Generally, Limb Lengthening was employed as a surgical treatment option for patients suffering from leg length discrepancy and dwarfism; as a means of correction and/or additional height gains. Nowadays, such surgical procedures are being used cosmetically, for people suffering from less than average stature to gain a few inches of added height. Throughout the last century, ever since Ilizarov invented his apparatus for the limb lengthening process, many medical breakthroughs have been made, to make the procedure safer and faster. But, underneath all the latest methods of limb lengthening the medical process remains the same; that is, bones, either the femur or tibia; are surgically separated, then slowly distracted at the rate of 1mm per day till the desired height is achieved. Then, the apparatus is affixed in position for the bone to regrow or consolidate between the gaps over several months. These days, there are several methods by which this process is realized, all with different post-op recovery times and patient's comfort levels; e.g. Ilizarov, HolyFix, LON, Precice 2 and Precice Stryde.
There are three different types of limb lengthening techniques; all of which have their own set of challenges.
It is quintessential for any successful surgery to understand the post-operative periods; which is split into three distinct phases, after the surgery; to avoid any risk of complication and achieve the best possible results. Each phase has a distinct set of risks and possible complications and has its importance of specific care requirements.
Post- Surgery Hospitalization
This period usually lasts between 5 to 7 days after the surgery, and after which the patient is discharged from the hospital and they can begin distraction at the comfort of their residence. Now, depending on the method of surgery, each has its own set of challenges and care requirements. With methods that employ the external fixator, including Ilizarov, HolyFix and LON; the risk of infection persists till the time that the external fixators are removed; by the end of distraction. Generally, with external fixators, the nursing staff would teach cleaning routines and provide care and handling instruction for the external fixators. The pin sites or the areas where the pins of the external fixators are attached within the bone; there would be skin openings which require regular cleaning and care; patients will be instructed the importance of pin site care and early warning signs of any infections developing; which could present as swelling, redness and/or secretion discharge from the pin site skin openings. If any such symptom is noticed, it is imperative to contact your doctor, so they could prescribe a course of antibiotics to counter any possible infection.
Although an extremely rare complication, a Fat Embolism (FE) is a portion of fat (intravascular) that can become lodged within a blood vessel and cause blood flow blockage. This can become a possibility with bone fractures, especially of the pelvis, femur (thighbone) and tibia (shinbone). However, there are preventive methods, the surgeon employs a surgical technique, whereby the bones are vented during the drilling (reaming) of the bone canal. The surgeons, vent out the bone canal by drilling holes into the bone where the bone is to be separated, before the separating of the bone; thus a pressure buildup into the bone canal, the reaming are ejected out of the holes safely, preventing chances of any fat embolisms. However, even though the risk of fat embolisms is very low, they can make a patient very ill, which might require a stay in the ICU or even death, in the worst case. This is why the patients are kept 5 to 7 days at the hospital, to ensure that such a problem does not arise and after a 5th to 7th day of the surgery, the risk fat embolism dissipates.
Pulmonary Embolism (PE) & Deep Vein Thrombosis (DVT)
DVT is a possible risk factor after any orthopedic surgery or fracture and the single most effective way for avoiding such a complication is prevention with blood thinner, especially anti-coagulants; which are prescribed to the patients; after the surgery. The cost of all these post-op medications is included in the surgical prices. The real danger of a DVT is when a clot dislodges and travels to the lungs of the patient; although very extremely rare; but the outcome is very risky and can cause shortness of breath, chest pains and death in certain cases. This is why the patients are prescribed anticoagulants after the surgery to avoid any such risk. Furthermore, it must be understood that smoking and oral contraceptives could increase the risk of DVT; this is why the surgeons have strict qualification requirements for the selection of their patients.
Distraction or Lengthening Phase
At the end of the hospitalization period, the distraction phase begins; whereby the patients are instructed to distract the bone, daily, at about 1 mm per day, generally, This rate is variable and can change due to several factors and your progress; taken into consideration by the doctor.
