What is Quadrilateral Surgery? A Detailed Guide

Limb lengthening surgeries generally involve the surgical extension of the bones in the legs. In conventional methods, the procedure is often performed on a single area, for example, only the upper leg (femur) or only the lower leg (tibia). However, quadrilateral (four-fold) limb lengthening surgery is a surgical method applied to four areas in total—both the upper leg (femur) and lower leg (tibia) regions of both legs. With this method, it is possible for patients to achieve the total height increase they aim for in a shorter time. Of course, as with any surgical operation, there are advantages, disadvantages, and points that need attention.

In this guide, we will examine in detail how quadrilateral limb lengthening surgery is performed, its advantages and disadvantages, costs, what awaits the patient during the recovery period, and the considerations that need attention.

1- Quadrilateral Limb Lengthening Surgery: Purpose and Suitable Candidates

Purpose:

  • Patients who aim for a higher total height increase
  • Situations where lengthening only the upper leg (femur) or only the lower leg (tibia) would be insufficient
  • Those who want to achieve a greater amount of lengthening in a shorter period

 Suitable Candidates:

  • Individuals who do not have any bone disease (such as osteoporosis) or chronic conditions that could prevent surgery, and whose overall health is appropriate for surgery
  • Patients who are psychologically ready for the process (as a long rehabilitation period and patient compliance are required)
  • Candidates deemed suitable for quadrilateral surgery based on physical examination and radiological evaluations by a doctor
  • Before this surgery, the patient’s expectations, medical history, bone structure, and the targeted lengthening amount are comprehensively evaluated. Therefore, the decision to operate should be made jointly by the patient and the doctor.

2- Basic Information on How Quadrilateral Surgery Is Performed

In limb lengthening surgeries, a controlled fracture (osteotomy) is created in the bone. Then, by gradually increasing the distance between the bones, new bone tissue is encouraged to form. In the quadrilateral method, this procedure is applied to both the upper leg (femur) and lower leg (tibia). The basic steps are as follows:


Surgical Preparation and Planning

  •  Detailed X-rays, blood tests, ECG, bone mineral density, and anesthesia evaluations are carried out before the surgery.
  • How much lengthening will be done on which bones will be determined according to the patient’s physical structure.
  •  Material planning is done according to the patient’s bone structure before the surgery.

Osteotomy (Bone Cut)

  • By making a small incision in the planned areas, the bone is accessed and a controlled fracture is created.
  • This is done in both the upper leg and lower leg regions (on both legs).

 

Boy Uzatma Ameliyatı Yöntemleri: Kombine (LON) - Precice

Method Selection (Internal Nail or External Fixator)

  •  External Fixator (External Device/Stabilizer): An external metal rod is mounted onto the bones. Visible metal rods on the outside of the patient’s leg hold the bones. During the lengthening process, the patient makes daily millimetric adjustments via a screw or special Allen key through the opening under the fixator.
  •  Internal Fixator (Internal Nail): Intramedullary nails (which pass through the bone canal) are placed in the incision area. The lengthening mechanism is inside the nail, and daily millimetric lengthening is achieved with the help of a magnetic remote control.

In quadrilateral surgery, both methods (LON–Precice) can be used. For example, the Precice method can be used in the upper leg, while the LON method can be used in the lower leg, aiming to maximize both patient comfort and surgical success. You can watch the moment of limb lengthening in Precice and LON methods in the video below.


 Postoperative Lengthening Process

  • Usually, around 5–6 days after the surgery, the stage called “distraction” begins, during which the bone starts being lengthened.
  • According to the program determined by the patient’s doctor, an average of 1.75–2 mm of lengthening per day is performed. This amount is adjusted according to the speed of the bone’s healing.
  • The lengthening period continues until the targeted height increase is achieved.
  • Once the lengthening process is completed, if the Combined method was used, the fixators are removed.

Consolidation Period (Bone Strengthening – Consolidation)

  • After achieving the desired lengthening, the bones need to harden and fuse. This period can last 12–15 months, depending on the amount of extension.
  •  The nails in the bone are removed by the doctor once the bone has sufficiently hardened. The nails used in the Combined/LON method are removed upon request. Our doctor recommends removing the intramedullary nails used in the Precice 2 method, because they are not MRI-compatible and less is known about their long-term effects.

