Limb Lengthening

• You will receive a thorough health assessment: including medical history. You may be advised to modify certain lifestyle factors and you may be referred to another specialist. You may be asked to stop taking certain medications as your surgery date approaches. X-rays, CT scans, and MRIs will be used to evaluate your condition and plan your surgery.  
• Skin and bowel preparation: On the evening before your surgery, you will be asked to wash your leg using the sponge provided at your pre-admission clinic. A skin test may be administered if an iodine allergy is suspected. You will also be provided medicine to help you evacuate your bowels prior to surgery.
• Patient education: if neccessary, you may speak with a physiotherapist who can advise you on post-operative mobility. 

On the day of the surgery

• You will be asked to complete your surgical paperwork and will meet with the anaesthetist.
• The surgical site will be prepared and you will be positioned according to the preoperative plan.
• You will be administered general or regional anaesthesia depending on your health status. Local nerve blocks may also be used to help manage your post-operative pain.
• For femoral lengthening, the surgical approach is typically from the top of the femur (the greater trochanter) and for tibial lengthening, from the upper part of the shin (the tibial plateau). A small incision (2-4cm) will be made near the hip or the knee, depending on the bone to be lengthened.
• A bone awl is used to create an opening into the medullary canal of the bone.
• An osteotomy will be performed on the target bone, typically mid-way along its length (mid-diaphysis), using an oscillating surgical saw or chisel.
• The medullary canal will be widened (reamed) using specialised tools to ensure that the bone accommodates the nail without damaging it.
• The nail is inserted into the medullary canal and properly aligned. Once correct placement has been confirmed, the nail is secured into place using locking screws at the top and bottom. This prevents movement or rotation of the nail during the lengthening process.
• The wound will be sutured and dressed, and you will be taken to post-operative recovery.

The lengthening (distraction) phase

Following surgery, you will remain in hospital for several days for monitoring and early rehabilitation. You will be prescribed painkillers to support you through any post-operative pain. The bone itself will be left alone for up to one week to allow healing to begin. This is known as the latency phase.

This period is followed by the distraction phase in which an External Remote Controller (ERC) device is used to distract (part) the two sections of the osteotomised bone. This is normally completed at a rate of 1mm a day, typically over the course of several sessions per day. The rate of lengthening can vary, according to the target bone, or the patient’s health status, although should not normally exceed 1mm.

As the two halves of the bone are parted, new bone begins to form in the gap. This bone is known as regenerate bone.  At the same time, nerves, blood vessels, skin and muscle also begin to grow to accommodate the increased distance that they must cover. Throughout the distraction phase, you will be very closely monitored for signs of complication and particularly for signs that lengthening is being undertaken too quickly, since this can quickly result in deformity within the new bone, or too slowly, which risks premature consolidation in individuals with a faster-than-average rate of bone healing.

The distraction phase ends once the target length has been reached. The nail will remain in the bone for the moment. The maximum safe limit for lengthening is generally 4-5cm in the tibia, and 5-8cm in the femur. It is possible to lengthen both the tibia and femur within the same leg, but not at the same time.

Some practitioners may promise an increase in stature in excess of these safe limits, but to attempt to lengthen further carries a huge risk of very serious, and potentially life-changing, complications, as well as further issue around the proportion of the legs relative to the rest of the body. 

The consolidation phase

The distraction phase is followed by the consolidation phase.  Typically, the consolidation phase will last twice as long as the lengthening phase, and as a result can last for several months, or longer depending on the length reached. For example, 10cm of length will require 14.5 weeks of lengthening and 29 weeks of consolidation, notwithstanding individual requirements or protocol adaptations.

During consolidation, the regenerate bone growth hardens and calcifies. Normally, you can begin to partially weight bear on the lengthened limb while consolidation is ongoing, using crutches or a walker to support most of your bodyweight. This gradual weightbearing encourages the bone to consolidate. Alongside weightbearing, you may be asked to modify your diet to support bone healing.

Once the new bone has fully healed, the nail can be removed as an outpatient procedure. It may be possible to weight bear earlier in the consolidation process by exchanging the lengthening nail for a solid nail capable of supporting your bodyweight. This, however, will entail a second surgical procedure.

Physiotherapy

Throughout the lengthening process, you will be required to follow a very intensive course of physiotherapy (typically five days per week) designed to ensure proper healing, mobility and function.

Immediately following your surgery, physiotherapy will be targeted toward pain management, the reduction of swelling and the prevention of muscle atrophy and stiffness in the joint. Exercises will typically focus on passive and active range of motion in the knee and ankle, including ankle dorsiflexion and knee flexion, since these joints are at increased risk of stiffness. Isometric exercises are also used to maintain muscle strength without moving the limb.

During the distraction phase, exercises typically focus on stretching to prevent contractures (tightening of muscles around the joints) and maintain flexibility. For femoral lengthening, these focus on the hamstrings, quadriceps and hip flexors; for tibial lengthening, on the gastrocnemius, soleus and Achilles tendon. Active strengthening exercises, including core work, resistance band work and leg raises, are used to support stability in the lengthening limb.

As weightbearing increases, balance exercises, like single-leg standing or standing on a balance board, can help the body adjust to the new position of the component parts of the lengthening limb.

During the consolidation phase, the physiotherapeutic focus shifts to strengthening the new bone and improving mobility using it. As such, your regime will now include resistance training, using bands or free weights, to rebuild muscle, particularly including closed-chain exercises like squats and step-ups to help build functional strength.

Joint mobilisation exercises are used to address stiffness or restriction in the knee, ankle or hip joints, while, with full weightbearing, gait training focuses on walking biomechanics and gait stability.

Aftercare

At one week post-surgery, you will be required to attend a wound check and at two weeks your sutures will be removed. At 6 weeks, you will undergo further X-rays to assess healing, and at three months after your surgery for the same reason. You may be prescribed blood thinners to reduce the risk of a clot developing.