Bone Lengthening for Congenital Conditions, Limb Discrepancies and Angular Deformities of Long Bones
DESCRIPTION
Bone lengthening (e.g., Ilizarov technique) involves the application of an external fixator device that attaches to the underlying bone via transfixion wires. A corticotomy is performed, permitting attachment of the wires. Periodic adjustment of the external fixator produces a distractive lengthening force, which gradually stimulates new bone growth.
POLICY
Bone lengthening for the correction of function related to congenital conditions, post-traumatic limb length discrepancies, and/or angular/rotational deformities of long bones (i.e., humerus, radius, ulna, femur, tibia, and fibula) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Bone lengthening of less than 3 cm is considered not medically necessary.
Bone lengthening/remodeling for appearance/esthetic purposes (e.g., short stature) is considered cosmetic.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Bone lengthening is considered medically appropriate if any of the following criteria are met:
Demonstrable non-union of a long bone with or without bone loss or infection; or
When lengthening of an amputated stump is needed for proper fitting of a prosthesis; or
Where leg lengthening is needed to equalize leg length discrepancy greater than 6 cm; or
Bone defects with or without deformities.
ADDITIONAL INFORMATION
Bone lengthening of less than 6 cm or greater than 15 cm should be referred for BCBST physician review.
SOURCES
American Academy of Orthopaedic Surgeons. (2004, January/February). Management of posttraumatic segmental bone defects. Retrieved September 7, 2005 from http://www.jaaos.org/cgi/content/full/12/1/28.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2004). Ilizarov bone-lengthening procedure (7.01.11). Retrieved July 3, 2007 from BlueWeb. (4 articles and/or guidelines reviewed)
El-Rosasy, M., & Ayoub, M. (2007). Acute correction of proximal tibial deformities in adolescents using Ilizarov external fixator: Focal-dome versus straight-cut osteotomy. Journal of Pediatric Orthopaedics, 16 (2), 113-119. Abstract retrieved July 5, 2007 from PubMed database.
Hasenboehler, E., Smith, W. R., Laudicina, L., Philips, G. C., Stahel, P. F., & Morgan, S. J. (2006). Fatigue behavior of Ilizarov frame versus tibial interlocking nail in a comminuted tibial fracture model: A biomechanical study. Journal of Orthopaedic Surgery and Research, 1, 16.
Heiss, C., Meissner, S. A., Hoesel, L. M., Pfeil, J., & Schnettler, R. (2006). Posteromedial approach to proximal tibia for corticotomy in callus distractions. Clinical Orthopaedics and Related Research, 451, 182-188. Abstract retrieved July 5, 2007 from PubMed database.
Palusaka, S. A. (2004). Osteomyelitis. Clinics in Family Practice, 6 (1), 127-156.
Parsons, B., & Strauss, E. (2004). Surgical management of chronic osteomyelitis. The American Journal of Surgery, 188, 57S-66S.
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EFFECTIVE DATE |
8/9/2007 |
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ID_BT
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