in the leg, to correct leg-length differences, and treat non-unions. In most developing countries it is a highly specialized technique used mainly for deformity correction by experienced surgeons due to its complexity. Further development of the ring construct led to the Taylor Spatial Frame which is more versatile and far easier to use, but very costly. Intramedullary limb lengthening devices are also available, but are also a very costly option.

The apparatus is based on the principle which Ilizarov called "the theory of tensions". Through controlled and mechanically applied tension stress, Ilizarov was able to show that the bone and soft tissue can be made to regenerate in a reliable and reproducible manner.The top rings of the Ilizarov (fixed to the healthy bone by the tensioned wire) allow force to be transferred through the external frame (the vertical metal rods), bypassing the fracture site. Force is then transferred back to the healthy bone through the bottom ring and the tensioned wires. This allows the Ilizarov apparatus to act as a sort of bridge, both immobilizing the fracture site and relieving it of stress, while allowing for the movement of the entire limb and partial weight-bearing. Middle rings (and tensioned wires) act to hold the bone fragments in place and to give greater structural support to the apparatus and limb. However, the critical load bearing rings are the top and bottom rings which transfer the force from the healthy bone down to the healthy bone, bypassing the fracture site.

The procedure consists of an initial surgery, during which the bone is surgically fractured and the ring apparatus is attached. As the patient recovers, the fractured bone begins to grow together. While the bone is growing, the frame is adjusted by means of turning the nuts, thus increasing the space between two rings. As the rings are connected to opposite sides of the fracture, this adjustment, done four times a day, moves the now-healing fracture apart by approximately one millimeter per day. The incremental daily increases result in a considerable lengthening of the limb over time. Once the lengthening phase is complete, the apparatus stays on the limb for a consolidation period .

Regulatory Status

N/A

Rationale

A literature search for the period of 1995 through July 2004 reveals that the Ilizarov procedure is an effective and accepted procedure for the correction of congenital or post-traumatic limb length discrepancies and angular deformities of the limb (arm, forearm, thigh, or leg). (1-4)

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Gugenheim JJ. The Ilizarov method. Orthopedic and soft tissue applications. Clin Plast Surg 1998; 25(4):567-78.
2. Herbert AJ, Herzenberg JE, Paley D. A review for pediatricians on limb lengthening and the Ilizarov method. Curr Opin Pediatr 1995; 7(1):98-105.
3. Tsuchiya H, Tomita K. Distraction osteogenesis for treatment of bone loss in the lower extremity. J Orthop Sci 2003; 8(1):116-24.
4. DeCoster TA, Gehlert RJ, Mikola EA et al. Management of posttraumatic segmental bone defects. J Am Acad Orthop Surg 2004; 12(1):28-38.

5. Spiegelberg B, Parratt T, Dheerendra SK, Khan WS, Jennings R, Marsh DR. (2010). "Ilizarov principles of deformity correction". Annals of the Royal College of Surgeons of England

6. Paley, Dror; Kovelman, Harry F; Herzenberg, John E (October 1993). "Ilizarov technology". In Stauffer, Richard (ed.). Advances in Operative Orthopaedics: Volume 1 (PDF). Mosby Inc

CODES

Appplicable Modifiers

N/A

Policy History