Limb Lengthening
Understanding Limb Lengthening Surgery: A Comprehensive Guide
Limb lengthening surgery is designed to increase the length of bones in the arms or legs. This intricate process, known as osteotomy, involves the careful separation of the bone and a gradual process known as distraction, where the bone segments are slowly pulled apart. This creates a space—the osteotomy gap—where new bone tissue begins to form. Over time, as the bone segments continue to separate at a controlled pace, new bone regenerates, culminating in an increase in bone length.
This remarkable procedure leverages the body’s innate ability to generate new bone, along with the regeneration of surrounding soft tissues, ligaments, fascia, blood vessels, and nerves, ensuring a comprehensive enhancement of the limb’s length and function. At the core of limb lengthening is the principle of distraction osteogenesis, a technique that has transformed the possibilities for individuals seeking femur lengthening, tibia lengthening surgery, or an overall height increase through surgery.
Whether you’re considering leg lengthening surgery for cosmetic reasons, such as height increase surgery, or to correct discrepancies in limb length, our facility in Turkey stands at the forefront of this advanced medical practice. Our experienced surgeons utilize state-of-the-art technology and techniques to ensure optimal results for each patient, making limb lengthening surgery in Turkey a sought-after solution for those looking to enhance their stature or improve their quality of life.
How Does Limb Lengthening Work ?
Limb lengthening and deformity correction operate on the principle of distraction osteogenesis. When a bone fractures, the body naturally initiates the regeneration of new bone tissue to heal and restore integrity. In limb lengthening, a deliberate surgical osteotomy (bone cut) is performed, creating two segments that are slowly distracted using orthopedic devices.
The comprehensive process unfolds in three stages:
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Osteotomy: Surgically cutting the bone into two segments.
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Distraction: Controlled separation of bone segments using internal nails or external fixators.
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Consolidation: New bone tissue gradually fills the gap, leading to mineralization and hardening.
Bone segments can be lengthened approximately 10-15% of their original length, with an average rate of one millimeter per day. The lengthening phase is succeeded by consolidation, during which new bone solidifies. Throughout this process, soft tissues—including nerves, muscles, vessels, and skin—stretch and adapt to accommodate the limb lengthening, contributing to a comprehensive and successful outcome.
Limb Lengthening Surgery
During surgery, the surgeon will perform an osteotomy, a procedure where the bone is cut to create two separate segments. Along with the osteotomy, an orthopedic lengthening device will be applied to the bone. These devices can be either internal or external.
Internal devices, such as the PRECICE nail, are inserted into the bone. External fixators, such as the monorail fixator or the Circular (Ilizarov) frame fixator, remain outside the body.
The internal method surgery involves the insertion of an intramedullary nail, performing the osteotomy, and fixing the nail in place. The Lengthening Over Nail (LON) method combines the insertion of the intramedullary nail, performing the osteotomy, and attaching an external fixator. Both surgical methods require minimal incisions.
Limb Lengthening Surgery Methods
Cosmetic limb lengthening uses three main techniques: the internal method (Precice 2), the external method and the combined method (LON).
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Internal (PRECICE) Method: This technique involves inserting specialized intramedullary nails into the bone. These nails are designed to gradually extend, allowing the bone to lengthen over time. The process is controlled by a magnetic external remote controller. Since all components are internal, there are no visible devices on the outside, making it a more discreet and comfortable option.
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External Method: This technique only uses an external fixator, a device attached to the outside of the bone and extremity. Since the external method does not have an intramedullary nail, it can lead to alignment problems, lack of stabilization, and the fixator needs to remain on the leg for a very long time until the bone heals. Due to these issues, the external method is no longer used for cosmetic lengthening. External method is preferred in more severe deformities.
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Combined (LON) Method: This approach uses both an internal nail and an external fixator. The internal nail goes inside the bone, while the external fixator is attached to the outside of the bone. This combination allows for better control of the lengthening process, offering the benefits of internal stabilization with the added control of external adjustment. The external fixator is typically removed once the desired length is achieved, and the internal nail remains to support the bone as it heals.
