Is Leg Lengthening Surgery Safe? Considerations & Risk Mitigation

Leg (limb) lengthening surgery is a height increasing procedure where the lower limbs are elongated over the span of months. Although every surgery has risks, the potential complications of this procedure are frequently over exaggerated [1]. In fact, the surgery showed many successful stories of a better life and treatments for those suffering with height dysphoria [2]. 

The surgery isn’t a cure-all for stature dissatisfaction, but it has been shown to improve some patients’ lives. To ensure the best chances of success, the patient’s medical history and the eligibility of an experienced surgeon need to be evaluated to maximize their safety and the success rate. [3].

Safety & Efficacy of Your Surgeon

Arguably, the best precaution that one can take to ensure a successful procedure is the expertise of an experienced surgeon. Money can be earned, limbs on the other hand, are subject to permanent damage. Despite assurances, it’s the unequivocal truth that amateurish practices can leave a devastating impact on the body of an already ailing individual. Complications can range from blood clots, malunion, internal bleeding and infection all the way to spinal nerve damage [4].

The possibility of complications greatly expands when complex cases of limb salvaging are included, with them being subjected to about 5% of the total failures [5]. The consultation and precautions of an expert is what seems to separate regretting the post-op experience from one of bliss [3]. An experienced surgeon will make sure that the candidate is subject to extensive medical tests, psychologically suited, fulfills the age criteria, functional judgement by an experienced physiotherapist, able to respond to any unprecedented complications and finally persistent rehabilitation [3] [6].

Increase The Chances of Success by Using The Safest Methods

Limb-lengthening practices have undergone their fair share of revolutionizations with a history that goes all the way to the distant reaches of 1970. Even today, the debate over the most effective practice of this procedure is ongoing. The archaic method of external fixators has largely been abandoned due to its tendency of soft tissue scarring, muscle tethering and infections [8]. These days, internal fixators have gained traction due to their unobtrusiveness and comfort. Currently, the lengthening nails PRECICE and STRYDE, which do not require rotation for distraction, are becoming popular [1].

PRECICE

New advances in medical technology has led to the advent of the PRECICE system, using an internal nail which can be extended with the touch of a remote control, this new intramedullary limb lengthening system allows for minimal obtrusiveness, complications and risks [10]. Additionally, PRECICE models have reported only a minuscule amount of minor complications. No cases of significant nerve damage or infections have been reported [10].

STRYDE

Keeping up with its hard-earned tradition of modernization and safety, the PRECICE model was enhanced upon with the STRYDE. The new system offers 200% or greater postoperative weight-bearing compared to previous systems [11]. STRYDE displayed no events of mechanical failure and four times faster healing of the femur [11]. The STRYDE has even attained a 100% success and recovery rate with a fair share of patients attaining their desired height [12].

Both STRYDE and PRECICE are trailblazers in the cosmetic surgery field, for a rare chance at almost zero risk, high success rate and a quick recovery rate [10] [12]. Garnering a reputation for guaranteed success albeit with significant expenses, STRYDE was one of the most effective nails or methods before the recall.

Long Term Risks, Complications & Side Effects

Unfortunately, even the most robust of leg lengthening methods are not without its detractions. Side effects may be a part and parcel of any generalized medical procedure but the riskier of the pair, long term risks and complications are still a point of anxiety. Any long-term complications carry the risk of permanent disability or even death. Despite most surgeries going perfectly fine, it doesn’t hurt to be wary of possible difficulties and taking up the proper precautions [10]. 

Most, if not all the likely side effects of leg lengthening side effects can be categorized:

•     Muscle pain
•     Muscle stiffness
•     Muscle weakness
•     Swelling
•     Nerve pain
•     Insomnia
•     Knee contracture
•     Hip contracture
•     Ankle contracture

Please note, this is not an exhaustive list. 

Most of these side effects are very minor and contribute little to no effect on the average person and will almost always disappear after a few months [13]. Only the joint conjectures (knee, hip and ankle) and nerve pain last for any significant period, however physical therapy is often a good retort to any unusually lasting side effects [14]. Practicing prescribed methods of physical therapy throughout the recovery phase helps hold these conjectures at bay and ferments a speedy recovery.

However, in case of long-term complications and risks, a stronger dose of precautions and recovery practices is essential to ensure safety.

Nerve Injury

The deterioration of normal sensitivity of tibia nerves in the post-surgical phase is often a sign of potential nerve injury. This can lead to either hypersensitivity or low-sensitivity and usually has its inception at the time of the surgery itself. However, any skilled personnel can easily detect any potential nerve issues and treat them by slowing the rate of detraction.

