The History & Evolution of Limb Lengthening Surgery

Leg lengthening surgery was originally used as part of anthropometric cosmetology (correcting deformities in upper and lower limbs by holding fractures in place or gradually pulling the bone apart to remedy a leg length discrepancy) and has existed in some form for centuries. 

Today, while it continues to help remedy limb length discrepancies, it’s also evolved into a cosmetic surgery used by many who wish to be taller, whether that’s due to social stigma or personal preference.

The methods we use in the modern-day were innovated more than 100 years ago and it’s fascinating to look into the history of limb lengthening to understand just how far we’ve come in just over a century. From cumbersome distraction methods like bulky external fixators, to today’s intramedullary nails such as PRECICE and STRYDE.

The History Behind Limb Lengthening Surgery

Reliable methods of limb lengthening surgery have been around since the 19th and early 20th centuries, but they had a high rate of complications and infections due to the technology of their time.

The first step towards modern limb lengthening methods was taken in the year 1905, when Alessandro Codivilla from Italy described his method of distraction osteogenesis – the synthesis of new bone by separating two pieces and allowing bone to form between them [1].

Yet, there’s been countless breakthroughs since then.

A Timeline of Limb Lengthening Breakthroughs

Though the history of this surgery is long and complicated, some breakthrough moments defined the path to modern-day limb lengthening.

• 1905 – Alessandro Codivilla develops the first modern femur lengthening device
• 1921 – Vittorio Putti’s “osteon”, which allowed continual distraction 
• 1939 – Leroy Abbott and John Saunders create a list of complications in limb lengthening, Gerhard Küntscher makes the Küntscher nail or the first modern day intramedullary nail
• 1960s – Heinz Wagner creates a device that allows patients to move their legs while healing
• 1949 – Ilizarov invents the Ilizarov apparatus, which was a massive improvement in external fixation devices due to it being adjustable, siff, and lightweight
• 1983 – Bliskunov creates the “Intramedullary Skeletal Kinetic Distractor” intramedullary nail, the first modern intramedullary nail
• 1988 – Rainer Baumgart creates FITBONE, the first motorized intramedullary nail
• 2011 – The PRECICE nail is introduced by NuVasive, a partially weight-bearing nail with minimal pain and no external fixation required
• 2019 – PRECICE STRYDE, a fully weight-bearing intramedullary nail, created by NuVasive

The Early Days & Pioneers of Limb Lengthening

In 1905, renowned Italian surgeon “Father of Modern-Day Leg Lengthening”, Alessandro Codivilla, published a change in his method of femur lengthening in the Journal of Bone Surgery.

Vittorio Putti followed this up with a method of continued bone distraction, and other pioneers built on it to create external fixators much like the Ilizarov apparatus commonly used today.

First Methods of Femur Lengthening (1905)

Codivilla suggested applying “a sudden and intense force” to the bone and then holding the two pieces in place using a plaster cast on the leg.The surgeon would then apply this force as many times as necessary to restart the process.

However, this intense force tended to cause delayed nervous reactions, which manifested in the form of “convulsive attacks”, besides necrosis or death of cells around the ankle, heel, and instep. These complications would force the surgeon to stop the lengthening process.

Codivilla’s method eventually evolved into using a distraction bed to pull the pieces apart and holding the broken pieces of bone in place with a nail to limit these complications. This nail would have screws poking out of the leg, which the surgeon could use to reduce the distraction by bringing the two pieces of bone closer to each other, but not to increase it.

Soon, Codivilla began using two nails, one in the calcaneus bone in the heel and one in the tibia, to avoid rotation of the leg which impeded proper lengthening. With this method, he achieved 3-8 cm of added length.

However, the only way to minimize complications was to reduce the extent of distraction. The patient had to keep the leg fully extended throughout this process, preventing them from walking and making those months quite uncomfortable.

Vittorio Putti’s method followed this technique. A student of Codivilla, Putti believed that the only way to combat the resistance offered by the soft tissues around the femur was to continuously distract the bones instead of breaking and pulling them apart in one go. So, he developed a way to apply continuous “traction”, i.e., moving the bone pieces apart continuously rather than at once.