LON with Monorail
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Type : External + Internal (Combined)
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Bone: Femur
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Weightbearing: Full
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Lengthening Capacity: More than 8 cm
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Fixator: Monorail
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IM Nail: Solid Titanium Nail
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Dailiy Lengthening: Manual
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Advantages: Price, Full Weightbearing
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Disadvantages: Less Comfort, Infection, Scars
PRECICE 2
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Type : Internal
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Bone: Femur and Tibia
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Weightbearing: Partial
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Lengthening Capacity: 8 cm
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Fixator: None
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IM Nail: PRECICE 2 Titanium Nail
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Dailiy Lengthening: External Remote Controller
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Advantages: Less Scars, Patient Comfort, Less Infection Risk
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Disadvantages: Partial Weight Bearing, Price
LON with Ilizarov Frame
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Type : External + Internal (Combined)
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Bone: Tibia
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Weightbearing: Full
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Lengthening Capacity: More than 8 cm
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Fixator: Ilizarov Frame
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IM Nail: Solid Titanium Nail
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Dailiy Lengthening: Manual
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Advantages: Price, Full Weightbearing
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Disadvantages: Less Comfort, Infection, Scars
PRECICE MAX
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Type : Internal
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Bone: Femur and Tibia
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Weightbearing: Full
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Lengthening Capacity: 8 cm
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Fixator: None
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IM Nail: PRECICE MAX Titanium Nail
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Dailiy Lengthening: External Remote Controller
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Advantages: Full Weightbearing, Less Scars, Patient Comfort, Less Infection Risk
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Disadvantages: Price
Limb Lengthening Periods
Latency (Hospitalization) Period
The period spent under observation in the hospital between the operation and the start of the lengthening is called the latency period. During the latency period, callus (new bone tissue) is expected to begin to form between the osteotomy bone ends and no lengthening is performed. After the new bone tissue begins to form at a sufficient level, lengthening is initiated. The latency period usually takes 5-10 days.
Distraction (Lengthening) Period
It is the period from the start of the lengthening process until the targeted length is reached and the lengthening is completed. The patient adjusts the orthopedic device so that it slowly pulls apart the two bone segments. This gradual process of slowly separating the two bone segments is called distraction, which means “pulling apart.” As the two bone segments are slowly pulled apart, new bone forms in the space between them. Usually the lengthening rate is 1 millimeter per day.
Consolidation (Healing) Period
The distraction phase is followed by the consolidation phase, where the regenerate bone slowly hardens. The new bone will not be “healed” until the regenerate bone has hardened and calcified. During consolidation period, the new bone tissue, which gains sufficient hardness and durability, begins to carry a load. After the regenerate bone has fully consolidated, intramedullary nail can be removed.
Which bones you can lengthen to increase your height?
Femur Lengthening
Lengthening surgery can be applied to the thigh(femur) bone. Internal and combined techniques can be applied. The fixator suitable for the femur bone in the LON method is the Monorail fixator. The rate of bone union is faster than the tibia. The lengthening rate for the femur is usually 1 millimeter per day. The safety limit for femur is 8 centimeters.
Tibia Lengthening
Lengthening surgery can be applied to the shin(tibia) bone. Internal and combined techniques can be applied. The fixator suitable for the tibia bone in the LON method is the Circular (ilizarov) frame fixator. Along with the tibia, the fibula is also extended. The lengthening rate for the tibia is usually 0.75 millimeter per day.The safety limit for tibia is 6 centimeters.
Safe Limits In Limb Lengthening
How much taller can you get ?
After limb lengthening surgery, the body undergoes a gradual process, lengthening bones at an average rate of 1 millimeter per day. It’s vital to recognize that, while bones have remarkable healing capacity, the surrounding soft tissues—muscles, nerves, tendons, and fascia—need to adapt at the same rate. The body’s ability to form new bone tissue is high, but there are limits to how much soft tissues can safely stretch without damage.
Extensive studies over many years have established safe limits for limb lengthening, averaging 8 cm for the femur (thigh) and 6 cm for the tibia (shin). However, it’s crucial to understand that these are general guidelines, with individual variations. The key lies in ongoing clinical evaluations during the lengthening process.
