What is Limb Lengthening ?
Limb lengthening is a surgical procedure to lengthen bones in the arms or legs. Lengthening works by separating the bone(osteotomy) and very slowly pulling the bone segments apart (distraction), so new bone tissue is formed in the space between the bones (osteotomy gap). When bone segments slowly separate, bone regenerates, resulting in increased bone length. Limb lengthening is achieved by using the body’s own capacity to regenerate new bone, as well as the soft tissues, ligaments, fascia, blood vessels, and nerves that surround and support it. Limb lengthening is achieved with the utilization of the principle of distraction osteogenesis.
How Does Limb Lengthening Works ?
Limb lengthening and deformity correction work on the principle of distraction osteogenesis. When bone breaks(fracture), new bone tissue naturally begins to regenerate at the fracture site to restore the bone’s integrity and fix the fracture. Limb lengthening works by surgically cutting a bone in two (osteotomy) and then separating the two bone sections, allowing new bone(callus) to grow into the space between them.
The full process consists of three steps:
1. An osteotomy (bone cut) is performed to seperate the bone in two.
2. Two bone segments are slowly distracted at a controlled rate and rhythm by orthopedic devices such as internal nails or external fixators.
3.The new bone tissue gradually fills the gap(osteotomy gap) and hardens.
Bone segments can be lengthened approximately 10-15% of their original full length. This rate is an average rate and can vary from person to person. Bone ends are usually separated at a rate of about one millimeter (1 mm) per day.
The lengthening phase (distraction) of the treatment is followed by mineralization and hardening (consolidation) of the new bone. In this process, soft tissues such as nerves, muscles, vessels, skin are stretched and grow during limb lengthening process.
Limb Lengthening Surgery
During surgery, surgeon will cut the bone to create two separate bone segments. The surgical procedure to cut a bone is called an osteotomy. Surgeon will also apply an orthopedic lengthening device to the bone. Orthopedic lengthening devices that are inserted into the bone are called internal devices, such as the PRECICE nail. Orthopedic lengthening devices that remain outside of the body are called external fixators, such as the monorail fixator or the Circular (ilizarov) frame fixator. Internal method surgery includes insertion of the intramedullary nail, osteotomy and fixation of the nail. LON method surgery includes insertion of the intramedullary nail, osteotomy and attaching the external fixator. Surgeons make minimal incisions in both methods.
Limb Lengthening Surgery Methods
In general, there are 2 methods used in cosmetic limb lengthening. These are internal (Precice) and LON (combined) methods. In internal methods, intramedullary nails with the ability to extend are placed inside the bone and it is a completely closed method. There is no orthopedic device attached to the bone from the outside of the body. In the combine method, in addition to the intramedullary nail placed in the bone, the orthopedic device (external fixator) that provides lengthening is attached to the bone from outside the body
The LON method is a combined method. It is applied by inserting an intramedullary nail into the bone and the external fixator is fixed to the bone from the outside.
The LON method is a combined method. It is applied by inserting an intramedullary nail into the bone and the external fixator is fixed to the bone from the outside.
Precice STRYDE is the leading internal system available for stature lengthening and limb reconstruction. Precice STRYDE intramedullary nail is composed of stainless steel, and electromagnetically motorized.
Limb Lengthening Periods
Latency 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 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 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 can be lengthened in cosmetic height lengthening?
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.
How much taller can I get?
Safe Limits In Limb Lengthening
After limb lengthening surgery, bones are usually lengthened at a rate of 1 millimeter per day. The soft tissues around the bone have to lengthen at the same rate and length. The healing capacity of bone tissue and the ability to form new bone tissue is quite high, but there is a maximum limit to which soft tissues such as muscles, nerves, tendons and fascia can heal without damage. Safe limits in limb lengthening are determined by the lengthening capacity of the soft tissue. Although the safe limits vary from person to person, as a result of many years of studies, the safe limit has been determined as 8 cm for the femur(thigh) and 6 cm for the tibia(shin). These limits are the average limits and the important thing is the clinical evaluation of the patient during lengthening. Exceeding the safe limits is risky and can cause permanent physical damage. We do not risk the health of any of our patients to grow 1 centimeter longer. SAFETY FIRST.
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.