He created a device he called the “osteon”, which was the first device to hold both pieces of the femur in place along with a mechanism to pull them apart gradually. It consisted of two nails as well as an outer and an inner tube that could slide in and out of each other. The surgeon or the patient could use a screw on the outside to pull them apart.

The patient could now relax their knees and hips a little compared to the complete extension required by Codivilla’s method. A scale on the side of the apparatus allowed the surgeon to view the force and distraction applied. 

However, they still couldn’t walk and had a high risk of complications.

An Orthopedic Evolution – Development of Distraction Techniques (1939)

In 1939, Leroy Abbott and John Saunders created a bed-based semi-circular external fixation device that used roughly the same principle as Putti’s method and had pins to hold the bones in place. Alongside that, they detailed the risks of limb lengthening in their day:

• Deformities of the foot, like bowing or rotating outwards
• Deformities of the knee, like knock knees
• Bowing of the tibia along with malunion/nonunion
• Limited motion of the ankle
• Weakening of the leg muscles
• Nervous issues, like paralysis of specific muscles
• Circulation issues, causing chronic swelling in the leg
• Wound and pin infections
• Necrosis or death of bone

The goal of leg lengthening from this point on was to make the process more efficient and comfortable and reduce the risk of such complications.

German surgeon Heinz Wagner developed the first device that allowed patients to move their legs and walk for short amounts of time. Parallel screws were attached to the bone and joined with a tube square consisting of two tubes that could slide in and out. The screws inside the bone connected through a clamp that could swivel in two directions – perpendicular and parallel to the tube.

However, he was a proponent of aggressive and rapid distraction and cutting soft tissues to encourage them to distract along with the bone. This aggressiveness led to a high rate of complications and almost no new bone formation.

However, in 1997 De Bastiani, an Italian surgeon, noticed this high complication risk and created the Orthofix device, an external fixator much more adaptable than Wagner’s apparatus. More than that, he and his colleagues introduced several critical advancements in leg lengthening techniques still followed today, namely:

1. Corticotomy – Breaking the bone via a small incision instead of aggressive force
2. Callotasis – Beginning distraction 10-15 days post-surgery and only distracting 1 mm a day
3. Recording the “healing index” or days taken by patients to heal (approximately 38 days)

The First Intramedullary Nails (1939)

While external fixators were getting more advanced, a technique called intramedullary nailing saw its advent into the modern age as well. While it wasn’t yet used for lengthening, it would eventually become an alternative to the external fixators of the past.

As seen before, patients suffer soft tissue scars, muscle tethers, and pin infections/inflammation with external fixation so orthopedic experts developed intramedullary nails to resolve this problem.

Intramedullary nailing has its own diverse history. Evidence of this technique – placing fixtures inside the bone marrow to stabilize the bone or heal injuries – dates back to the Aztecs in the 16th century [5]. These methods saw improvements over the 19th century, but they weren’t yet enough for effective deformity correction and limb lengthening.

Gerhard Küntscher, a German orthopedic surgeon, first introduced the method of intramedullary nailing in femur fractures in 1939. He developed the Küntscher nail – an internal fixator used to hold bone fragments for fracture healing.

The technique became popular during World War II as 60 surgeons had adopted it by 1944. All fracture-healing methods used before had a healing time of about six weeks, but patients who used the Küntscher nail could be up and walking in days. However, it wasn’t yet advanced or accessible enough to match the external methods of the day.

Advent of the Ilizarov Apparatus (1946)

After three years of work, the modern-day Ilizarov apparatus – an external fixation device with circular rings surrounding the leg – first came to fruition in 1949 as a breakthrough in the history of limb lengthening. It’s pins and wires connect the instrument to the limb, and these pins attach to external screws, which the patient can use for gradual distraction.

Through a “theory of tensions”, Ilizarov immobilizes the fracture site and takes stress off it, so patients can stand and walk for short periods. The middle rings hold the bone fragments in place, while the upper and lower limbs transfer force to the two pieces of bone.

Who invented The Ilizarov Apparatus? 

It was the brainchild of Professor Gavriil A. Ilizarov, inspired by a shaft bow harness used on a horse [2]. Born in Italy, the Ilizarov apparatus offers much more flexibility in leg lengthening and deformity correction than its predecessors, along with a lower risk of complications.

