Limb lengthening is a surgical technique used to progressively increase the length of bones. The procedure is indicated in people who are short because of congenital growth abnormalities, trauma, or deformities impairing growth in childhood. It involves an osteotomy and gradual distraction of the bone callus at the osteotomy site, providing controlled lengthening of the original bone. The technique of limb lengthening has evolved over recent decades, particularly regarding the operative techniques and post-op limb lengthening care protocols. The common indication for limb lengthening is for short stature, but more complex indications exist.
The method used for bone lengthening is termed distraction osteogenesis. There are two general techniques used in limb lengthening surgery: traditional Ilizarov bone lengthening and the more recent intramedullary lengthening technique. The primary method used in recent years has been distraction osteogenesis utilizing an external fixator. Successful patient selection demands adherence to strict protocols of accuracy in the diagnosis and preoperative assessments. Improvement in function, as well as the specific interest of individual patients who may accept disability but demand to be taller, are motivating factors for patients when they elect limb lengthening as a therapeutic option. Height and size are emotive issues, and the orthopedic surgeon and the rest of the multidisciplinary team must establish a good rapport with the patient, parents, or both. Patient treatment is essential for a better limb-lengthening surgery recovery.
Limb lengthening surgery recovery can be quite variable and can depend on several factors. Younger patients (either children or non-smoking adults) who do not suffer from any significant overall medical issues tend to have quicker limb extension recovery time, owing to their bodies’ strong limb lengthening healing process. The overall strength of a patient’s immune system and health profile at the time of surgery also need to be considered. Meanwhile, a young patient with pre-existing conditions may face challenges during recovery. The type of limb lengthening and the amount of lengthening required can also play a role in how long it will take for patients to experience a full recovery. In general, surgical complications can extend the timeline of recovery. Patients who do not participate in physical therapy may find their recovery prolonged as well. However, generally, recovery rates can vary from patient to patient. Although the average recovery timelines for specific lengthening procedures have been established, clinicians caution that the degree of variability can span a fourfold difference in time across all lengthening methods.
Patients who have undergone limb lengthening surgery recovery are encouraged to adhere to operative guidelines handed out. It is widely accepted that individuals who follow recommended protocols tend to have faster limb extension recovery time. Surgery, and specifically acute limb lengthening, necessitates a period of immobilization, where the limb is kept as stable as possible to permit the initial stages of bone healing. A highly mobile limb during the limb lengthening healing process can result in non- or slow unions. Uneven forces on an assembling bone, as well as other types of biological and mechanical stresses, can increase the risk of non-union. Once the bone is fully healed, it is still wise to arrange for suitable rehabilitation and exercise protocols. During the lengthening process, the affected limb may also tire quickly; on average, activity is reduced to roughly 30% of normal function, which is another factor that may add to an increased length of structural recovery after the frame is removed. What to expect after limb extension is psychosocial support which may also play a critical role in recovery. There is an established link between mental health and physical healing, and as such, surgeons are encouraged to evaluate the emotional health of limb lengthening surgery candidates. Emotional stability has also been linked to better wound profiles post-surgery.
Follow-ups are scheduled 2 weeks after the surgery, then every 4 weeks after that. Lengthening is started one week after removal of the last frame if it is hypertrophic and/or the planned or actual length difference is less than 3 cm. Whenever possible, the surgeon plans for the lengthening goal to be achieved within the first month out of the frame. Pain is expected most prominently after waking up in the morning and is usually relieved by taking deep breaths to expand the chest. Mothers or other caregivers in close contact with the lengthening patients need to encourage them to maintain a good pain relief plan to tolerate this discomfort. At home, surgical site cleanliness is necessary to prevent infection: dressings should be maintained clean and dry, adhering tapes should not be removed, and the doctor or nurse is responsible for changing them. When to ask for medical attention: fever above 38 °C, drainage of a copious amount of cloudy fluid, wound separation, increased pain, or redness around the incision. Patients are encouraged to maintain a diet high in protein and calcium. An adequate daily supply of water, of at least 35 ml/kg, is necessary to help meet the demand for increased bone formation. Activity is resumed in response to the return of pain when normal levels of activity are attained. At this point, the pain is expected to be located more distally in the lengthened area. Walking is achieved in the first family planned visit in a continuing, ambulating direction. Patients should return to the clinic when the frame is removed, or one year after the surgery if the last lengthening device has already been removed. An X-ray is taken to check the progress of the consolidation and ensure that the alignment is not harmful.
What to expect after limb extension: The goal of treatment for a number of complications is to restore a situation where wound healing can proceed, where weight-bearing capacity is reestablished, and where manipulation can be handled safely. In some instances, a part of the implants may need to be removed. Signs of metal hypersensitivity are one of the well-recognized potential complications. It is recommended that in patients with post-traumatic bone defects, early attempts should be made to optimize healing by using bone stimulation and bone graft substitutes, as immediate interim fixator surgery might be associated with a risk for delayed healing. Patient educational information, emphasizing the symptoms suggesting an infection or limb lengthening healing process problems, as well as the principle of prioritizing the treatment of infections over non-unions, should be provided preoperatively.
There is a strong correlation between lengthening rates faster than 1 mm per day and a higher risk for pin site infections. In those cases where sleeve methods are employed, rod breakages are very common if too much distraction is attempted. Mark limiting inbuilt distraction is a valuable consultation during the preoperative appointment. Rod fractures are a common complication when too heavy a weight is put on the leg. As identified, the need for a temporary frame will be fewer when all data is gathered from an osteoporotic patient, as the callus from lengthening will usually be stronger than the bone. Hematogenous infections are common with the increase of daily lengthening protocols. An increase to 1.0 mm lengthening a day did not show the same increase in infection rate in combination with the affected callus density. Some cosmetic lengthening patients suspect themselves to be infected due to the discoloration of the callus. Screenings for SIRS did not show an increased likelihood of infection.
Understanding patient expectations and acceptance must be the foundation of a successful reconstructive surgery. Patients can anticipate their acute limb extension recovery time by taking a mean of 3 to 4 months to reach full weight-bearing precautions before entering an approximately 1.5-year period of newly regulated bone and soft tissue mechanics following surgical interventions. Hard callus formation begins within the first several postoperative months, signaled by increased radiographic transparency at the corticotomy or fresh osteotomy site. This is only the beginning, so “Do not believe a thing until you see hard callus.” Fully formed bone strength returns in a mean of an additional 15.5 months for children and 19.1 months for adults, beginning at the time of callus initiation. The effect of location and anatomy must be factored into these estimates and is part of the informed decision-making process for each patient.
Patients ought to expect more efficient gait events than they previously had, including a decreased calf to quad ratio during running. While the endurance and recovery mechanisms, such as musculoskeletal, are characterized in literature, there remains minimal data tracking psychological adjustments that occur from supramax to minimax during this time. Disappointingly low rates of satisfaction may also stem from unmet aesthetic objectives. Postoperatively, there is likely to be a review of joint function, knee and ankle movement, including an X-ray of the orthosis to check its position. At the time of their post-op limb lengthening care review, 2 to 3 months or 6 weeks following frame removal, we also explore their future intentions: patients are counseled to maintain joint function and encouraged to continue with their own health and fitness.
Our goal is to improve the quality of life of patients by managing the process of limb lengthening and boot lengthening in a healthy and safe manner.
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