Limb lengthening surgery, also known as distraction osteogenesis, is a complex procedure used to lengthen limbs or correct bone deformities. Limb shortening or deformities can be present from birth, be genetic, occur due to trauma or microtrauma, or result from a medical condition. Limb lengthening procedures reverse the often devastating effects of having limbs of different length or noticeable deformities.
The technique and technology have evolved over the years to now include the most precise lengthening devices and implants available. Limb lengthening surgery patients must undergo a thorough medical evaluation and are provided with a complete patient education on lengthening to provide informed consent.
They must also comply with a customized lengthening and rehabilitation protocol. Only patients healthy enough to heal their lengthened segments without incident and with realistic expectations of the lengthening process and of the final result are considered candidates. One of the primary considerations of most surgeons in candidate selection is the psychological disposition of the patient. They must demonstrate understanding, motivation, and commitment to coping with the process of limb lengthening, which is a substantial undertaking.
Limb lengthening surgery can take a patient’s holistic approach: anatomical, functional, and psychological consequences are relevant for the decision to lengthen the limbs. Many different techniques and devices have been developed, each with their own outcomes and rates of complications. Lengthening can be carried out surgically and is performed using a device called an external or internal fixator.
Modern investigators are trying to meet the needs of patients with limb length discrepancy using both external and internal fixators that offer more comfort, less restriction on daily activities, and fewer pin site infections. This has now converted this substantial inconvenience into a major asset in addressing leg discrepancy.
The increased surgical experience has led to a reduction in lengthening time, both in terms of external fixation using monolateral and circular frames and intramedullary lengthening nails. A prospective study showed that femoral lengthening using monolateral fixators and intramedullary limb lengthening nails is associated with excellent efficacy and cost-effectiveness in limb-lengthening surgery. Several fixed or bony lengthening techniques exist and are continuously being modified to yield better results with fewer complications.
Increased application can be found in plastic surgery for correction of posttraumatic limb deformities, bone loss, limb lengthening, and distortions. Hence, the surgery and limb lengthening recovery are not a simple procedure but a part of the complex frame of the regenerative changes present in every regenerative biologic process.
The admirable quality of an externally applied fixator is not just lengthening but also correcting simultaneously, with predictable results achieved without the use of bone grafting and with a lower underlying osteotomy or osteotomies techniques. Recently reported surgical techniques can achieve a predictably accurate lengthening of the lower extremity without any substantial limb shortening in a single-stage operation.
Post-operative rehabilitation, the use of advanced computer-assisted techniques during surgery, highly qualified surgical and anesthesiologic staff, and the use of high-quality operating room facilities helped to maximize the benefits of these techniques. Computer-assisted surgical techniques have been developed for rapid, accurate surgery and will be presented too.
Limb lengthening benefits and the purpose of the surgery is to help patients have an improved quality of life by allowing them to walk and partake in activities without extreme pain or disability associated with having a limb length inequality. Correcting limb length is one goal, but it is assumed that people have a variety of limb shape abnormalities in the process like being bow-legged, knock-kneed, or having a form of antalgic gait. The results of patients treated for all of these conditions give the overall impression that both general function and these conditions individually improve over time.
The most consistent benefit is limb equalization in both simple and complex cases. In the long term, reducing the stress across one’s joints and reducing the stress pattern across one’s joints can theoretically help prevent osteoarthritis of the knee and hip. Lengthening accelerates the pace of deconditioning of patients, and proper attention to rehab is important. The ultimate limb lengthening benefits are best achieved when a multidisciplinary care team works together to treat someone with limb length inequality. The team usually includes a surgeon, physical therapist, social worker, and psychological health professionals.
Limb lengthening recovery patients require post-operative care just after the lengthening procedure, whilst still in the hospital or clinic setting. Forms of treatment may include preventive measures against deep venous thrombosis, which involves wearing compression stockings, remaining hydrated, and maintaining a stable heart rate and proper oxygen saturation. X-rays are taken on a weekly basis in order to monitor the bone distraction process.
Clinical evaluation includes the assessment of vital signs, oxygen saturation, recent labs, and physical examination. Furthermore, fewer exams are conducted as patients make progress during their clinical recovery and are able to walk and support their weight. All documentary material is collected to be reviewed during the pre-operative phase for the patients.
Following femoral or tibial distraction osteogenesis surgery, patients are able to go home one or two days after surgery or as soon as they have learned to walk safely. The limb lengthening recovery process is set for six weeks, at which time it is preferable for patients to complete their prescribed physical therapy, which may be time-consuming and exhausting. Physiotherapy is the most common treatment for recovery. During the acute phase, the idea of physical therapy is to control and alleviate pain while also beginning passive motion exercises in order to remove inflammation.
Other steps in rehabilitation can include straight-leg raises, active-assisted knee and ankle flexion, as well as quadriceps and soleus stretching. As part of walking re-education, weight-bearing and stepping can be performed with elbow crutches and protective weight-bearing as the patient progresses. Usually, the patient is fully weight-bearing for three months post-surgery. On average, several people resume walking normally in as little as six months post-operation. Some patients may also be given a splint or a brace. Regular visits are planned once per week for around 200 min.