 

3- Advantages of the Quadrilateral Method

 

Possibility of Greater Lengthening

Since the procedure is performed on four areas across both legs, a greater total limb lengthening (for example, instead of 6–8 cm, 8–15 cm or more) can be achieved compared to lengthening only the upper leg or only the lower leg. You can examine the before-and-after photo of our patient who gained 13 cm with two surgeries.


 

Aesthetic Appearance and Balance

Since both the upper leg and lower leg are lengthened together, the leg proportion and muscle-strength balance can provide a more natural appearance.


In the photo above, the patient’s body measurements were taken, and the golden ratio calculation was made for the upper and lower leg.

Time Savings

Because four areas are lengthened at once, it may be possible to have a shorter treatment period with a single surgery plan instead of two separate surgeries.

However, postoperative care and follow-up periods may be longer; still, the total treatment process (instead of multiple surgeries spread over several years) is completed in one intensive period.

No Need for Repeated Anesthesia

If the patient has a risky profile for anesthesia or wants to minimize the stress of surgery, the quadrilateral method can offer an advantage by completing the procedure in a single operation.

4- Disadvantages and Challenges of the Quadrilateral Method

More Difficult and Longer Surgery

The four-fold operation requires a high degree of surgical experience and skill. Both the surgery duration and the patient’s hospital stay may increase.

Level of Pain and Discomfort

Performing the procedure on both the lower and upper legs simultaneously can increase postoperative pain and discomfort. Pain management is one of the critical stages of this surgery.

Greater Need for Rehabilitation

The recovery period requires meticulous follow-up with muscle-strengthening exercises, physical therapy, and mobilization activities.

Since there are fractures in both the upper and lower parts of the leg, regaining the ability to walk, climb stairs, and perform daily activities may take longer. With a proper and regular physical therapy program, the return to normal life can be accelerated. You can watch our patient’s movements showing their return to normal life in the video below.


Increased Risk of Complications

When lengthening is applied to longer bone segments, the risk to nerves, blood vessels, and muscle structures may increase.

Complications such as tissue stiffness, joint limitation, or infection may occur more frequently in quadrilateral operations.

High Cost

Depending on the methods chosen for the four-fold operation, surgery costs may nearly double, and extended hospital stays and treatment expenses represent a disadvantage.

5- Recovery Period and Rehabilitation

After quadrilateral surgery, patients usually stay in the hospital for 4–6 days. During this period, pain management, wound care, and early-stage walking skills are addressed with the help of physical therapy specialists.

The First Days (Hospital Stay)

  • To reduce the risk of blood clotting, your doctor may recommend blood-thinning medications and varicose stockings.

Lengthening Period

  • Around 5 days after the surgery, the lengthening stage begins. Lengthening is done at the pace determined by the doctor (on average 1.75–2 mm per day).
  • X-rays are taken every 15 days to monitor the lengthening. The bone healing (osteogenesis) status and the accuracy of the lengthening are observed.
  • During this process, physical therapy is extremely important. Stretching exercises and light strength training are performed to maintain the flexibility and strength of muscles, tendons, and joints.

Consolidation Period (Bone Hardening – Consolidation)

  • After reaching the targeted limb lengthening, the lengthening process is stopped. If the Combined method was applied, the fixators are removed. Then, the bone tissue is expected to solidify and fuse.
  • This period can last 12–15 months, depending on the amount of lengthening and the patient’s bone healing potential.
  • Intramedullary nails can only be removed by your doctor once the bone is sufficiently solid.

Physical Therapy and Returning to Daily Life

  • An intensive physical therapy program is implemented to strengthen the leg muscles, increase joint range of motion, and restore a normal walking pattern.
  • Since both the upper leg and lower leg are lengthened simultaneously in quadrilateral surgery, extra care should be taken against the risk of limping or unbalanced walking.
  • If necessary, medical aids such as crutches, a walker, or a wheelchair may be used. You can watch a portion of our patient’s daily physical therapy program in the video below.

 


6- In Which Cases Quadrilateral Surgery Is Not Performed and Why

When choosing a combined method for both the lower and upper legs, surgical risks increase. For this reason, our doctor requires using the Precice method in either the lower leg or the upper leg. Using external fixators on both the lower and upper legs, along with intramedullary nails, increases the likelihood of the following risks:

Sleeping Position Restriction: The external device is placed on the inside of the lower leg and on the outside of the upper leg. This situation only allows sleeping on your back, significantly reducing sleep quality.

