Possible Side Effects & Risks of Leg (Limb) Lengthening Surgery

It’s the year 2022, and hundreds of people are using leg lengthening surgery every year to increase their height up to 6.3 inches. But surely there are limb lengthening risks and complications? [1]

Undoubtedly.

But by understanding what you’re up against and picking a surgeon who is well versed and experienced at handling complications, your chance of any serious leg lengthening complications can be kept to nearly zero. [1]

Note: as of March 2021, Nuvasive limb lengthening clinical trials are currently underway. More testing is being done to further assess the biological risks of all Precice System products, including Precice Stryde. You can learn more by reading the our Stryde nail recall article or the official NuVasive recall document. [2]

The Not-so-serious Limb Lengthening Surgery Side Effects & Complications

There are a handful of side effects from leg lengthening surgery that you just can’t avoid. They are a natural consequence of the inflammatory process that is limb lengthening.

Briefly, all of the guaranteed limb lengthening surgery side effects:

• Muscle pain
• Muscle stiffness
• Muscle weakness
• Nerve pain
• Difficulty falling and staying asleep
• Difficulty concentrating (mental fog from constant dull pain and achiness)

Yes, that means every single person who undergoes limb lengthening can expect to experience the above symptoms to at least some degree. [3]

However, none of these are permanent, with the exception of nerve pain; a small percentage of patients deal with low levels of lingering nerve pain for months or years after surgery. In very rare cases, the nerve pain can become permanent. [3]

The key is to pick a surgeon who is able to handle complications because they WILL happen at some point during the lengthening process. A good surgeon will know the warning signs of a more serious complication well before it ever ends up being truly serious.

They can then adjust your distraction rate or even stop distraction altogether and retract such in the very rare case of a more serious complication like a non-union (lack of bone growth in the gap created during the distraction phase).

For this reason, you can expect to get weekly or bimonthly x-rays so that your surgeon can constantly review how you’re doing and make adjustments as needed on the fly. Keep in mind, the leg lengthening surgery is not a race. It’s a marathon. And any good surgeon knows this and will help keep you safe while you reach your height increase goals.

Moderate Limb Lengthening Surgery Side Effects & Complications

It’s common for doctors to stop the distraction or lengthening phase because of moderate side effects such as joint contractures. However, with enough dedication, these side effects can be lessened to some extent.

Joint Contractures (Muscle Stiffness and Muscle Weakness)

A joint contracture occurs when a joint is unable to move in its full range of motion. These contractures are extremely common and nothing to worry about (they happen to all height surgery patients) as long as you address them quickly and properly.

There are 3 common types of contractures when it comes to leg lengthening, depending on which segment you choose to lengthen:

1. Knee contracture
2. Hip contracture
3. Ankle contracture (tibiae lengthening)

Luckily, physical therapy is the best way to mitigate contractures [3]. By staying consistent with your rehab throughout the lengthening phase, you can keep the severity of your contractures down significantly. Those that slack on P.T. during distraction, however, pay the price with bad contractures that make it difficult to even stand in place for very long.

Knee Contracture

A knee contracture is extremely common during femur leg lengthening and should be expected. Only a small portion of patients with hyper-flexibility, such as gymnasts and dancers, will be able to lengthen a full 6-8cm with zero knee contractures.

So what exactly is it?

The inability to fully extend (and flex) your knee. It makes walking difficult and will negatively affect your gait during the process.

To help prevent an extreme knee contracture, your surgeon can perform an ITB release. The ITB can be severed completely during the initial surgery and insertion of your limb lengthening device since it will have no problems growing back and regenerating itself completely.

Dr. Paley routinely performs this with all femur lengthening. That should probably tell you something.

Hip Contracture

A hip contracture is also extremely common and affects your gait and your ability to flex and extend at the hips.

Some things that are difficult if you have a hip contracture:

• Standing from a seated position
• Walking (lack of glute engagement)
• Squatting in place

Ankle Contracture and Achilles Tendon Contracture

An ankle contracture is only likely for those lengthening their tibiae.

But if you plan to lengthen tibs, you should expect an ankle contracture. In fact, an ankle contracture is precisely what will determine how much height you can gain.

What does this mean?

A good surgeon will only allow you to continue lengthening your tibias so long as you do not have an equinus contracture (also known as ballerina foot). This means you must constantly fight to keep your dorsiflexion in a healthy range of + 10-15 degrees.

