Limb lengthening is a process by which our limbs upper limbs and lower limbs, are made longer. Lengthening a limb may be needed because it is shorter than the opposite side.
A limb can be shorter for many reasons such as congenital condition like Hemimelia, or congenital shortening of the Femur (thigh bone). Conditions that result in cessation of growth (a growth arrest) - like infection and injury, can also result in a short limb. A deformity often accompanies the shortening in these cases.
Lengthening is carried out on the shorter limb or limb segment in order to make the 2 limbs equal. Any deformity that is present is simultaneously corrected. Some of the children have large lengthening goals (15 cms or more), and therefore need 3 to 4 surgeries over time.
6-year-old boy with congenital short femur.
immediately after surgery.
show gradual elongation of bone with creation of gap in the divided bone.
shows the external lengthening device (Fixator).
show gradual elongation of bone with creation of gap in the divided bone.
show bone filling in the gap.
show bone filling in the gap.
shows the bone as completely healed. The femur bone is longer by 4 .5 cms. Fixator was removed at this stage.
Quite frequently, lengthening is carried out for both lower limbs. Lengthening both lower limbs results in an increase in height. In our clinic, this is commonly done for people who have genetic problems which render them small, and desirous of gaining a functional height. ( see Fig 7 and 8)
Occasionally, people of normal or slightly less than normal height wish to gain stature. The process of lengthening both lower limbs is applied to them as well.
A 14-year-old female child with severe shortening. Bothe the Tibiae (Leg bones) are being lengthened.
5 cm lengthening and height gain has been achieved with fully strong new bone formation. This girl will undergo 3 further lengthenings in order to achieve a ‘functional height’.
The method to biologically lengthen bone was invented by Prof. Gavriil Ilizarov, a Russian doctor. He created new bone by gradually increasing the gap between surgically divided ends of bone. He developed a system of predictable safe Intramedullary limb-lengthening termed as Distraction Osteogenesis. As the gap increased between bone ends and filled with bone, the soft tissues also increased the length in response to the distraction stress. Nerves, blood vessels, muscles, all increased their length proportionally. This phenomenon was labelled as distraction histiogenesis.
The distraction osteogenesis forms the basis for all lengthening of limbs that are carried out today. We have learnt from Prof. Ilizarov's methods that lengthening a lower limb bone segment by 4 cms can be safe at one time. At times, 2 segments (such as Femur and tibia) can be simultaneously or sequentially lengthened to achieve a lengthening of 8 cms. Lengthening of the same bone can be repeated after a gap of 3 years.
Have a physical check by Dr Sarup and his associates on the appointment day.
Expect a scannogram x-ray to be done. A plan of treatment will be formalized after full evaluation and will be discussed with you.
Blood tests, Pre-anaesthesia check will be carried out. A date for surgery with pre-operative instructions will be given. An estimate of cost will be given.
You must discuss any questions you have with Dr Sanjay Sarup or his team. It is helpful to write these down before the consultation.
You will need to discuss all the special needs that you may have. Physiotherapy and dressings are possible at home, and our dedicated team members will make home visits. You may need to make arrangements to study / work from home for a few months. You will need ambulation assistive devices like walker, crutches etc. You will also meet our physiotherapists who will train you on exercise, and walking aids. The home environment may need to be checked out by our therapist to suggest aids and assistive devices.
You/your patient will be admitted on the day of surgery, usually 2-3 hours before the procedure.
Final checks will be carried out, consent forms will be signed and you / your patient will proceed for surgery.
Dr Sarup and his associates will see you after the operation and apprise you on the procedure.
We usually bring the patient back to the out-patient Pediatric Spine Clinic in Gurgaon once a week till lengthening is completed.
It takes at least a month after fixator removal to be reasonably mobile and be able to return to work or school.
Large lengthening can be tedious. Patients and their families have to work hard with us and our health care specialists. We, as a team at COSCC, help all our patients to achieve the best possible results.
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You may have various questions which the following pages may answer. Should you have more queries, our staff will be happy to answer them for you.
It depends on the clinical situation. Broadly speaking, Limb lengthening is done in 2 situations
This is by far the most common situation in our centre.
A limb may be shorter
When lower limbs are of different lengths, it causes an asymmetry. If the difference is small (1 centimetre-1.5 centimetre), it may be hardly noticeable.
If the difference is over 2 centimetres (cm), a limp becomes noticeable.
With larger difference in limb lengths (limb length discrepancy – LLD), the problem increases. In addition to being cosmetically disadvantageous, walking and running become abnormal and difficult. The limp is proportional to amount of limb length discrepancy.