Generally, this is the phase where most common complications are likely to occur and surgeons are vigilant during this stage for any early signs of complication arising. Thus, a doctor’s consultation is scheduled every second week, with fresh x-rays; for the doctor to ascertain your progress. Our international patients are required to ascertain fresh x-rays and physiotherapy reports every two weeks and email them to the doctors before an online consultation, every two weeks. During, the doctor consultations, the doctor assesses the distraction measurements and the level of bone maturation or regrowth within the distracted gaps created. The cost of all these post-surgery doctors consultations is included in the surgical packages offered.
Now some specific complications may arise during this stage of the recovery process.
Muscle Cramping and Contractures
Generally, this is the most common problem associated with Limb lengthening surgery; as bone distraction happens the muscles and nerves and pulled apart slowly and can cause the muscles to tighten and cramp. It is common for a muscle contracture to occur; which happens when a muscle gets too tight and pulled that it does not allow the joint moves freely and entirely. The only real and preventative solution to this complication is Physiotherapy (PT); hence it’s essential to have several sessions of PT per week and regular regime of exercise and stretches daily. Generally, surgeons advise PT to every patient of LL surgery; as it is the only way for the muscles and nerves to adapt to the new bine growth and allow movement with muscle growth simultaneously. Thus, the patients need to maintain the proper movement of their ligaments and prevent contractures during distraction as it helps in reducing the time required to return to normal after the distraction phase is completed.
Nerve Compression or Injury
Nerve compression or injury can happen with any lengthening procedure, and this is why the rate of distraction is limited to 1 mm per day; which is the most important aspect in controlling such a complication, the control of the lengthening rate. Secondly, the doctors have to be vigilant in recognizing a nerve symptom in its early beginnings; if any motor problems occur and/or muscle weakness or paralysis is noticed then a nerve decompression procedure becomes necessary, immediately; which is done on an outpatient basis.
Early Bone Consolidation during Distraction (Premature Consolidation)
This complication is very much dependent on person to person; as what happens is that the new bone growth bridges the surgical gap created to achieve newly added height faster than the bone is distracted to achieve the new height and this can happen if the patients are a fast bone healer. The most common way of avoiding such a complication to speed up the rate of distraction for a week or so. However, if the bone gap is bridged before this and premature consolidation does occur, then a small outpatient’s basis surgery becomes necessary to re-cut the bone with a small incision. It must be noted that with internal methods of limb lengthening, such as PRECICE 2 and PRECICE STRYDE, this complication may rarely occur, as the doctor can easily control the rate of distraction.
Slow Unification or Non- Unification of Bones
Generally, slow or failure of the bone to consolidate or heal is a possibility with any limb lengthening surgery; and the best course of action is preventative precautions. At the very start the doctors, identify factors that could affect bone healing, before the surgery. These factors may include:
Hence, before the surgery, the doctor examines the patients’ blood test results and prescribes the necessary supplements to cover the deficiencies. The patient is also put on bone growth supplements, which help in quicker bone regrowth after the surgery.
The most important aspect, after the surgery; is the rate of distraction. It is a known fact that lengthening too fast can cause delayed or failure for the bone to consolidate. Fast distraction rates are the most common cause of poor bone formation, in most cases. However, with the Precice internal systems, the rate of distraction issue can be easily managed, as the electromagnetic remote offers complete control over the rate of distraction; which can be slowed, stopped or even in worst cases retrograded (reversed) to initiate bone growth again; till the time significant bone regrowth can be examined. Following retrograding, once the bine starts to heal again, lengthening can be stated again; this is a huge advantage of external fixator type lengthening systems and with Precice internal nailing systems as well.