P.T., just as with femur surgery, is critical.

Many patients are forced to stop at only 3 or 4 cm because they failed to do enough stretching every day.

However, unlike with femur lengthening, there is an easy cheat code for fighting ankle contractures: a splint. But not just any splint. A Dynasplint.

Serious Limb Lengthening Surgery Side Effects & Complications

Everything discussed so far is almost expected, but the following complications should be taken into serious consideration.

Nerve Injury

Nerve injury is not typical with femur lengthening but does occur more frequently during tibia lengthening. During the distraction phase, if you feel any pain on the top of your foot or find yourself wanting a foot massage frequently, you may have entrapment of the tibia’s peroneal nerve.

The pain can lead to increased sensitivity (hyperesthesia) or lessened sensitivity (hypoesthesia).

In some cases, the immediate post-surgical nerve pain following leg lengthening surgery for tibiae can reach an 8/10 or above on the pain scale! However, this is not common.

A skilled surgeon can discover potential nerve problems with a special device called a Pressure Sensitive Sensory Device (PSSD).

However, most of the time nerve problems are easily identified and treated by slowing down the rate of distraction. 

A peroneal nerve decompression is not optional if you plan to lengthen both your femurs and your tibiae.  To increase the chances of maximizing your height increase surgery, you must get this nerve decompression. Further proving this point, the top doctor in the USA currently (Dr. Paley) includes this for all of his sequential lengthening (quad patients).

This is a very minor procedure that can be done at the same time of your limb lengthening surgery. The surgeon will find your peroneal nerve and release surrounding soft tissues to relieve pressure on the nerve during the procedure.

But don’t worry–if your doctor doesn’t normally perform this procedure, you can always get it later if it is truly needed.

Bone Formation Issues: Slow Union and Non-Union

In healthy adults with no vitamin deficiencies (vitamin D is critical for limb lengthening), bone formation is typically not a problem.

However, in some cases this bone regeneration will be too slow for the normal rate of distraction ~1 millimeter per day, and the patient must slow down the rate of distraction.

• Slow union is when the bone grows much slower than normal
• Non-union is when the bone is failing to grow at all

In the rare cases of non-union where bone regeneration is not improving, a decision must be made between the surgeon and patient on whether lengthening should continue. In these cases, lengthening further is not recommended because any additional length of distraction will require a bigger, more invasive bone graft.

Finally, a bisphosphonate infusion treatment can also be applied to prevent the resorption of bone and aid the natural bone remodeling process.

https://www.youtube.com/watch?v=EO6LK8IlD0w

Premature Consolidation

Almost all patients–even those who are otherwise responding great to the leg lengthening process–are susceptible. From Paley himself, “The incidence of this complication is about 1%”, but if it happens, you must undergo another procedure to re-break the bone. [1] 

While it is an outpatient procedure, it can still cost tens of thousands of dollars. Plus, it’s extra surgery that will create further pain and inflammation for your body that is already recovering from the traumatic, leg-breaking process!

Not to worry! The solution is actually quite simple as long as your doctor reviews your follow-up x-rays on a weekly or bi-monthly basis. If your bone formation is too high, the lengthening rate will be increased. This means you will also be done with your leg lengthening surgery faster!

Fat Embolism

A fat embolism (FE) is possibly the scariest risk associated with leg lengthening. Fortunately, with a good doctor there is very little to fear.

When the surgeon inserts the internal lengthening nail into your bone (such as the Precice or Stryde nail), a process called reaming takes place.

As the surgeon is reaming the bone, it creates a hole in the bone for the nail to actually fit into. This process builds up pressure in the bone and causes bone marrow to be compressed.

This means there is a possibility of fat from your bone marrow making its way into your bloodstream. If filtered by the body’s lungs, something called a fat embolism can occur. Keep in mind that small amounts of fat are no problem for your lungs and don’t cause any adverse symptoms.

However, larger amounts of fat can lead to:

• Shortness of breath
• Lower oxygen levels
• Intubation and ventilation treatment
• Death

Clearly, a severe fat embolism (FE) is no joke. In most cases, a FE can be easily addressed with the use of an oxygen mask. The surgical team will require you to wear a mask that provides a higher concentration of oxygen than normal air. [1]

While it is extremely rare, it can happen. That’s why picking a good surgeon is critical.