The “Ilizarov Man” model showcases its adaptability to any deformity, portraying a skeleton with the Ilizarov attached to every limb on its body [3]. Ilizarov not only looked after tens of thousands of patients himself, but he also studied soft tissue genesis on dogs and other animals to prevent tissue complications as much as possible.

Across multiple scientific publications and a comprehensive textbook called Transosseous Osteosynthesis, Ilizarov established the apparatus as a revolutionary moment in the field of limb lengthening surgery.

The technique gained popularity across the Soviet Union in 1968 when surgeons used the Ilizarov to treat Soviet world-record-holding high jumper Valery Brumel, who had broken his tibia in a motorcycle accident [4].

The apparatus made its debut in the US in 1987, under Dr. Victor Frankel and Dr. Stuart Green, who wrote the first English translation of Ilizarov’s textbook.

The most significant innovation made with the Ilizarov was the Taylor Spatial Frame, consisting of 6 struts fixed between two circular fixators. These adjustable struts have computer software that allows motion and adjustment with 6 degrees of freedom.

Invented by orthopedic surgeon Charles Taylor, the frame allows surgeons to correct multiple deformities at once since the struts can adjust the bone to the minutest degree. It’s especially beneficial for repairing complex fractures, also known as orthopedic traumatology.

However, the fact remains that it’s cumbersome, and people still can’t walk properly while using the frame, only walking for short distances.

A Breakthrough Innovation – Motorized Intramedullary Nails (1983 – Present)

While intramedullary nails were already in use since 1939 while the Ilizarov apparatus was still coming into being, these nails faded into the annals of history because of high amounts of pain when rotated and mechanical issues.

The first sliding-tube intramedullary nail is attributed to Russian surgeon Bliskunov in 1983, followed by Albizzia’s “Intramedullary Skeletal Kinetic Distractor”. These nails consisted of two concentric tubes (one inside the other) that could slide up and down, and the patient could rotate external components to distract the bones [1]. However, this method was also too painful to be sustainable.

A breakthrough occurred in 1988 when Rainer Baumgart created the first motor-driven intramedullary nail, changing the history of limb lengthening forever [6]. This nail evolved into the FITBONE, a remotely controlled lengthening nail implanted inside the bone marrow that uses electromagnetism to transmit signals from the external controller to the internal device.

Remotely controlled nails completely negated the need for an external apparatus, making them the most convenient option for limb lengthening. They consist of two metal rods, one inside the other, and the internal rod moves away from the external to gradually lengthen the legs. An induction coil placed on the skin next to an inner coil allows the patient to use a remote controller to control distraction.

Since these nails don’t have pins and wires sticking out of the skin, they have a lower rate of infections. They also have reduced recovery times as patients can stand and walk for most of the lengthening period due to the device’s internal support.

Most intramedullary nails are also weight-bearing, so now patients can walk short distances with them. The FITBONE implant is still prevalent today, but further advancements have made limb lengthening even more convenient for the average person.

The Present Day of Limb Lengthening

The popularity of limb lengthening has risen exponentially, with an estimation of 150-300 patients getting the procedure done each year [7]. Multiple kinds of intramedullary nails exist today, the most popular being the PRECICE 2.2 and the PRECICE STRYDE by NuVasive Specialized Orthopedics.

While the 2.2 is made of titanium alloy and allows patients to walk some distance, the STRYDE is fully weight-bearing with stainless steel Biodur 108, allowing patients to walk all through their lengthening process [8]. Patients don’t have atrophied muscles at the end of their lengthening journey and can go through physical therapy, reducing recovery times significantly.

Of course, these modern nails make for higher costs of limb lengthening and are often out of reach for the average person. On the other hand, external lengthening devices like the Ilizarov still exist today. They tend to be cheaper than intramedullary nails, meaning they might be a better option for many people financially.

Regardless of the method, we’ve come a long way from the days of frequent infection and complications, though some risks are still there today. However, regular doctor visits and physical therapy can minimize these risks.

The Future of Limb Lengthening Surgery

The future of limb lengthening lies in improving recovery times (including supplements for a quick recovery), reducing risks, and eliminating social stigma against this cosmetic procedure.

