Limb lengthening techniques have a long history dating back to ancient medicine. Developments in the technology of the Ilizarov apparatus have significantly contributed to advances in the process and the ability to lengthen limbs effectively while minimizing morbidity. Limb lengthening is most commonly performed on individuals with conditions present from birth, acquired illnesses such as infections, or following trauma. There is now also a subgroup of patients who undergo the procedure for aesthetic or psychological reasons. The most common reason is to be within ±5 cm of the normal height for a person’s country. The field is particularly relevant in society today; indeed, in the UK alone, the National Health Service delineates frequently measured height threshold values at which a patient would be eligible to receive injections or limb lengthening.
Limb lengthening is an example of medical and surgical treatment where informed consent is especially important; this is because the beneficiaries of the procedure are often minors, but additional children and adults may experience further limitations in relation to their understanding or decision-making ability. This article aims to identify the different limb-lengthening techniques available, discussing their rationale and outcomes in order to compare them. In this way, readers will understand the principles of each technique and be able to appreciate the strengths and limitations of each approach. The techniques will be assessed based on the above-mentioned factors in limb lengthening surgery objectives. The guide concludes with examples of the situations in which each technique might be most usefully applied.
Orthopedic reconstructive surgery provides various treatment options in which we correct fractured and deformed bones, such as limb length discrepancy or bone defects using different limb-lengthening techniques. Traditionally, an open incision is performed in these processes to the affected bone sites. Based on the invasiveness, therapy can be divided into more and less invasive lengthening surgical methods. The classical but still in use limb lengthening techniques fall into a section of an invasive surgical method. One of the best standard and most famous methods is the Ilizarov external fixator technique, from which today’s effective invasive monotube intramedullary lengthening nails without external fixation systems have developed. All these effective and popular methods of lengthening reconstructions have been gradually evolving as the outcome of the development of the unique device used for the particular technique.
The Ilizarov technique is based on the principle of distraction osteogenesis or callus distraction, which have the same meaning. Young callus formation, or regeneration, is promoted by the gradual separation of the regenerating bone segment. External fixation is mainly performed according to the closed method because the formation of a complex external circular guiding fixation frame can be done using special X-ray check fingers and sterile gloves according to the type of lengthening, followed by the application of only special lengthening or shortening monolateral pins or wire. The modern protocol is familiar in clinical practice where percutaneously advanced humidity-activated locking pins without antidisplacement proximal triangular tips were introduced along the ILN, which are handscrew fixed. The ILN was hand locked with humidity-activated locking screws in elastic volume. Ideal operations performed with humane postoperative care are also provided on an outpatient basis. The main advantages are excellent safety, good healing response, faster consolidation, and better preservation of physiological anatomy that allows early active movement of the limb. The main disadvantage is that these are inappropriate for many patients with this condition and, as a result, this technique is rarely offered.
In conclusion, the comparison of the best limb-lengthening method to elongate the bone confirms the effectiveness of all discussed techniques. Despite its invasive nature, hypercallus distraction, or MAS is still regarded as a safe and reliable procedure with significant potential to gain bone length. The shortening–lengthening procedure seems to be even more effective than hypercallus distraction since it does not require time-consuming consolidation, being a single-staged technique. On the other hand, the low-invasive and complication-free Ilizarov distraction method with bone transport, as well as lengthening over a nail, are suitable alternative techniques, especially for patients with short to average stature. The present study provides an overview of different limb extension options, recommending the most appropriate solutions, especially for a chosen type of patient.
Determining the success of the types of limb lengthening surgery is certainly not only about the effectiveness of the result but also its safety. This article will critically compare the limb extension options reviewed earlier. After analyzing the existing literature, it can be concluded that the types of limb-lengthening surgery presented above are equally effective in terms of obtaining bone length and shortening the treatment. In the analyzed methods, the timing of the bone cut is different, which results in varying patient satisfaction across different techniques. Based on the obtained results, one cannot clearly indicate a single method as the best one for all patients. Each of the presented techniques seems to be effective in gaining bone length, but each is also associated with certain specific complications. The decision on the method should be made based on the needs and expectations of the patient, as well as the individual circumstances of the patient and the doctor.
The choice of the best limb lengthening method is influenced by several factors: the age, sex, and general condition of the patient; the level and type of deformities; the patient’s psychological condition; the goal of obtaining lengthening; the sacrifice of operation time; the type of pain that they are tolerant of; whether there is a distance from the place of care with the doctor, hospital, or physical therapy; and in some cultures, cosmopolitan issues. Since the principles for selecting and final decision-making techniques for each patient do not correspond one hundred percent, the range of patients also varies greatly from one to another. Therefore, professional limb lengthening surgeons have preferences in selecting the best working techniques according to the patient’s condition. Among the most important techniques that are adopted for lower limb deformity correction are the Ilizarov method; internal bone lengthening techniques intramedullary devices; and external bone lengthening techniques or bifocal alternatives. The most common of these changes is called the “nail nail.” Many factors need to be considered in choosing the “best” techniques, like individual bones, but the availability of working with these techniques is the most important. Surgical and clinical experience is required to create the patient and, ultimately, decision-making in a “joint” or shared decision-making method according to the attitudes of patients, the availability of health services, and the scope of the area. Time and cost-effectiveness in the choice of external lengthening, the insurance system for the availability, appropriate and emerging local or global treatment, and some ethical considerations; it is forbidden to use techniques by culture; one should not perform the most expensive treatment techniques in the area, or some patients may want to have the latest limb lengthening techniques even if they have to spend some negligently expensive costs for treatment out of pocket. All these factors are taken into consideration in order to make the technique the most suitable for each individual patient.
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