Limb lengthening surgery is a complex surgical procedure indicated to increase the length of a lower or upper extremity-for example, after injury, due to a congenital condition, or for reconstruction after tumor surgery. The concept of leg-lengthening or arm-lengthening is almost as old as the surgery itself, but what was once a very lengthy and painful process with high risks and questionable limb-lengthening surgery outcomes has evolved into a well-established state-of-the-art procedure. The number of operating patients either for medical or cosmetic reasons makes its characterization and the understanding of its benefits and limitations a growingly important issue. Several clinical conditions are aided by the lengthening of an extremity such as achondroplasia, radial club hand, post-traumatic limb length discrepancy, and discrepancy after the removal of a primary sarcoma of the extremity.
Bone lengthening can either be performed on healthy bone or on permanently damaged bone after an injury. There are many surgical strategies and techniques; however, the one common denominator in all these strategies is that the lengthening of bone is performed in steps-precise and controlled. Several techniques and devices exist that a surgeon can use for performing a bone-lengthening procedure. Most procedures can be classified according to the origin of the energy: manual or motorized techniques owing to either compressed gas or electricity. The aim of this comprehensive review is to reflect on the limb lengthening surgery safety and risks. While an informed decision in non-mandated procedures should be carried out with a good understanding of the known and agreed risks and benefits, this can also be extended to medical limb lengthening surgeries and also to non-mandated cosmetic procedures.
Several risks of limb lengthening and complications may develop during limb lengthening and deformity correction surgeries. If these risks of limb lengthening are not managed properly, the patient may sustain small injuries, or bedsores, or may have to discontinue rehabilitation, resulting in a lengthy treatment period or delayed functional recovery. Approximately 80% of mild complications and 42% of severe limb extension complications occur during the external fixation period. The possibility of limb extension complications is relatively high during those hospitalization periods. The surgeon’s technical experience can impact the risk of complications. Regardless of the lengthening method used, the patient is exposed to various surgical risks, such as infection, partially blocked blood vessels, embolism, deep vein thrombosis, compartment syndrome, insufficient blood products, failure to provide appropriate anesthesia, and other malfunctions, as well as adverse events related to the lengthening method.
Complications that may occur do not necessarily cause a negative impact on achieving our primary goals of limb lengthening or deformity correction. It is noted that patients with a greater mean number of limb extension complications were more inclined to develop psychosocial problems, while patients were identical concerning the number of severe complications. Minor complications are almost always only a passing annoyance to the affected patients, although they may be saddening, and the significance they have on our patient’s perception of ‘complications’ is not matched by their mild impairment. The values do not inform us about the natural and serious impact the status of adversity may have on the overall outcome of the reported effects. In fact, there is little evidence of the impact of adversity on long-term utilitarian and emotional well-being from the perspective of the parents of limb-lengthening patients who have average-adjusted limb-lengthening surgery outcomes. The aspiring surgeon must seek ultimate and unified informed consent and must clearly address the minor, interim, and severe complications, including their occurrence and impact.
There are various bands of factors that can critically influence the overall limb lengthening surgery safety and effectiveness of the limb lengthening process in patients. In terms of patient-related factors, age and the underlying reason for the lengthening are significantly associated with the rates of major complications. Besides these, motor nerve deficits and the mode of device activation also have determinative effects on the outcomes of surgery. In addition to the patients, factors related to the medical team, technology, and surgical environment also influence the success and safety of bone lengthening surgery. Surgical experience and technique are the determinative points for reducing the risk of limb extension complications. The role and extent of proper postoperative care and rehabilitation also impact the final outcomes of the patient in a significant manner. The developments in the fields of surgical tools on one hand and progress in surgical environments on the other also exhibit a significant impact on the development of the surgery. Furthermore, complete sterile conditions, the expertise of medical staff, and timely management of complications all serve to enhance the overall limb lengthening surgery safety. Consequently, while surgical results and underlying reasons for the surgery generally create a significant impact on the main limb lengthening surgery outcomes, age and regulatory status play a partial but prominent role in the prognosis.
Although many limb-lengthening surgery outcomes exist, those that have been in use for the longest time are likely to dominate in disparate parts of the world. For example, the unique technique appears to account for many pediatric femoral lengthenings in certain regions. That said, new techniques are emerging, which have yet to be validated in the study of any series. Other examples of recent and validated reports on innovative surgical techniques in limb lengthening surgery safety include a cable-tensioned system and a three-axis motorized intramedullary lengthening nail that includes various devices. These combined techniques can lessen the healing index by a factor ranging from 1 to 2 in weight-bearing bilateral or unilateral lengthening due to decreased strains at the level of regeneration. As yet, prospective randomized trials are not available for these devices or new techniques. The methods are hindered not only by the financial aspects but also by the training and level of experience necessary for the surgeon.
Ongoing education and training of surgeons are paramount to keep up with the rapidly advancing technology. This means consensus guidelines not only on the construct but also on the best practices for soft tissue, joint distraction, and debridement at the level of the internal implant. Such guidelines should draw from the development and evaluation of existing tissue distraction biologics and the materials for the release of corticotomy healing software. As the user experience with new technologies evolves, interdisciplinary active community-based research can focus on the development of new retractors and specialized surgical tools, including coring and new-generation bone transportation intramedullary nails. New technologies may help to address some of those unknowns.
Future research could help to standardize practices in this field, ensuring wide-ranging access to evidence-based studies for all patients and facilities seeking to confirm the best way to care for them. Guidelines could be issued for daily surgical practices by researching the most effective measures to be taken before, during, and after a limb estimation cycle. Appropriate prospective data collection and sharing will be an important practice to allow adherence to ethical principles and would benefit patients. Areas of focus are specific devices or tools used for the following procedures, including bicortical drilling at the site of the regeneration, choice of antibiotic prophylaxis, non-steroidal anti-inflammatory agents, deep vein thrombosis, and cholecystokinin disease prophylaxis. The availability of clear evidence on ethical scientific results relies on audit instruments developed for appropriate clinical conditions. At present, it is unclear if and the purpose of minimizing the use of radial hemostasis therapy, platelet alterations, or bone heating quality time points including incidence management description comparison. Engaging in ethical patient care will be an important step for researchers now. An analysis illustrated an unsubstantiated added benefit and a higher level of persistence from the orthopedic community as a result of the comparison decision.
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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