Bone Formation Issues & Premature Consolidation

The unusual circumstance of a slower-than-usual or no bone formation rate is a serious complication as well. This type of complication is rather rare as it only occurs in adults with a distinct deficiency of vitamin D, which can be avoided provided that the prescribed surgeon takes the necessary precautions. However, if the situation cannot be remedied promptly, the surgeon will discuss the termination of the entire procedure with the patient.

Another rare, but complex complication is one of premature consolidation (where the bone heals too early or quick). While the prospect of early bone consolidation is rare [16], its consequences are nothing to scoff at; adding thousands more to leg lengthening surgery costs and it’s a significantly more dangerous procedure to re-break the bone [16]. With Dr. Paley, the costs of complications can costs upwards of $15,000 – $30,000.

Fat Embolism

A fat embolism is one of the most lethal possibilities of probable unwanted events. Either due to the increase in endo-medullary pressure during insertion of the nail or during the drilling, there is a slight possibility of fat from the bone marrow bleeding its way into the bloodstream. This has potentially fatal consequences with acute symptoms of oxygen deprivation, shortness of breath and even death. [17] However, a skilled surgeon can circumvent these risks by recognizing the warning signs and taking the proper precautions immediately.

Deep Vein Thrombosis & Pulmonary Embolism

A complication resulting from a surgical mistake, Deep Vein Thrombosis (DVT) is a blood clot that occurs near the surgical area resulting from any bone damage. Doctors always take the proper preventive measures regarding DVT by prescribing anticoagulants [18].

A Pulmonary Embolism (PE) forms from an uncontrolled DVT snaking its way into blood circulation. With the increased blood pressure messing up the circulation, an acute chest pain and shortness of breath soon follows [18]. The actions of an experienced surgeon are essential at this stage, who will immediately start administering anti-coagulating agents [18].

Axial Deviation & Fibular Compression

Axial Deviation is an indicator of amateurish surgical practices rather than something on the patient’s accord. An unskilled surgeon may accidentally misalign the leg bones (surgery without a nail) during the surgical procedure, resulting in deviation.

A fibula related complication can easily sweep under the radar but is hard to weed out. Complications related to the fibula during lengthening causes malalignment and decreasing the lengthening rate [19]. Again, skilled professionals can detect any potential misalignments before the worst comes to pass as the fibula surgery itself needs a high degree of expertise.

How Physical Therapy Keeps You Safe During Recovery

Outside of a successful surgery itself, the post-op period is perhaps the most important for one’s long term recovery and growth. This physical therapy contributes tangibly to one’s growing physical as well as mental health. This therapy is vital and will be recommended by the doctors themselves.

Internal Therapy

The physical therapy starts right in the post-op bed with splinting, bed to wheelchair transitioning and gait training. These minimal exercises ensure safety and independence in the patient.

External Therapy

Once discharged, the patient is tasked with continuing their regime with regular stretching and in-person therapy. The patient will work to develop their strength, mobility, gait and coordination.

The goals of these therapies are to engage in assisted recovery, energize the body, and maximize coordination and functional independence. Because, it is not only the body that needs to recover but the mind as well. Overtime and with dedication towards physical therapy, mobility will increase as the pain subsides. Moreover, following a regular physical therapy regime also maintains consistent leg length and further stimulates its growth [21][22].

It’s important to note that the increased strain will temporarily stifle mobility as the bones continue to grow [22]. However, the most important aspect is maintaining the prescribed regime consistently lest lengthening will be prematurely halted.

Conclusion

While it’s tempting to label cosmetic leg lengthening surgery as dangerous and risky, the truth is far greyer than that. The rare case of failure usually arises through blatant malpractice, outdated techniques, freak accidents and flagrant disregard for professional expertise. Today, advancements in limb lengthening combined with other radical medical advancements like the precise stryde nails have netted greater safety and a high chance of success for any individual (given they choose a qualified surgeon).

References

[1] Hosny, G. A. (2020). Limb lengthening history, evolution, complications and current concepts. Journal of Orthopaedics and Traumatology, 21(1). https://doi.org/10.1186/s10195-019-0541-3

[2] Guerreschi, F., & Tsibidakis, H. (2016). Cosmetic lengthening: What are the limits? Journal of Children’s Orthopaedics, 10(6), 597–604. https://doi.org/10.1007/s11832-016-0791-z

[3] Hasler, C. C., & Krieg, A. H. (2012). Current concepts of leg lengthening. Journal of Children’s Orthopaedics, 6(2), 89–104. https://doi.org/10.1007/s11832-012-0391-5

[4] Patel, N. K., Krumme, J., & Golladay, G. J. (2021). Incidence, injury mechanisms, and recovery of iatrogenic nerve injuries during hip and knee arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, Publish Ahead of Print. https://doi.org/10.5435/jaaos-d-21-00122

[5] Rozbruch, R. (n.d.). Limb Lengthening: An overview by s. Robert Rozbruch: HSS. Hospital for Special Surgery. Retrieved September 17, 2021, from https://www.hss.edu/conditions_limb-lengthening-overview.asp.

