Ilizarov (Holyfix) Vs LON: The Difficult Choice

Although there are modern and high-end technologies such as Precice 2.2 and Precice Stryde for cosmetic limb lengthening surgery, there is still a considerable demand for leg lengthening operation methods such as Ilizarov and LON (Lengthening Over Nails). This is mainly due to their more affordable prices compared to motorized nails, and their proven reliability in the field. But what about making a choice between these two methods: fully external fixation (Ilizarov/Holyfix/TSF) and LON? In this article, we are presenting you the outcomes of our researches and rich experience with our patients, in order to provide you a more detailed insight into both types of height increase surgery.

The significant differences of these limb lengthening surgery methods aside, there is one important thing Ilizarov and LON methods have in common: external fixation. This is one of the decisive factors for many people considering leg lengthening operation. The prescence of external fixator devices attached to patients’ legs cause the necessity of regular pin site care and bandage changes where pins enter the skin and soft tissue to hold the bone together. Obviously, there are holes that are left open and there is a risk of getting infection into these cuts in case the pin site care is done without enough care and frequency. The longer the duration spent with external fixators, the more extra work and risk of infection for the patient. Having metal fixators on legs also means limited mobility during fixation period, and a considerable amount of pain and discomfort. Taking all of these into account, it becomes quite clear that patients would gladly get rid of the external fixators as early as possible.

According to the outcomes of a study carried by Burghardt RD et all, “the mean external fixation time for the LON group was 2.6 months and for the matched case group (Ilizarov group) 7.6 months”*. This huge difference in durations of external fixation makes it clear that LON has a huge advantage. Early removal of external devices also positively affects the motivation and psychology of the patients. Highly motivated patients put more effort into physiotherapy and physical exercises and see better results in shorter time. Another significant positive result of early removal of fixators is patients can get back to their daily life, work and studies earlier than they would in Ilizarov or Holyfix methods.

A visual comparison of Holyfix (fully external) and LON methods. Note the prescence of internal nail in LON.

Another advantage of the LON method is increased stability of the bone during lengthening period. This is due to the intramedullary nail implanted into the bone cavity. This advantage of LON method is also supported by the same study by Burghardt RD et all, where it is mentioned that “In three LON patients, we corrected axial deviations that developed during the lengthening by using external hinges placed on the circular frame. Seven patients in the matched case group (group of patients operated with Ilizarov method) developed axial deviation during lengthening”. 3 patients in LON group vs. 7 patients in Ilizarov group is a significant difference, although the mentioned study involved a limited number of patients operated by each method. This has also been confirmed by our experience with our patients. In patients operated with Holyfix (a modernized monolateral device based on Ilizarov technique), we observe slight deviation of the bone on x-rays taken during lengthening (distraction) period. Because there is no internal nail to support the bone and hold it from inside. Luckily, this slight deviation is correctable by additional adjustments made to Ilizarov/Holyfix external device. The bone can be given the right angle and fixated in this position before it has consolidated. This type of deviations are seen more rarely with our patients operated with LON method.

To summarize the positive sides of LON surgery, according to Burghardt RD et all, “the three main advantages of the LON technique are reducing the duration of treatment with external fixation, preventing fracture of the new bone, and restoring knee and ankle ROM (range of motion) more quickly”.

Even though LON wins over classical external methods in many aspects, it has its disadvantages too. One of them is increased cost. LON costs more than Ilizarov/Holyfix for two main reasons: the prescence of additional internal nail (cost of the material), and increased operation staff cost due to higher skills and longer operation time required to successfully accomplish a LON limb lengthening surgery.

To compare, we  perform limb lengthening surgery with Holyfix method for 14500 eur (till 30 Sep 2019), while LON surgery costs 18000 eur. To learn more about the methods applied by our doctors, and their respective costs (as well as services included in package price), please visit SERVICES.

On the other hand, in LON method there is a possibility of deep infection spreading to the bones. This is prevented in two ways: 1. Doctor has to ensure the pins of external device don’t contact the intramedullary nail (which is ensured by nearly all experienced limb lengthening surgeons)  2. The patient has to be extremely careful about pin site care and overall hygiene of the legs, and has to inform the doctor whenever there is even a slight hint of infection on surface. As it can be understood, it is quite easy to prevent deep infection by sticking to doctor recommendations. Before our patients leave the hospital, the technique of bandage change and cleaning of the pin sites is carefully explained by the doctor/doctor assistant. We make sure that patients will be able to do it themselves after being released from the hospital.

Although it is still possible to get pin site infection in Ilizarov/Holyfix methods (in fact, 20-30% of Ilizarov and LON patients see slight infection and pus at the pin sites to some extent), it is highly unlikely that the infection will spread into the bone and cause major complications. Nevertheless, appropriate care should be taken even at a minor hint of infection. Minor infections are quite treatable with oral antibiotics and thorough cleaning of pin sites with antiseptics. For patients who stay in Turkey under our control, our doctor asssistants can provide this additional care and ensure that the infection is treated in no more than around 1 week or so. For those who return to their home country shortly after the surgery, patients can visit a local hospital, or contact their limb lengthening surgeon for further guidance.

To conclude, it can be really difficult to make a choice of leg lengthening operation method, especially there are both advantages and disadvantages of each possible choice. Being aware of this difficulty, we have prepared this article to put some light into strong and weak parts of each method. We tried to make an honest comparison of two budget-friendly methods of limb lengthening, in hope to make decision making easier for you. Please do not forget that you can always contact our patient consultants for individual consultation and further information about each method.

* R. D. Burghardt, MD, Research Coordinator, A. Manzotti, MD, Director, A. Bhave, PT, Division Head of Rehabilitation, D. Paley, MD, FRCSC, Director, and J. E. Herzenberg, MD, FRCSC, Director ,“Tibial lengthening over intramedullary nails. A matched case comparison with Ilizarov tibial lengthening”, Bone and Joint Research 2016 Jan. ; 5(1): 1–10. Published online 2016 Aug 17.