Limb Lengthening Post-op Period, Problems and Complications
Leg Lengthening is a complex process that has traditionally been performed on people with limb length discrepancy. It has also been an option for people suffering from dwarfism, who want to gain additional height. More recently, the procedure has been used for people with short stature to add two or three extra inches of height. Limb lengthening for height increase can be done using different surgical techniques, whether with external fixation and/or internal osteosynthesis. Current methods for leg lengthening are: ilizarov, LON/LATN (limb lengthening technique that combines external and internal methods), intramedullary nailing (FITBONE, PRECICE, Precice Stryde). Please see this link for detailed information: Limb Lengthening Surgery Methods. Limb lengthening post-op period may be divided into three periods, and during these three periods one lays emphasis on different aspects of care.
The Early Post-op period (the Latent Phase)
The early limb lengthening post-op period extends from the time the patient comes out of surgery till the beginning of distraction.
After leg lengthening operation, nursing staff teach patients how to clean and care for the skin around the pins that attach the external fixator to the limb (pin site care). Patients are also shown how to recognize and treat early signs of infection (warmth, swelling and redness) and told not to neglect pin site care, which takes about 30-40 minutes every day until the device is removed. It is very important in preventing infection from developing. If there is any redness and pain around a pin-site associated with increased or purulent discharge the patient can start a course of antibiotics.
After the end of the latency period (about 7-10 days after surgery) the lengthening phase of the bone is started. By that time you will have learned how to use the device properly. The rate of lengthening is approximately 0.5 – 1 mm per day. It can be accelerated or delayed as per doctor’s advice according to the progress.
It is during the distraction phase that most of the complications of the treatment will occur, and consequently the surgeon has to be constantly on the lookout for the known complications. During the distraction phase, the patient should be seen at least every two weeks. At these visits one should perform a detailed clinical examination covering the points as well as X-ray studies. Out of town patients can just send X-rays and physical therapy reports instead of coming in. After reviewing the x-rays, the doctor email patient, or patient has an online consultation with the doctor, where he/she is given updated weight-bearing instructions depending on the progress of the consolidation (if patient has a surgery with intramedullary nailing system) and other problems or concerns one may have, also is discussed. Specifically, the doctor measures the length of distraction and assesses the degree of maturity of the “regenerate” (the newly formed bone in the area of distraction). The cost of these consultations is included in the total package price.
When the lengthening of the bone to the planned length has been completed, the newly formed callus (it is also called “Regenerate”) needs time to strengthen and to convert to normal bone with satisfactory weight bearing ability. This is called consolidation.
The fixator will remain until the end of the consolidation phase to allow the newly-formed bone to harden. No further adjustments are made to the fixator. The total time in the external fixator can be estimated to be approximately 1 month for each centimeter of lengthening in children and 1.5 to 2 months (or longer) per centimeter for adults. For patients who had surgery with Ilizarov method or other external fixators, the device is removed when new bones are able to carry patient’s weight.At the end of distraction, Ilizarov recommends “training the regenerate”. Simply put, this involves overlengthening the limb by 7 to 10 mm and then compressing this back to the proper length in a gradual fashion. This ensures a larger cross sectional area of regenerate to participate in the consolidation. With Ilizarov frame you will already have been fully weight bearing since after the surgery.
Finally before actually removing the frame the patient may be administered a ‘stress test’ in which all the uprights connecting the proximal and distal segments of bone are disconnected and the patient asked to use the limb in a functional manner (weight bearing for the lower limb and functional activities for the upper limb). If the patient is able to do this the frame can then be removed with confidence. Actual removal of the fixator is usually done under anesthesia. In adults, though it is possible to do without it, it is not recommended as the removal of half pins is quite painful. For futher information you can see: Limb lengthening surgery by Ilizarov Method
During the consolidation phase, if you have a Precice Nail, you will continue to walk with weight bearing restrictions. No more alterations will be made to the PRECICE nail. The PRECICE nail will remain in place throughout the consolidation phase to support the regenerate bone. Depending on the bone that has been lengthened, the length of the regenerate and individual parameters of the patient, full weight bearing is usually allowed between 6 and 8 weeks after the end of the lengthening phase.
The implantable lengthening device should be removed. Although it is made of inert metal (either titanium or stainless steel), there are also other materials including rare earth magnets, etc. The moving parts also can lead to wear and even corrosion. Although it is sealed inside a waterproof chamber, it is possible that after years this seal could leak and the rare-earth magnet be exposed to body fluids. For these reasons it is preferable to remove the device. Timing of nail removal is not critical, it is recommended to be done between 1 and 2 years after insertion. There is no urgency in the timing of removal but it should be done. The removal is an outpatient procedure. Removal of implanted metal devices requires another surgical procedure under general anesthesia.
The cost for removal is not included in the initial package price.