If, after taking these precautions, there is still delayed bone formation, the “accordion technique”; is employed whereby the bone is compressed and distracted at 1 mm per day; with repeated cycles, it stimulates bone regrowth and healing and avoids any need for additional surgery. This is the advantage of using external fixator and Precice systems; that it allows complete control to the doctors; hence it suppresses the need for expensive bone graft surgery to initiate bone growth; which can be achieved without any further surgery. This is the reason why we offer the methods that we do; which allow maximum doctor control and precautions for any risk of complication.
With a tibial limb lengthening surgery, the fibula needs to be lengthened as well, simultaneously. However, the implanted lengthening devices only lengthen the tibia; hence the fibula is affixed to the tibia, during the surgery, so that both bones are lengthened simultaneously. Hence is the fibula is not affixed to the tibia properly and at both ends; top and bottom; it could lead to severe complications; ranging from arthritis of the ankle, contractures of the knees and even partial dislocation of the fibula. The fibula needs to be properly affixed at the bone end to the tibia; therefore, usually, a fibular complication is more to do with the competence of the surgeon than any other factors or implantable devices used for lengthening purposes.
Consolidation or Bone Healing Phase
This phase starts as soon as the distraction or bone lengthening is completed. Generally, a “callus” is formed between the bone gaps which need time to fortify and calcify into bone growths; which can gain the ability to become fully weight-bearing by the end of this consolidation phase. The risk of complications dramatically eliminates during this consolidation phase; as the patient's ability for movement and function increases. Furthermore, movement of the ligaments is very important at this stage and is encouraged for faster healing for the callus to calcify into the new bone. The most important factors which may affect bone healing are primarily the age of the patient, the bone segment which is operated on (femur or tibia) and the distraction gap. Generally, the consolidation time is much less for the femurs than the tibia; as the femoral bones, tents to heal faster in comparison. Furthermore, patients within younger age groups tend to heal faster than older patients, as well.
Now the advantage of having a Precice system for limb lengthening, is that once distraction stops consolidation begins automatically, and with the Precice Stryde nail system, the patients can return to daily life much quicker as the nails can easily bear the patients weight, in comparison to older version of Precice 2; which could not.
It must be understood that physiotherapy (PT) is important with any limb lengthening surgical procedure; be it any method or device. During case studies of previous patients with iatrogenic problems; the most common element and the root of the problem lies in the lack of PT. the patients must follow a strict routine of PT, after the surgery, even in the distraction phases; to avoid any complications and for faster recovery time. It is common for a perfectly executed surgery to be riddled with patient mobility issues due to the lack of PT, as the muscle and nerves do not get enough movement and do not adapt to the new bone growth, simultaneously.
Physiotherapy is greatly encouraged during the bone healing or consolidation stage as it helps is muscle refortification and adoption to the new limb growth. It’s recommended daily and the whole idea behind the daily routine is to encourage and preserve the mobility feature of the knee joints, hips and ankles. This is extremely vital to preserve the mobility feature after the surgery, as generally patients can become agitated or disturbed with pain and discomfort but this could lead to serious problems as lack of movement could lead to contractures; a common complication with limb lengthening procedures.
Nutritional and Dietary care during Recovery
Apart from physiotherapy, patients are generally advised to have a nutritional diet rich in calcium such as leafy greens, fish, milk and milk-based products; in addition to calcium supplements. To speed up bone growth, patients are advised to slow introduce weight on their legs, to increase blood circulation and bone growth. Furthermore, patients need to get as much sunlight as possible, as without Vitamin D from the sun; it becomes quite hard for the bones to calcify; it’s a known medical fact that open wounds and broken bones tend to heal quite faster with enough sunlight.
Lastly, we would like to finish this article with a note; with a small piece of advice. As no patient wants to undergo unforeseen problems, complications, and costs; even though the doctors are vigilant in expecting and predicting a problem; the patient needs to be well informed of the risks and they must take note of the precaution and adhere to vigilantly; for the best results possible.
To inquire about Limb Lengthening surgeries and the risks involved, please contact us at [email protected]
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