Severe Movement Restriction: Simultaneous surgery on both the upper and lower legs causes serious restriction of movement in the ankle, knee, and hip joints. Walking, meeting basic needs, or getting out of bed becomes almost impossible.

Slow Healing: Fracturing four bones at once significantly slows the healing process and increases the risk of nonunion (lack of bone fusion). Additionally, proper muscle healing can become more difficult.

Excessive Strain on Muscles: Lengthening 2 mm per day (instead of the usual 1 mm) puts excessive strain on the muscles and increases the risk of tearing.

Life-Threatening Risks: Lengthening four bones at the same time can lead to multiple traumas and increase the risk of embolism, which can have fatal consequences.

These serious risks should be carefully evaluated and meticulously addressed by the doctor.

7- Quadrilateral Limb Lengthening Surgery Price

Limb lengthening surgery is a significant investment, and we aim to make our patients’ decision-making process easier by presenting costs transparently. At Wannabetaller, while providing services at high-quality standards, we also determine our pricing in a clear and understandable manner. By offering two different Quadrilateral methods, we provide our patients with the most suitable options for their needs:

Precice + Lon: 64.000 USD

This package includes the Precice + LON system, which enables lengthening of both the upper and lower leg bones together. This method offers more stable and balanced recovery by ensuring controlled lengthening in both leg regions. The Precice method is used in either the lower or the upper leg, and the Lon method is applied in the other area.

Precice + Precice: 87.000 USD

This package covers the Precice + Precice method, where the Precice system is used separately in both bone regions. Compared to the Lon method, this approach is more comfortable but more costly.

Services that are included in these packages:

  •  Meeting you at the airport upon arrival
  •  VIP transportation throughout your entire journey
  •  Accommodation in a 4-star hotel for 2 days before the operation
  •  An English-speaking caregiver to assist you during your hospital stay
  •  A complimentary Istanbul tour, including historical and touristic visits, a boat tour, and meals at famous restaurants
  •  Medical examinations before the surgery
  •  5 days of hospitalization
  •  Assistance from a physiotherapist and related medications during your hospitalization
  •  Provision of a walker, crutches, and wheelchair
  •  A Limb Lengthening Patient Kit with a 40-page patient guide
  •  Free consultations with doctors and consultants whenever you need
  •  All hospital charges related to the operating room and recovery room
  •  Fees for the hospital, surgeon, anesthesiologist, and surgery assistants

 Note: In the package where the LON method is applied, the external fixator removal surgery is also included in the price.

Post-operation Accommodation Prices

In the image below, you can find our monthly and 3-month rates, as well as the included services, for our patients who prefer hotel accommodation after surgery.


 

Below are our monthly and 3-month rates and the included services for patients who prefer to stay at home.


Transparent and Open Pricing

There are no hidden fees in our services. All costs are openly shared with the patient during the very first consultation by providing a detailed price quotation. This way, our patients have full knowledge of the costs before starting the treatment process.

 

8- Frequently Asked Questions and Answers

How Much Can I Lengthen?

Every patient’s bone structure, age, and overall health differ. Generally, a total lengthening of 8–15 cm (and sometimes more) can be achieved, but you’ll learn the exact figure in a detailed consultation with your surgeon.

How Is Pain Managed in Quadrilateral Surgery?

Postoperative pain can be managed with painkillers prescribed by your doctor and by maintaining early mobility. Physical therapy also helps reduce pain and increase comfort.

When Can I Return to Work or School After Surgery?

This depends on several factors: how much you are lengthening, how quickly you heal, your physical workload, and whether you undergo a LON or Precice procedure.

If you have a desk job, some remote work might be possible during the lengthening process, albeit with limitations. However, for physically demanding jobs, waiting until full recovery is necessary.

Are Surgical Scars Permanent?

Any surgical intervention can leave scars at the incision sites and where the fixators enter and exit. With today’s advanced surgical techniques, every effort is made to minimize scarring. You can see examples of scars for different methods in the images below.

precice iz

Can I Exercise After the Lengthening Process Is Complete?

Once your bone tissue is fully healed and strengthened—and after receiving your doctor’s approval—you can gradually resume exercise. Returning to professional-level sports requires a longer waiting period and full participation in a suitable rehabilitation program.