Long-term follow-up visits are scheduled one, two, and five years post-operation, as well as on an as-needed basis. The medical team is so well informed about the patient’s condition and can provide feedback and good advice. Depending on the patient’s improvement, the surgeon can suggest lengthening the other leg. Telephone consultation is also provided for individuals who are unable to make the visit.
Factors influencing the limb lengthening cost are important for understanding the price of limb lengthening surgeries. The type of method or the number of surgeries conducted, or the place where these surgeries are performed, is impressive for cost. The cost might be effective for the duration of stay at the hospital or the fees of the doctor conducting the surgery. In addition to these, the experiments affected the cost of limb lengthening with the name brand. When all these factors are considered, it can be said that the peak limb lengthening costs in a specific country are known.
Method and Materials: As a methodology, general web search engines were used, but also articles and studies comparing the price of limb lengthening cost in different countries.
Results: In Turkey, limb lengthening cost generally changes between $9,000 and $77,500. The differences in the prices themselves were investigated and were found to be based on the specified method, while external fixators and internal surgeries make a difference in the price compared to the amount of union done regardless of the method used. In addition, external and internal surgeries require hospitalization for a certain period of time.
It is seen that the cost of hotel or other rental expenses increases as this period is extended. Even though this is expected to increase limb lengthening cost significantly, it should be remembered that this is an expensive situation in terms of accessibility. It is important to consider these factors when learning the limb lengthening cost in today’s circumstances.
It is a known fact that the main hurdles of this treatment are pain and discomfort. During surgery under anesthesia, immediately after surgery with the patient under the influence of the anesthetic, and conscious after extubation (removal of the endotracheal tube), when the pain can no longer be masked, and during stay in hospital and at home after discharge. Finally, we describe how we aim to ‘vaccinate’ against pain with psychological support.
In medical terms, Clinching Syndrome coincides with the inflammatory phase. The purpose of the limb lengthening surgery method described here makes these fractures inevitable, after all, we forcefully pull tendons and muscles along strained bones. Not every patient is in a position to cope with the physical and emotional consequences of this process, seeing as they also have to go to work and keep their families satisfied while they are in excruciating pain and discomfort. It is critical that our patients can deal with pain well or that the pain can be neutralized as soon as possible, as these factors are critical for ensuring surgical success and patient well-being in general.
There is a neuronal reason, associated with cortical damage in the limb lengthening recovery process, as to why this is crucial. We know that larger corrections also cause less pain than smaller ones, which seems contradictory but that the body can ultimately handle. However, certain conditions must be met, one of which is good pain management. Bone pain is different from other types. Muscle pain may come from tired or overexerted tissue, or from insufficient recovery, but if the patient can cope with the pain, they can keep going. Bone pain is different, however.
Concerning nonoperative treatments, the healing potential as well as the safety of recovery after nonoperative distraction (e.g., external fixator, telescopic nail implanted before puberty) have not yet been established clinically. Limited findings in experimental animals suggest the challenge of mass hypertrophy during premature full-weight bearing in anatomy-bone-healing defects, which needs further assessment.
Therefore, the safety of full-weight bearing and forceful exercises may need radiological stress evaluation before the end of planned SLL. Physical activities, including standing, walking, stair climbing, and riding an exercise cycle, are necessary not only for healing and bone formation but also to enable the reobtained lengthened limb to be functionally equivalent to the normal contralateral limb after the end of the recovery from elongation.
Therefore, we proposed force models of physical activities for safety purposes requiring only actual limb length discrepancy at the time of discharge, safe corrected weight distribution, and stable knee-ankle angles in the bridging position before initiation of full-weight bearing.
Limb lengthening surgery has made considerable progress due to the ever-improving techniques for the surgery, limb lengthening recovery and the developments in the internal and external fixation tools used to maintain controlled distraction. Consequently, more patients can be treated and the surgical indications for the treatment of limb length discrepancy have expanded to encompass numerous orthopedic, neurologic, and congenital causes of short stature, as well as many psychological indications.
Despite the significant number of negative opinions and some case reports and papers, the scientific data prove the following: the procedure is relatively safe, the number of complications has decreased notably, and after the distraction and follow-up period, results show excellent functional recovery of all the upper limb functions, almost normal range of motion, adequate strength, and reduced pain.
Considering the excellent results obtained with motor and sensory recovery, one of the most important issues to be addressed certainly is the poor emotional and psychological status observed in some patients.
Finding the answer to this dilemma will enable surgical decisions to be made more precisely, reducing the number of affected patients and improving results. Continuous research on post-operative care procedures and the analysis of longer-term monitoring are needed to ensure the successful completion of such operative management. Lastly, future developments are likely to regard a more refined surgical technique, a better functional outcome, an expanding group of candidates, and the improvement of technologies.
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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