[6] Elbatrawy, Y., & Ragab, I. M. (2015). Safe cosmetic leg lengthening for short stature: Long-term outcomes. Orthopedics, 38(7). https://doi.org/10.3928/01477447-20150701-51

[7] Birch, J. G. (2017). A brief history of limb lengthening. Journal of Pediatric Orthopaedics, 37(Supplement 2). https://doi.org/10.1097/bpo.0000000000001021

[8] Fragomen AT, Rozbruch SR. The mechanics of external fixation. HSS J 2007; Feb 3(1):13-29.

[9] Vitruvius. (2014). Leg lengthening successful results. https://paleyinstitute.org. Paley Institute. Retrieved from https://paleyinstitute.org/centers-of-excellence/stature-lengthening/patient-testimonial/#/.

[10] Paley, D. (2015). PRECICE INTRAMEDULLARY limb lengthening system. Expert Review of Medical Devices, 12(3), 231–249. https://doi.org/10.1586/17434440.2015.1005604

[11] Galal, S., Shin, J., Principe, P., Khabyeh-Hasbani, N., Mehta, R., Hamilton, A., Rozbruch, S. R., & Fragomen, A. T. (2021). STRYDE versus PRECICE Magnetic internal lengthening nail for femur lengthening. Archives of Orthopaedic and Trauma Surgery. https://doi.org/10.1007/s00402-021-03943-8

[12] Robbins, C., & Paley, D. (2020). Stryde weight-bearing INTERNAL lengthening nail. Techniques in Orthopaedics, 35(3), 201–208. https://doi.org/10.1097/bto.0000000000000475

[13] Fragomen, A. T. (2020). Motorized INTRAMEDULLARY LENGTHENING Nails: Outcomes and complications. Techniques in Orthopaedics, 35(3), 225–232. https://doi.org/10.1097/bto.0000000000000458

[14] Paley, D. (2018). Stature Lengthening Guidebook. Florida; Paley Institute.

[15] Wanna Be Taller. (2020). Swelling Side Effect. https://wannabetaller.com. Retrieved from https://wannabetaller.com/limb-lengthening-side-effects-complications/.

[16] https://paleyinstitute.org/wp-content/uploads/Cosmetic-Stature-Lengthening-FAQs.pdf

Paley, D. (n.d.). Cosmetic Stature Lengthening Frequently Asked Questions (FAQ’s). Paley Orthopedic & Spine Institute. https://paleyinstitute.org/wp-content/uploads/Cosmetic-Stature-Lengthening-FAQs15.pdf.

[17] Blondel, B., Violas, P., Launay, F., Sales de Gauzy, J., Kohler, R., Jouve, J. L., & Bollini, G. (2008). Embolie graisseuse au cours des allongements de membres par clou centromédullaire: à propos de trois cas [Fat embolism during limb lengthening with a centromedullary nail: three cases]. Revue de chirurgie orthopedique et reparatrice de l’appareil moteur, 94(5), 510–514. https://doi.org/10.1016/j.rco.2008.03.030

[18] Sakuma, M., Nakamura, M., Yamada, N., Ota, S., Shirato, K., Nakano, T., Ito, M., & Kobayashi, T. (2009). Venous thromboembolism deep vein Thrombosis with pulmonary Embolism, deep vein Thrombosis alone, and pulmonary EMBOLISM ALONE. Circulation Journal, 73(2), 305–309. https://doi.org/10.1253/circj.cj-08-0372

[18] Kim, S.-J., Agashe, M. V., Song, S.-H., & Song, H.-R. (2012). Fibula-related complications during bilateral tibial lengthening. Acta Orthopaedica, 83(3), 271–275. https://doi.org/10.3109/17453674.2012.665328

[20] Paley Institute. (n.d.). Extension stretch during therapy. https://paleyinstitute.org. Retrieved from https://paleyinstitute.org/centers-of-excellence/physical-occupational-therapy/physical-therapy-protocols/#/.

[21] Jackman, T., Devine, N., & Seiger, C. (2013). Home health physical therapy intervention for an adolescent after intramedullary skeletal kinetic distractor limb-lengthening surgery: a case report. Journal of allied health, 42(3), 163–168.

[22] Paley, D. (2018). Physical Therapy Protocols. https://paleyinstitute.org. Retrieved September 17, 2021, from https://paleyinstitute.org/centers-of-excellence/physical-occupational-therapy/physical-therapy-protocols/#/.