Exceeding these safe limits poses risks and can lead to permanent physical damage. At our center, we prioritize patient safety, committing to health over mere centimeters. With a steadfast commitment to ‘Safety First,’ we ensure a responsible and secure approach to every limb lengthening procedure.
Lengthening Process in Limb Lengthening
LON Method
In the LON method, daily lengthening is done with an external fixator. The lengthening rate is usually 1 millimeter per day. Total lengthening of 1 millimeter is usually divided into four and applied every 6 hours. When the lengthening time comes, the patient completes the lengthening by turning the apparatus of the fixator 90 degrees. The lengthening rotation is quite and simple and patients can easily do it themselves. Lengthening is stopped when the target length is reached.
PRECICE Method
In the Precice system, the lengthening is performed with the external remote control (ERC) system. ERC device is placed in a certain marked area of ​​the patients leg and lengthening is done with a single button, and it is very easy and comfortable for the patient. The PRECICE has excellent rate control and patients report minimal pain associated with lengthening. Generally, lengthening is done 3 times or 4 times a day, and generally 1 mm lengthening is achieved per day.
Limb Lengthening Physical Therapy
Physical therapy is one of the most important components of limb lengthening. Limb lengthening is a difficult and long process. It includes many complications. Physical therapy ensures that these complications are minimized. The aim of treatment is to maintain and increase range of motion, strengthen muscles, prevent contractures, and increase functionality.
After the lengthening process begins, the soft tissues around the bone, which grows 1mm per day, should grow at the same rate. However, these tissues cannot lengthen at this rate. This situation causes the most important complications of lengthening surgery. Stretching occurs in these tissues, especially in the muscle and nerve tissue. Tension increasing in the nerve tissue can cause pain, loss of sensation and loss of movement. The tension in the muscle tissue causes restriction of joint movement and loss of muscle strength. The physical therapy process is very important to avoid such complications.
As AFA, we offer the world’s most intensive and effective limb lengthening physiotherapy to our patients. Each of our physiotherapists specializes in limb lengthening. Our patients complete the extension process without any problem by taking intensive physical therapy 5 days a week without leaving their comfort zone.
Walking After Limb Lengthening Surgery
LON Method
LON Method
Weight Bearing Protocol
Lengthening Period: External fixators carry the entire body weight during the lengthening period. The weight bearing capacity of external fixators is quite high. LON method patients can walk using a walker or crutches. Walking without support is not recommended due to the risk of pin bending and the risk of falling.
Consolidation Period: Since the solid IM nail has a high weight-bearing capacity, the patient can walk with a full weight bearing, but it is recommended to use a walker or crutch until the callus tissue reaches sufficient hardness (1-2 months).
Walking Without Support: LON method patients can usually start walking without support about 1 month after the end of the lengthening. This period may increase for patients with slow bone healing.​
PRECICE Method
PRECICE Method
Weight Bearing Protocol
Lengthening Period: Precice 2 method patients must use a wheelchair during the lengthening period. They must perform walking exercises for short distances and definitely use a walker. PRECICE MAX method patients can walk with full weight bearing. However, they must use a walker or crutches due to the risk of falling.
Consolidation Period: In the consolidation phase, patients with the Precice 2 method must walk with partial weight bearing until the callus tissue reaches sufficient hardness, PRECICE MAX method patients can continue walking with full weight bearing.
Walking Without Support: PRECICE 2 patients can usually start walking without support 1-2 months after the lengthening is finished. PRECICE MAX patients need to wait 1 month after the end of the lengthening to regain balance.
Consolidation - Recovery Period
The consolidation or recovery period in limb lengthening begins after the desired length has been achieved and the bones are no longer being distracted. During this phase, the newly formed bone (callus) gradually hardens and strengthens, a process that can take several months depending on factors such as age, overall health, and adherence to post-surgical rehabilitation. Weight-bearing activities are usually increased gradually, often with the assistance of physical therapy, to promote bone remodeling and muscle adaptation. Proper nutrition, including sufficient calcium and vitamin D intake, is crucial to support bone healing. Regular follow-ups with X-rays are necessary to monitor bone consolidation, ensuring that it becomes dense and strong enough to withstand normal daily activities.
