Should I Lengthen Femurs or Tibias First? Does it Even Matter?

Many limb lengthening candidates wonder if they should get surgery on their femurs or tibias first. The fact is, it entirely depends on how much height they need to gain, their leg proportions, amount of free time they have and how much they’re willing to spend.

Below, we’ll discuss the pros and cons of leg lengthening surgery when it comes to lengthening the femurs or the tibias before one or the other. As well as which one you might consider doing first, if you decide to lengthen both.

Whatever you decide to go with, always follow the doctor’s orders as no height gain is more important than your health and safety. 

Sunk Costs: Time & Money

Femur lengthening generally comes out to be cheaper than tibia lengthening, both in terms of immediate surgery costs and money spent on recovery.

Surgery Costs

At the Paley Institute, patients have five options for lengthening with Precice STRYDE (including physical therapy post-surgery and rod removal).[1] Various doctors will have difference pricing, but no matter who you go with, these prices give you an idea of %’s between different segment and surgery options.

• Bilateral femur lengthening (lengthening both femurs at once) – $97,500
• Bilateral tibia lengthening (lengthening both tibias at once) – $109,000
• Quadrilateral femur and tibia lengthening (tibias and femurs, with tibia done three weeks after femur surgery) – $196,000
• Quadrilateral femur and tibia lengthening (femurs first, then tibia lengthening after one year) – $206,500
• Quadrilateral femur and tibia lengthening 2x (femurs first, tibias three weeks later, then repeating femurs and tibias 1 year after) – $280,000

It’s clear that lengthening only the femur costs at least $11,500 less than tibia lengthening, and all options, including extending the tibias, are much more expensive. If money is a significant concern, femur surgery might be the best option and there’s a few qualified doctors who perform the surgery for less than the above as well.

Time – Our Scarcest Resource

Time is something we’ll never get back and outside of taking time off from work, this surgery can impede on vacations, dating life, and the healing or consolidation period comes with a fair amount of pain for most.

In general, femurs heal about two times faster than tibias. Femurs require only one month of healing per centimeter of length instead of the two months per centimeter required by tibias.[2]

To put that into perspective, this means that if a patient lengthens their femurs by 4 cm, they’ll only require about four months of consolidation time while needing eight months for the same height gain in the tibias.

With the STRYDE nail, patients won’t need to use a walker throughout the entire consolidation or healing process, but with the Precice 2.2 they will require walking assistance such as a walker, crutches, or a cane through all of the healing period.

To avoid strain on their employer, family, their business, or even themselves, many patients opt for femur lengthening only, but this doesn’t take into account proportions, scars, or costs.

Potential Complications & Complexity

Femur lengthening is safer than tibia lengthening since doctors only need to break and distract the femur. To lengthen tibias, the fibulas, the thinner bones beside the tibias, need to be extended as well, creating a greater risk of fractures, malunions (improper healing of the two parts of the bone), and nonunions (when the two parts don’t consolidate and join again).

These complications require additional surgeries to fix, which usually aren’t covered in the initial cost, making tibia lengthening potentially more expensive.

If someone chooses tibia lengthening, it’s vital to choose a reputable surgeon with tons of experience because of the additional complexities.

Aesthetic Considerations

While it may not be a consideration for everyone, many leg lengthening patients might be conscious of their height, proportions, and post-surgery appearance.

Limb Proportions and Ratios

The average person has a tibia to femur ratio of 0.80 with a standard deviation of 0.02. This means the golden ratio of limb lengthening proportions is typically between 0.78-0.82.[3] Though this ratio doesn’t always affect how attractive others might find a person, it’s fair to consider it.[4]

The only way to accurately determine the length of the femur and the tibia is to get an x-ray measurement. If a patient is going in for limb lengthening, the surgeon will perform this scan, also known as an EOS scan, and let them know which surgery would be best for them.

Generally, suppose the tibia to femur ratio is within the normal range or higher than 0.82. In that case, femur lengthening may be preferable, and if it’s below 0.78, tibia lengthening might be the right option. The surgeon will also consider discrepancies in length caused by fractures or other injuries that occurred during adolescence, which might cause one femur or tibia to be significantly shorter than the other.

Scar Placement

For tibia lengthening, the scars typically appear on the front of the calves and are visible if the patient wears shorts. So, if they live somewhere hot and don’t want friends and family to know about their surgery, tibia lengthening might not be the best option.

During femur lengthening, the thigh will bear any scars caused by both rod placement and removal. Since most people cover their upper thighs with clothing, these scars would only be an issue in situations like the swimming pool or beach.

Scars will fade with time, though, and plastic surgery and laser removal can also remove them, which means this shouldn’t be the only deciding factor.

Efficiency & Surgery Option

If a patient is looking to gain height fast, lengthening the femur might be their best bet. Femurs can be extended by 8 cm (about 3 inches) at once,[5] while tibias can only safely gain 5 cm (a little less than 2 inches).[1]

If a patient wants the cheapest and safest option, again, femurs should be considered if they are only lengthening one segment.

When a bone lengthens too much, the muscle can’t keep up with it.[6] This discrepancy can cause side effects like muscle contractures and stiffness even while following the correct stretches and exercises every day. Contractures restrict muscle movement to the point that knee movement is severely impaired too.

Femurs can also be lengthened twice with a much shorter gap between the two surgeries since they recover faster.

Conclusion

Many patients opt to have their femurs lengthened first so afterwards, they can assess whether they’d like their tibias lengthened too. If they’re set on getting both bones or segments elongated in a short amount of time (quadrilateral), then surgeons will typically operate on the tibia first to give them a head start in the healing process since they take a longer time to heal.

In the end, only your surgeon can tell you how many surgeries you will need to achieve your height goals and which surgery you should get done first.

References

[1] Paley Orthopedic & Spine Institute. (2018). Costs & Financial Considerations. Paley Orthopedic & Spine Institute. https://paleyinstitute.org/centers-of-excellence/stature-lengthening/costs-financial-considerations/#/

[2] Paley Orthopedic & Spine Institute. (2018). Consolidation Phase. Paley Orthopedic & Spine Institute. https://paleyinstitute.org/centers-of-excellence/stature-lengthening/the-paley-method/consolidation-phase/#/

[3] Paley, D. (2018). Cosmetic Stature Lengthening FAQs [PDF]. Paley Orthopedic & Spine Institute. https://paleyinstitute.org/wp-content/uploads/Cosmetic-Stature-Lengthening-FAQs.pdf

[4] Versluys, T., Foley, R. A., & Skylark, W. J. (2018). The influence of leg-to-body ratio, arm-to-body ratio and intra-limb ratio on male human attractiveness. Royal Society open science, 5(5), 171790. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990728/

[5] Guerreschi, F., & Tsibidakis, H. (2016). Cosmetic lengthening: what are the limits?. Journal of children’s orthopaedics, 10(6), 597–604. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5145841/

[6] Makarov, M., Birch, J., & Samchukov, M. (2009). The role of variable muscle adaptation to limb lengthening in the development of joint contractures: an experimental study in the goat. Journal of pediatric orthopedics, 29(2), 175–181. https://pubmed.ncbi.nlm.nih.gov/19352244/