Over a period of time, the joints of the lower limb get affected and the joints of the lower spine (called facet joints) develop arthritis. Some children develop a scoliosis (a side bend of the spine) as well.
Once there is significant Limb Length Difference, Limb equalization is needed for the medical reasons described above.
This is referred to as cosmetic limb lengthening. Usually, the limbs are equal in this situation. Surgery is carried out on both the lower limbs to make them longer.
There can be 2 clinical circumstances where this is carried out:
In cosmetic limb lengthening, the decision to have surgery must be carefully made by the patient and the family.
Once The patient has decided to have surgery, our team will make a detailed assessment.
Blood tests, Radiographs, A Scannogram and measurements are carried out. Pre- anaesthesia checks are carried out.
Dr Sarup will examine you in detail and make a plan for surgery and its aftercare.
Patient is usually admitted on the day of surgery. A general anaesthetic is administered and an epidural cannula is placed in to prevent post surgery pain.
Under anaesthesia, the bone to be lengthened is divided. A lengthening device is placed to fix the bone (see types of lengthening). The patient is then woken up and brought back to the room. Physiotherapy is started the next day. The patient is discharged home on the 4th day after surgery.
Lengthening device is activated 7-12 days after the operation. Distraction is carried out between 0.75 to 1mm per day – usually done fractionally every 6-8 hours. Once target length is reached, lengthening is stopped.
Physiotherapy is continued on a daily basis to achieve good movement and strength for the leg muscles.
Dressing is carried out on alternate days.
The distraction creates a gap in the bone which gradually fills up with new bone. The soft tissues also undergo elongation with the distraction. The new lengthened bone slowly becomes as strong as normal bone, and the lengthened limb becomes as strong as the normal limb.
The surgery is carried out under anaesthesia and therefore it is painless.
All major surgeries have a variable degree of pain in the first 48 hours. We manage pain and discomfort with the help of epidural analgesia and intravenous analgesics.
Our dedicated pain team monitors patients in the post-operative period to ensure that pain is kept away.
External fixators tend to have a level of discomfort, especially with older children, but this is variable. This discomfort can be kept under excellent control with oral medication. Physiotherapy and exercises, done diligently, also go a long way in an early return to normalcy.
Limb lengthening has similar risks as any other routine operation where implants are used. Additionally, there are risks unique to this procedure - the bone healing may be delayed or may not be complete. There are solutions available if this happens.
However, it is highly advisable to have these procedures done by Orthopaedic surgeons who are well trained, and who have plenty of experience in this field.
Do choose your surgeon carefully.
In our clinic, the most common complication is a pin tract infection. This is treated with dressings and culture specific antibiotics.
The limb lengthening surgery itself is a short process requiring 5 days in the hospital.
Lengthening is started after 1 week. Lengthening is carried out at the rate of 1 mm per day. As a general rule, 4 centimetres of lengthening takes 60 days, and the external fixator has to maintained for a total period of 4 months.
If an internal lengthening device is used, the healing time is similar but the internal device is not removed.
Types of Limb lengthening systems and devices:
1) External fixator – Monolateral external fixator
In this lengthening device, the pins are applied to one side of the limb, and the fixator sits on one side – usually outer aspect of the thigh or the front side of the leg.
: This 5 year old is undergoing limb lengthening with a mono-lateral external fixator.
2) Circular external fixator system – Ilizarov type
Here, the system has metal rings that encircle the limb. The pins attach to the rings. This design is close to the classical system for limb lengthening.
; This 7 year old girl is having her femur ( thigh bone) lengthened over a classical ring fixator – ilizarov type.
3) Circular external fixator – Hexapod external fixator
This device uses 2 rings connected by a hexapod frame. The lengthening is planned out, and a computer software programme devises a lengthening plan. This system is more useful where the limb shortening is accompanied by a deformity.
: This 14 year old has a complex deformity with severe shortening. Both deformity correction and lengthening is being carried out over a hexapod frame. This system is exact and the lengthening program is guided by computer software.
4) Internal Lengthening device – Magnetic lengthening Nail system.
This is a new system now available in India. A magnetic lengthening Nail device is inserted into the bone to be lengthened. The entire device is internal and not visible. Lengthening is achieved 3-4 times a day by placing a magnet driver over the leg to achieve a distraction of 1 mm per day.
The metal self-elongating device is inserted surgically within the bone. There is no external device. A remote hand-held controller activates the lengthening of the nail. The discomfort and inconvenience is minimal by this method.