PRECICE Method - 1 year after Surgery
LON Method - 1.5 year after Surgery
General Recovery Time
Average Recovery Timeline After Limb Lengthening Surgery
The recovery process after limb lengthening surgery follows a structured timeline, but individual healing speed varies based on factors such as physical therapy intensity, self-exercise routines, and genetical differences. The schedule below reflects the average recovery timeline for 8 cm femur lengthening or 6 cm tibia lengthening. Smaller lengthening amounts generally result in a faster recovery.
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0-3 Months: Lengthening Phase Recovery
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Walking is done with a walker to maintain mobility.
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Intensive physical therapy is applied to prevent stiffness and maintain flexibility.
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Soft tissues (muscles, tendons, and ligaments) stretch to adapt to the new bone length.
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Range of motion is restricted, and careful stretching is required to prevent contractures.
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New bone tissue forms as gradual lengthening (distraction) occurs.
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Muscle strength decreases, and atrophy develops due to limited mobility and mechanical changes.
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3-4 Months: Early Post-Lengthening Phase Recovery
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Lengthening is complete, and intensive physical therapy continues to restore function.
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Walking with crutches begins as weight-bearing capacity gradually improves.
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Range of motion starts increasing, improving flexibility and mobility.
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New bone tissue consolidates, hardens, and strengthens.
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Muscle recovery begins, and hypertrophy (muscle growth) starts to reverse atrophy.
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4-6 Months: Late Post-Lengthening Phase Recovery
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If bone stiffness is sufficient, unassisted walking can begin.
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Range of motion continues to return to normal at a faster rate.
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New bone starts to fully support body weight, improving stability.
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Gait and balance normalize gradually, reducing limping.
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Muscle strength increases, supporting functional movement.
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6-12 Months: Functional Recovery Phase
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Bone tissue becomes significantly harder and more weight-bearing.
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Jogging, stair climbing, and low-impact activities can be introduced.
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Light gym exercises with low weights can be started for strength rebuilding.
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Muscle strength improves rapidly, reducing residual weakness.
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Soft tissues fully adapt to the new bone length, minimizing stiffness.
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Range of motion reaches its maximum potential.
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Self-stretching and strengthening exercises should continue consistently.
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After 1 Year: Full Activity Phase
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All physical activities can be resumed without restrictions.
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Activities such as sprinting, jumping, squats, and competitive sports can be safely performed.
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Bone weight-bearing capacity is fully restored, making it as strong as normal bone.
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Muscle strength is completely regained, allowing full athletic performance.
Intramedullary Nail Removal
Intramedullary nail removal is a surgical procedure performed after the bone has fully healed and consolidated, allowing for full weight-bearing without the need for internal fixation. This procedure is typically carried out 1.5 to 2 years after the initial implantation of the nail.
The decision to remove the intramedullary nail is crucial and should be made with careful evaluation. X-ray imaging must be thoroughly examined to ensure that the bone has fully healed and reached complete union. Premature removal of the nail before full bone consolidation can lead to complications, such as fractures or structural weakness in the bone.
To minimize risks, surgeons assess the density and hardness of the callus tissue in the consolidation phase before approving the procedure. Patients should follow their surgeon’s recommendations and avoid requesting early removal, as it may compromise the stability and strength of the bone.
Surgical Procedure
The removal of an intramedullary nail follows a structured surgical approach, which includes:
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Administration of general anesthesia
Making an incision to reach the nail head for access.
Attachment of a specialized apparatus to the intramedullary nail head for extraction.
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Removal of proximal and distal screws.
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Extraction of the intramedullary nail from the bone.
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Closure of incisions using aesthetic sutures.
Patients undergoing intramedullary nail removal typically require a short hospital stay, usually for one day. Following the procedure, they are able to walk with full weight-bearing immediately. Once the nail is successfully removed, no further surgical intervention is necessary, and the healing process continues naturally. The entire limb lengthening process is completed with the removal of the intramedullary nail.
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