A skilled doctor can recognize the warning signs of a FE well before it becomes life-threatening.

There are also some techniques that can be utilized:

• Releasing pressure in the bone by pre-drilling holes where the bone will be cut (the osteotomy site)
• Monitoring your pulse and blood pressure during surgery to adjust the reaming rate

Deep Vein Thrombosis & Pulmonary Embolism

A deep vein thrombosis (DVT) can occur after any orthopedic surgery or damage to bone, such as a fracture.

Essentially, it’s a blood clot that occurs due to increased blood pressure and swelling at and near the surgical areas.

An ounce of prevention is worth a pound of cure when it comes to DVT: a doctor will typically prescribe a low-level blood thinner such as baby aspirin to be continued throughout the entire lengthening phase.

What is the difference between a DVT and PE?

A pulmonary embolism (PE) occurs when the clot from a DVT makes its way into the circulation system and into the lungs.

Typical symptoms of PE:

• Shortness of breath
• Chest pain
• Death

Just as with a fat embolism, a PE is serious.

For this reason, it is absolutely essential that you reduce as many risk factors as possible:

1. Stop smoking (no exceptions!)
2. Stop taking oral contraceptives

High-risk patients, such as women who demand to remain on birth control, may be required to take an anticoagulant such as Xaralto. Your doctor will prescribe this for you as needed.

P.S. anticoagulant loosely means “anti-clotting”; it’s a medicine designed to prolong the time it takes your body to form blood clots. [4]

Axial Deviation

Axial deviation is likely the number one concern for those who try to cut costs and have the surgery performed in India or Russia.

What is it? There are two common types:

1. Valgus – Knock Knees
2. Varus – Bowlegs

It’s when your leg bones become misaligned during the lengthening process. And, it can happen very easily with an unskilled surgeon.

Risk of Axial Deviation During Femur Leg Lengthening Surgery

But it’s not uncommon to happen under ideal surgical circumstances. This is why when completing a femur lengthening, most top surgeons like Paley use a special technique of inserting the nail from the hip instead of the easier method of inserting through the knee.

Furthermore, a blocking screw can be used medially to prevent deviation.

Risk of Axial Deviation During Tibia Leg Lengthening Surgery

Some form of deviation is much more likely to occur when undergoing height surgery for tibs. This is because, when lengthened, the tibia will naturally begin to form into a valgus state, causing the knock-knee effect.

P.S. knock-knees are when you can’t put your feet together because your knees hit each other when you try to close your legs.

What can be done to prevent it?

1. The nail should be inserted very high in the tibia bone
2. The nail should be inserted far back, on the posterior side of the tibia bone
3. The nail should be center-aligned with the patella (knee cap)
4. A blocking screw should be used if there is left-over space between the nail and the side/back of the tibia bone

Finally, you can work to avoid this altogether by using the Stryde nail by Nuvasive, which resists axial deviation by offering an additional third (3) locking screw.

Fibular Complications

When undergoing surgery to get taller, if you choose to lengthen tibiae you will also be open to the risk of fibular side effects.

This occurs because, during leg lengthening surgery, a rod is only inserted into your tibias–not your fibulas. This is because the fibula bone is too thin to place an internal nail inside it.

For these reasons, the tibia and the fibula must be screwed together so that when one is lengthened the other is as well. If not, the tibia will lengthen more than the fibula, causing a severe bone misalignment issue.

Keep in mind many surgeons will avoid proper fibular fixation techniques because they are hard to execute. 

The consequences can be disastrous:

• The fibula pre-consolidates and dislocates at the top
• The fibula bone heals shorter, causing ankle arthritis and the inability to flex the knee fully

What is the right way to do it?

The fibula must be fixed to the tibia in multiple places. Additionally, a miscalculation of mere millimeters on any number of things during nail insertion can spell disaster:

1. Angle of nail
2. Level of nail
3. Positioning of nail within the bone
4. Diameter and nail type (there are many different “versions” of the latest and greatest Stryde nail, and knowing which to use under what circumstances is critical)
5. Screw type used

The message is clear: tibia lengthening takes a lot more skill than femur lengthening. Choosing the best doctor you can afford is always a good idea to minimize risk and side effects. Going with a low-cost doctor makes tibia lengthening riskier given the high level of surgical expertise it requires to pull off correctly.

As always, choose wisely and tread carefully.