Light sports are generally permitted around 8–12 months after surgery, while heavy sports often require about 12–15 months of recovery. During this period, you will share X-rays with your doctor to show how well your bones have fused and demonstrate your range of motion. Once your doctor approves, you can begin returning to your normal daily activities.

9- Conclusion and Recommendations

Quadrilateral (four-segment) height lengthening surgery is an attractive option for patients who desire greater lengthening and prefer completing the bone-lengthening process in one go. Because it involves lengthening both the lower and upper legs simultaneously, it offers the potential to reach your target height in a shorter amount of time. However, you should also consider the longer surgical duration, increased postoperative care, pain management, and higher risk of complications.

Key Points to Keep in Mind:

Choose an Experienced Doctor: Quadrilateral surgery requires advanced expertise. Work with an experienced orthopedic surgeon with solid references.

Set Realistic Expectations: Discuss your target lengthening, recovery timeline, and possible risks in detail with your doctor before deciding.

Nutrition and Smoking: A diet rich in protein, calcium, and vitamin D speeds up bone healing, while smoking negatively affects it.

Regular Check-Ups and Physiotherapy: Never skip routine check-ups and X-ray examinations during the lengthening period, and adhere strictly to your physiotherapy program.

Psychological Support: The process is long and requires patience. Seeking psychological support can be beneficial for staying strong both mentally and physically.

Remember, this guide is intended to provide general medical information. For a personalized, detailed medical evaluation and surgical plan, always consult a specialist orthopedic surgeon. When it comes to your health, you can only receive the most accurate information and advice through an in-person examination by your doctor.

Wannabetaller: You’re Safe with Our Comprehensive Services

 


Limb lengthening surgery, which is a demanding and long-term process, requires more than just surgical intervention to be completed successfully. Ensuring our patients’ comfort, safety, and satisfaction is our top priority. As Wannabetaller, the first limb lengthening surgery center established in Turkey, we offer comprehensive services that meet all the needs of our patients from A to Z. Here are the main services we provide:

1- Personalized Consultation and Planning

Every patient’s needs and goals are different. Our experienced team conducts a detailed preoperative evaluation to create the most suitable surgical plan. During this process, the patient’s medical history, physical condition, and expectations are taken into consideration.

2- Accommodation and VIP Transfer Services

During the surgery and recovery period, we offer luxury accommodation options for our patients’ comfort. To make transportation to our hospital easier, we provide VIP transfer services from the airport to the hotel and hospital, ensuring safe and comfortable travel.

3- Professional Nursing and 24/7 Care Support

In the postoperative period, our specialized nurses are available 24 hours a day, 7 days a week, to meet our patients’ needs and closely monitor the recovery process. They intervene quickly and effectively in any emergency situation.

4-Personalized Physical Therapy and Rehabilitation Programs

Physical therapy and rehabilitation are crucial for a successful recovery. Our expert physiotherapists prepare customized exercise programs to increase muscle strength, maintain joint mobility, and support the return to normal daily activities.

5- Regular Check-ups and Follow-up

During the postoperative period, regular check-ups are conducted to continuously monitor bone lengthening and healing. With X-ray results, bone fusion and the progress of the lengthening process are tracked, and treatment plans are adjusted if needed.

6- Psychological Support and Counseling Services

Limb lengthening surgery can be both physically and psychologically challenging. Our psychological counselors provide support to keep our patients’ spirits high and help them get through the process more comfortably.

7- International Patient Services

For our international patients, we offer comprehensive services regarding visa procedures, language support, and cultural adaptation. We aim to ensure a smooth and comfortable treatment process in Turkey by being with you every step of the way.

8- Postoperative Follow-up and Home Care Options

After the surgery and the hospital stay, we offer home care options to continue supporting the recovery process in a home environment. Within this scope, solutions such as nurse visits and at-home physical therapy services are provided, prioritizing our patients’ comfort.

As the Wannabetaller team, we continue to share the most up-to-date information about limb lengthening surgeries. If you are considering advanced surgical methods like quadrilateral surgery, you can get more detailed information from our patient consultants or learn about any medical and technical details you are curious about during your examination with our doctor.

For detailed information and an appointment:

Telephone&WhatsApp: +90 531 988 3090

E-mail: support@wannabetaller.com

Instagram: wannabetaller

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