Internal 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 stretch 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 in the Limb Lengthening
LON Method
Weight Bearing Protocol
Distraction Period: External fixators carry the entire body weight during the lengthening period. The load carrying capacity of external fixators is very high. LON method patients can walk with a full weight bearing, but walking with a walker is recommended during this period due to loss of balance. Consolidation Period: Since the IM nail has a high load-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).
Internal Method
Weight Bearing Protocol
Distraction Period: Precice 2 method patients can walk with partial weight bearing with an assistive device, while Stryde method patients can walk full weight bearing. However, it is recommended that every patient use a walker or crutches during the lengthening period due to loss of balance.
Consolidation Period: In the consolidation phase, patients with the Precice 2 method should walk with partial weight bearing for a while and use a walker. Stryde method patients can continue walking with full weight bearing.
Frequently Asked Questions about Limb Lengthening Surgery
1.Is limb lengthening surgery safe?
Nowadays, limb lengthening surgery has become safer and easier thanks to the recent developments in orthopedic surgical techniques. The success rate of limb lengthening surgery is very high. It is completely safe when the operation and follow-up are performed by an experienced surgeon and medical team, and when the patient is followed well, especially during the lengthening period. It is very important to notice and prevent complications that may occur in the surgery and in the following process. After good management of these processes, patients can fully recover and reach their full physical capacity.
2.Is limb lengthening a painful process?
The pain during the hospitalization period after limb lengthening surgery is not extreme and is completely controlled with painkillers. There is usually no pain at the beginning of the extension period. When tension begins in the soft tissues, there may be a feeling of tension and pain associated with it. Pain level varies from person to person, but it is certainly not an excessive pain. If the technique is applied correctly, the mild to moderate painkillers would be enough. The appropriate physical therapy program and early mobilization will reduce the need of painkillers. Extreme pain is often a sign of a complication or technical incompetence.
3. Can anyone get limb lengthening surgery ?
Anyone who has leg length discrepancy with or without limb deformity can do this surgery.But if it is going to be performed only for cosmetic reasons, patients should have an age between 20 and 50. We prefer the individuals who are non-smokers, have good physical and mental health and candidates without any chronic diseases or hormonal problems. For smokers, quitting to smoke is definitely obligatory.
4. How is the limb lengthening surgery performed?
Limb lengthening surgery is basically performed to lengthen the bone tissue. Long bones are cut at an appropriate level with minimal invasive technique. We call that “osteotomy”. Surrounding soft tissues are preserved carefully. Surgeon will also apply an orthopedic lengthening device to the bone. Orthopedic lengthening devices that are inserted into the bone are called internal devices, such as the PRECICE nail. Orthopedic lengthening devices that remain outside of the body are called external fixators, such as the monorail fixator or the Circular (ilizarov) frame fixator. The ends of the osteotomized bone are distracted 1 mm per day using an orthopedic device (intramedullary nail or external fixator). While the patient is lengthening, the bone tissue tries to heal and fill this gap. The gradual lengthening is achieved during the distraction. When the desired bone length is achieved, the distraction is stopped and the bone is expected to heal completely.
5. What are the limb lengthening surgery techniques?
We basically divide all lengthening techniques in 3 groups.
- External technique: This is an external technique. External fixators are externally placed on the limb for lengthening. Lengthening is done with external fixator. The external fixator remains in the extremity until the bone has fully healed. It is no longer preferred in the field of cosmetic lengthening.
- Combined(LON) technique: It is also known as lengthening over nail. The external fixator and the internal nail are implanted into the bone simultaneously. Lengthening is done with external fixator. After the lengthening is finished, the external fixator is removed and the intramedullary nail begins to bear the body weight.
- Internal technique: This is known as the internal method. There is no external fixator on the limb. There is only a special motorized intramedullary nail with lengthening function inside the bone. Lengthening is done by external remote control system. It is the most comfortable and advanced limb lengthening technique.
6. What is the combined (LON) method?
This technique is named combined because it is a combination of internal and external bone fixation methods.Combined technique basically provides the lengthening of bone with a unilateral or circular external fixator over the intramedullary nail. After the lengthening is completed, the external fixator is removed and the nail is locked by the screws. So, the time that patient carries the fixator is shortened and the internal nail becomes weight bearing after removal.
