Limb Lengthening

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Introduction

Limb lengthening is a highly specialised orthopaedic process dedicated to increasing the length of one or more limb segments. It relies on so-called distraction osteogenesis – a process where the long bone is cut, and once it starts healing through the formation of a bone regenerate, the bone ends are pulled apart and the regenerate undergoes a controlled and gradual stretching that stimulates regenerate growth and new bone formation.

Limb lengthening surgery was primarily developed to correct bone length differences to equalise limbs and in congenital syndromes which affect limb growth. The limb length discrepancies may be the results of congenital diseases, post-traumatic injuries or bone infections, consequences of tumour growth, neuromuscular conditions or developmental delay in limb segment growth. The procedure has evolved significantly over the years. With technical advancement and improved safety and effectiveness, an increasing interest in cosmetic stature lengthening is observed.

Indications and Contraindications

Limb Lengthening Indications

Congenital Limb Length Discrepancy: Children born with one limb shorter than the other (overgrowth or underdevelopment of the whole limb, or its segment) may undergo limb lengthening surgery to equalise limbs and normalise function.
Post-Traumatic Limb Shortening: A segmental shortening may develop after significant injury with substantial bone loss – limb lengthening can restore the lost bone length.
Bone Infections (Osteomyelitis): A segmental shortening may develop after chronic bone infection and radical bone resection – limb lengthening can restore the lost bone length.
Limb Length Discrepancy from Previous Surgeries: limb length discrepancy can be a result of repetitive surgeries, surgical complications or tumour resection – bone lengthening is necessary to restore function.
Achondroplasia and other forms of Dwarfism: Skeletal dysplasia causes short stature, which compromises the patient’s participation in daily life activities (walking upstairs, stepping on the train, reaching up to the buttons on an elevator, or down to the pedals in the car). Stature lengthening will increase their height and improve functioning in society.
Cosmetic/stature lengthening: In some cases, individuals may choose limb lengthening surgery for cosmetic reasons to achieve a taller stature. The indications however are very limited and patients undergo a meticulous screening prior to embarking on surgery.

Limb Lengthening Contraindications

While limb lengthening surgery can be beneficial, certain factors may preclude individuals from undergoing the procedure.

Uncontrolled Medical Conditions: A patient with uncontrolled diabetes, heart disease, or other significant medical conditions may not be a suitable candidate for the bone-lengthening process.
Smoking: Smoking has been proven to delay bone tissue formation and increase the rate of bone regeneration failure during the lengthening process. Patients are encouraged to either cease smoking or surrender the procedure.
Poor Bone Quality: Individuals with severely compromised bone quality have a higher risk of poor regenerate formation and therefore complications.
Active Infection: It is crucial to address an active infection first before any limb lengthening is initiated.
Neurological Disorders: Conditions affecting nerve function and sensation may preclude limb lengthening surgery due to the high risk of complications.
Recreational stimulants use and cognitive disorders: Limb lengthening is one of the most involving, time-consuming and fatiguing processes that need extensive patient involvement and cooperation. Patients will be meticulously examined and their preparedness for the journey will be assessed.
Incomplete Skeletal Growth: In children, if only possible, limb lengthening is postponed until the growth plates have matured to reduce the risk of growth disturbances.

Benefits and Risks

It is important to note that bone lengthening is a time-consuming and difficult process that takes a burden on the patient and their family life and can be hindered by a high rate of complications. It is crucial for a potential candidate to undergo a thorough evaluation by an experienced multidisciplinary team to determine the most appropriate surgical approach and to discuss the potential risks and benefits associated with the procedure. With proper patient selection, skilled surgical techniques, and diligent post-operative care, limb-lengthening surgery can yield successful outcomes, improving the functional and aesthetic aspects of the affected limb.

Surgical Approach

Limb lengthening surgery involves the gradual elongation of the bone, which is achieved using external or internal fixation devices. Regardless of the surgical technique, the lengthening process consists of three periods.

Pre-Surgery Information

The following is what can be expected prior to limb lengthening surgery:

Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.
Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be given, and the operation site will be shaved and cleaned.
Betadine skin prep will be applied to the area above the operation site and wrapped.
All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

There are two primary methods for performing limb lengthening surgery:

External Fixators: This technique involves the use of an external device, such as monoliteral fixators, simple ring fixators or complex hexapod-type frames, which are attached to the bone through pins or wires. The bone is then cut, and the device is adjusted regularly, several times a day, to apply controlled distraction forces to the bone ends, stimulating new bone growth in the distraction gap. External fixators offer flexibility in adjusting the length and alignment during the lengthening process, but often are uncomfortable for the patient.
Internal Lengthening Nails (Intramedullary Nails): The bone is cut and a motorised lengthening nail is inserted into the bone’s medullary canal. The nail has a telescopic design and is operated with electromagnetic waves applied externally to cause gradual elongation. Internal lengthening nails eliminate the need for an external frame but are limited by the amount of lengthening they can achieve in one procedure and provide less stability.

Combination of External and internal devices

Depending on the individual patient’s needs the process can involve a combination of external and internal fixation devices such as plates, cables, solid and motorised nails and external fixators.

The choice between external fixators and internal lengthening nails depends on factors such as the patient’s age, the extent of lengthening required, and the surgeon’s preference and expertise.

Post-Surgery Information

Hospital Stay: Bone lengthening is a serious surgery, you’ll typically be admitted into a hospital for several days for monitoring, initial rehabilitation and learning how to handle bone lengthening programs.
Pain Management: Pain medications will be administered to keep you comfortable. Bone lengthening is an ongoing process and long periods of pain management are usually expected.
Weight-Bearing: When necessary, you will remain non-weight-bearing for a period of time. Then you will commence weight-bearing gradually, with crutches, following your surgeon’s instructions.
Follow-Up: Regular follow-up appointments with the team will help monitor your progress and address any concerns:
- 1 week postop: for wound check,
- 2 weeks postop: for sutures removal. You will usually receive a lengthening program during this visit. In this case, you will need x-rays follow-up every two weeks, until the program has been completed.
- 6 weeks postop: for x-ray assessment of healing progress.
- Later at 3, 6, 9, 12 months postop and further annually an x-ray will be mandatory.

Physical Therapy: A tailored rehabilitation program will help regain strength, flexibility, and mobility and prevent joint contractures, which are common during limb lengthening.
Lifestyle Adjustments: Patients need to modify their activities and household environment to accommodate the lengthy bone-lengthening process, to ensure optimal healing and comfort.

After the surgery and application of the distraction device, there is a 7-10 days period of latency, that allows for primary bone regenerate formation. Further, during the process of lengthening, the regenerate is distracted at a rate of 0.5-1mm daily (in 2-3 increments) until the full length is restored.

Finally, the consolidation takes place and usually lasts at least twice as long as the distraction period. For example, in order to obtain 10 cm (100mm) of bone length, it will take: 1 week of latency period, 100 days (14.5 weeks) of lengthening and 29 weeks (twice that of the lengthening duration) of consolidation time. That is at least 10 months if no complications are encountered.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000