During the consolidation phase the risk of complications is reduced markedly, and the patient’s functional abilities increase. Movement and ambulation are encouraged to ensure a speedy consolidation of the regenerate. The age of the patient, bone segment (femur, tibia), corticotomy level and the level of osteotomy (distraction gap) play a big role in the bone-healing. Distraction – consolidation time versus distraction gap is significantly less for femoral than tibial lengthening. Patients 20 years and older healed slower than patients younger than the age of 20 years. Patients 20 to 29 years old healed faster than patients older than 30 years and slower than patients younger than 20 years.
Lengthening over nail (LON, monorail method)
A different strategy for the distraction and consolidation phases aims at reducing the total fixator time by simultaneously placing an intramedullary solid nail at the time of osteotomy and by removing the external device at the end of distraction.
After the distraction phase, the nail is locked to stabilise the gained length and axis before removal of the fixator. The main concern of combining external fixation with solid nailing is deep infection. The risk ranges between 5 and 15 %.
Much is spoken about physiotherapy and it’s importance in the both internal and external methods. Unfortunately, this is infrequently translated into practice. One just has to look at many cases with iatrogenic problems to realize that lack of physiotherapy lies at the root of the majority of these. The patient has to participate in a proper program of exercises, mobilization and ambulation. This cannot be stressed enough. Lack of proper physiotherapy can turn even the technically excellent surgery into a poor result, and nowhere is this more true than in the subspecialty of Ilizarov surgery.
Physiotherapy continues during the consolidation phase with the goal of muscle strengthening and re-education and improvement of proprioception of the limb.
This is even more vital in the early post-op period, because the patient with pain is not going to be very cooperative in the physiotherapy and mobilization. Pain also will cause the adoption of protective postures such as flexion of the knee, plantar flexion of the ankle, which later develop into contractures one of the commonest ‘complications’ of the external fixators, especially Ilizarov method.
Physiotherapy session is done every day. The goal of physiotherapy is to preserve the ROM of the joints of the knee, hip and ankle and to stretch the muscles and tendons.
Complications and risks
Cosmetic Leg Lengthening (also called Limb Lengthening) procedures can not be compared with more simple plastic surgery options. They are very complex, painful, expensive and require long recovery times from one half to one full year.
There are some risks and complications related to cosmetic limb lengthening surgery, and for that reason patients should be well informed about all it.
All the risks associated with surgery and the administration of anesthesia exist, including adverse reactions to medications, bleeding and breathing problems.
Specific risks and complications associated with Limb Lengthening Surgery are: poor bone healing (non-union), Premature consolidation, osteomyelitis (bone infection), injury to blood vessels, nerve injury, joint stiffness (contractures), pin loosening in the anchor sites, destruction of cartilage and most common serious risk is infection of the pin sites or wires going through the bone that may result in further bone or skin infections. Pain and difficulty sleeping are other problems that arise during limb lengthening period. Pain is very subjective and the pain threshold vary among people. Each person deals with it in different ways.
Previous designs of internal bone lengthening devices have been fraught with imprecise distraction, resulting in nerve injuries, joint contractures, non-unions, and other complications.
Delayed or failure of consolidation: slow or failed bone healing can occur with any lengthening surgery. This complication can usually be prevented by making drill holes at the level of the planned osteotomy before reaming the bone.
Muscle contractures: muscles normally get tight with lengthening. A muscle contracture occurs when a muscle gets tight enough to prevent a joint from moving through its entire range of motion. To prevent muscle contractures physical therapy is essential. The patient should do daily stretches of the muscles and joints. E.g. knee joint and quadriceps muscles for femur lengthening and ankle joint and Achilles tendon for tibial lengthening. In addition to formal physical therapy the patient should do their own stretches at home several times per day.
Premature consolidation: in this complication the patient bone bridges the gap and prevents further lengthening. Premature consolidation can occur with any method if the patient is a very rapid bone healer. The patient in these cases is able to make bone faster than the speed at which the bone is being lengthened. The only way to prevent this is to speed up the lengthening intentionally for a week or two. The Precice nail with its rate control allows the surgeon to do this. If premature consolidation does occur it requires an outpatient small surgery to re-break the bone through a tiny incision.
Another frequent worry for the patient as well as the surgeon is that of bathing and washing the fixator. This is completely safe, provided that the limb and the fixator is thoroughly dried and the pinsites cleaned again after the bathing.
During the recovery period, physical therapy plays a very important role in keeping the patient’s joints flexible and in maintaining muscle strength. Patients are advised to eat a nutritious diet (milk and milk products, sesame, Dark leafy greens, sardines and etc.) and to take calcium supplements. To speed up the bone healing process, gradual weight-bearing is encouraged. And of course sunlight… Without sunlight, the bones cannot become calcified. Open wounds and broken bones heal faster in sunlight. Patients are usually provided with an external system that stimulates bone growth at the site, either an ultrasound device or one that creates a painless electromagnetic field.