7. What is the motorized nail (Internal) method?
Motorized nails are the most comfortable, less invasive and up-to-date technologies.There is no fixator outside, only an intramedullary nail is implanted into the bone. Therefore, the patient feels more comfortable and free to move. The risks of complications of internal method are less than the others. The motorized telescopic nail provides the lengthening with the help of an external remote controller. Patients can comfortably do the lengthening by themselves with this device.
8. How much can I lengthen each bone? What are the safe limits for cosmetic leg lengthening?
Unfortunately, there are optimum safe limits in cosmetic limb lengthening. The most important factor is the adaptation capacity of surrounding soft tissues such as muscles, nerves, vessels, tendons and ligaments. According to the literature, it is reasonable to limit the maximum 8 cm for femurs and 6 cm for tibias in order to avoid complications. Higher lengthening rates should only be aimed to achieve within the second surgery. Our major goal is to protect our patient’s full functional capacity during lengthening. Functions come before lengthening rate. So, we never do or let the patient do anything which will put my patient’s health at risk. Our goal is not only to make them taller but also to keep them healthy.
9. How long is the hospital stay in Limb Lengthening surgery?
If everything goes well, patients stay in the hospital for 5 to 10 days after the surgery. During this period, the patient is under observation for 24 hours. The patient gets medical and physical therapy, regular dressings are done and a brief introduction about the lengthening process is given to the patient.
10. What is optimal daily lengthening rate ?
According to experiences and scientific studies, average 1 mm per day is the optimum rate for leg lengthening. Soft tissues such as nerves, muscles, vessels, tendons and ligaments can adapt to the best in that rate. The daily lengthening amount can be changed by the surgeon according to some criteria such as the quality of the patient’s bone union, the tension level of the soft tissues with lengthening.
11. How much time is needed for limb lengthening process?
The amount and frequency of lengthening are closely related to the healing potential of the bone tissue. Lengthening starts on the 7-10th day after the surgery. No matter what method the patient uses for surgery, 1 mm lengthening is achieved in a day, so the patient will lengthen by 1 cm in every 10 days. So the 8 cm lengthening takes 80 days, the 7 cm lengthening takes 70 days and the 6 cm lengthening takes 60 days.
12. How long does it take to recover from limb lengthening ? When can I return to normal life?
The patients can return to their normal life within 6 months after the operation. Patient can walk and work in the office. However, the patient will be allowed to return to sports after 9 months. It is recommended to return to competitive sports after 1 year. Usually, 1-1.5 years after the surgery, bone and soft tissue healing is completed and the patient reaches full physical capacity.
13. When can I walk after limb lengthening surgery ?
On the 1st day after the operation, the patient can stand up and walk. The patient is not allowed to walk with whole-body weight. A walker is used to support the patient’s walking. The walking protocol is taught to the patient according to the method applied, the patient’s body weight and the durability of the orthopedic device used. During the lengthening period, the patient can walk by following this protocol.
14. What are the most important steps in limb lengthening surgery ?
Limb lengthening surgery has three important steps. Planning, surgery and follow-up. These three steps are very crucial and closely related to each other. One can not be fully completed without the other. Detailed and correct planning makes the surgery easier. Meticulous surgical technique increases success rate and reduces risks. Regular follow up periods keep the surgeon awake against complications before it’s too late. All is necessary for successful lengthening.
15. Is There Any Age Limit for Limb Lengthening Surgery ? What is the best age to get limb lengthening ?
Bone and soft tissue healing capacity is much higher at younger ages. Therefore, having surgery as young as possible greatly reduces the risk of complications. If limb lengthening surgery is going to be performed only for cosmetic reasons, patients should have an age between 20 and 50. In order for the lengthening surgery to be performed in young people, the height growth must be stopped. Height growth usually stops at the age of 118-20. However, in some people, height growth continues after the age of 18. Whether the lengthening continues or not is decided by looking at the condition of the epiphyseal plate in the bones. The closure (ossification) of the epiphyseal plate, which can be seen easily on the x-ray, means that the lengthening has stopped, and limb lengthening surgery can be performed. The status of bone quality is important in determining the upper age limit. As age progresses, bone quality decreases and bone resorption increases. This means that the bone of the person who has had lengthening surgery will have difficulty in union. Generally, limb lengthening surgery is not preferred for people over 50 years old.