In the coming 3-5 years, there’s speculation that limb lengthening devices are likely to become more intuitive and precise, meaning they may be able to measure muscle tension, bone density, etc., during the lengthening process to anticipate and mitigate future complications before they occur [9].

Making lengthening devices stronger is also a priority, so patients can retain even more of their physical ability while lengthening. Lengthening devices may become miniaturized as well, providing easy deformity correction in the fingers, toes, and other small, bony parts of the body.

Pre-procedure testing might see some positive changes, too, as knowledge of muscle and vascular recovery during lengthening increases [10]. With testing, surgeons may be able to calibrate a completely individualized distraction and recovery program to optimize recovery times and results.

Better evaluation of bone strength and improved materials and designs can also suppress the likelihood of fractures. With increased knowledge and experience, doctors may also develop better post-surgery muscle rebuilding practices, avoiding muscle tension and breakage-related complications.

Finally, as limb lengthening becomes safer and less expensive and height stigma gets recognized more readily in the public sphere, social stigma against limb lengthening will hopefully decrease. Limb lengthening often sounds like a bizarre procedure – breaking patients’ legs to lengthen them is bound to confuse a layperson!

As stigma decreases, more doctors will enter this field and patients will have better support systems to get them through this long and complicated process. Though side effects will still exist, the future of will be as exciting as the history of limb lengthening since the field is full of brilliant pioneers, just as it’s always been. 

References

[1] Birch, J. G. (2017, September). A Brief History of Limb Lengthening. Journal of Pediatric Orthopaedics, 37, S1-S8. https://journals.lww.com/pedorthopaedics/Fulltext/2017/09001/A_Brief_History_of_Limb_Lengthening.2.aspx 

[2] The Ilizarov Method: History and Scope. (2007). In S. R. Rozbruch & S. Ilizarov (Eds.), Limb Lengthening and Reconstruction Surgery (pp. 3-6). Taylor & Francis. https://books.google.co.in/books?id=yNTED-6REewC 

[3] Bafor, A. (2020). Distraction osteogenesis: A review of the literature. Nigerian Journal of Orthopedics and Trauma, 19(1), 1-9. https://www.njotonline.org/article.asp?issn=1596-4582;year=2020;volume=19;issue=1;spage=1;epage=9;aulast=Bafor 

[4] Spiegelberg, B., Parratt, T., Dheerendra, S. K., Khan, W. S., Jennings, R., & Marsh, D. R. (2010). Ilizarov principles of deformity correction. Annals of the Royal College of Surgeons of England, 92(2), 101–105. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025247/ 

[5] Born, C. T., Pidgeon, T., & Taglang, G. (2014). 75 years of contemporary intramedullary nailing. Journal of orthopaedic trauma, 28 Suppl 8, S1–S2. https://pubmed.ncbi.nlm.nih.gov/25046409/ 

[6] Orthofix. (2020, May 14). FITBONE – Orthofix – US. Orthofix. Retrieved February 14, 2022, from https://www.orthofix.com/ifus/fitbone/ 

[7] Brada, T. (2020, December 5). Leg-lengthening: The people having surgery to be a bit taller. BBC. Retrieved February 14, 2022, from https://www.bbc.com/news/world-55146906 

[8] Jellesen, M. S., Lomholt, T. N., Hansen, R. Q., Mathiesen, T., Gundlach, C., Kold, S., Nygaard, T., Mikuzis, M., Olesen, U. K., & Rölfing, J. D. (2021). The STRYDE limb lengthening nail is susceptible to mechanically assisted crevice corrosion: an analysis of 23 retrieved implants. Acta orthopaedica, 92(5), 621–627. https://pubmed.ncbi.nlm.nih.gov/34102950/ 

[9] Guichet, J.-M. (2017). The cosmetic dream and future of lengthening procedures. Journal of Limb Lengthening & Reconstruction, 3(2), 75-77. https://www.jlimblengthrecon.org/article.asp?issn=2455-3719;year=2017;volume=3;issue=2;spage=75;epage=77;aulast=Guichet 

[10] Cyborg4Life. (2021, June 18). Near future of limb lengthening surgery…devices, cost, surgeons, recovery, society [Video]. YouTube. https://www.youtube.com/watch?v=JUx1w-NI9Ic