Most of the Leg Lengthening procedures used today are variations on the Ilizarov method, devised by Russian physician Gavril Abramovich Ilizarov in 1951. Several doctors who perform the surgery in the United States studied with Dr. Ilizarov in Russia in the 1980's.
There are four phases: Preparation, Surgery, Lengthening and Strengthening.
The patient has his or her initial consultations with the physician during this phase. The physician should explain all aspects of the operation and recovery. X-Rays are taken of the legs so that a custom Ilizarov external fixator device can be built specially for the patient. Some centers may also perform a psychological evaluation to ensure that the patient will be able to endure the entire procedure, with the necessary positive attitude.
In the most common procedure, the tibia and fibula bones of both lower legs
are broken and an external fixator device is attached to each half of each severed bone. The device is attached to the bones using pins or wires that go through small holes drilled through the patient's skin.
Also called Distraction, this phase begins about a week after surgery and continues over the next
two to three months, depenmding on how much lengthening is desired. The fixator device is lengthened, increasing the distance between both halves
of each bone. New bone growth occurs in the space in between. The lengthening is applied
slowly, about 1mm a day. Typically a screw is turned four times a day to achieve the 1mm per day separation. External fixator devices may also be motorized to achieve
continuous lengthening throughout the process. Patients should be scheduled for one to two hours of therapy each day during lengthening. By the end of this phase, the lower legs have been increased two to three inches.
The patient is generally confined to a wheelchair during the Lengthening phase and must not bear any weight on the growing bone.
This phase may also be called the Consolidation phase. For the following three to six months,
the patient continues to use a wheelchair until the newly grown bone is strong enough to bear the patient's weight. The external fixator device continues to be used to keep the two bones properly aligned, but is no longer lengthened. During bone Strengthening, physical therapy can be reduced to three times a week. At the end of the Strengthening phase, a simple operation is performed to remove the external fixator device, and the patients can usually walk on their own, no longer needing a wheelchair. However, they may require a cast for an additional month for protection of the legs.
Physical Therapy and Attitude
Two critical success factors for the procedure are extensive physical and occupational therapy and a positive attitude. Patients should be scheduled for one to two hours of therapy each day during the lengthening phase. This can be reduced to three times a week during the strengthening phase. Important: Some facilities have no formal program for physical therapy. The importance of physical therapy to the healing process can not be stressed strongly enough. Though very painful (PT is sometimes described as Pain and Torture), omitting it could lengthen recovery by two or three times the durations listed on this page. What should be a half year recovery can easily be extended to a one or two year recovery, without proper physical therapy.
A positive attitude is also important. The patient doesn't just wait to be healed after the operation. He or she must actively work for it. The patient must also be prepared to be immobilized for half a year or more. In our busy day to day lives, it is difficult for most of us to appreciate what it means to be confined and have to depend on other people for basic daily activities.
The entire Leg Lengthening procedure is very painful so proper pain management is key. Chronic pain can significantly
impair recovery. There are limitations to the types of pain management medications that can be used. Anti-inflammatory drugs have been shown to slow bone growth and will only be prescribed in emergencies. Narcotic drugs may cause the patient to become addicted and the doctor will probably want to keep away from them as well. Significant pain can also prevent the patient from doing physical therapy during the Lengthening and Strengthening phases. Getting enough sleep is also important for recovery and may be a problem when the pain is very bad. Sleeping pills can be taken for a short amount of time after surgery but eventually they may stop working.
Risks and Complications
As with any operation, there are risks of complications. There is a 25% risk of complications following cosmetic leg lengthening, which is relatively high. The greatest risk is infection at the sites where the pins enter the skin. Special care must be taken to ensure that these sites are kept clean. Anti-bacterial ointments must be applied on a regular schedule. Other risks include:
- Bone Infection (osteomyelitis) may result in bone destruction or stiffening of joints if the infection spreads. Acute osteomyelitis is caused by bacteria that enters the body through a wound. The onset may be sudden, with chills, high fever, and severe pain. Intravenous antibiotic treatment will usually clear up the infection.
- Injury to blood vessels can impair circulation and prevent proper bone growth.
- Poor bone healing. This includes delayed healing or failure of the new bone to form a union with the old bone. There is a one in 12 chance of the new bone breaking within weeks of completion of the Strengthening phase.
- Angulations can cause the leg to be angled inwards or outwards.
- Nerve injury could cause the patient to loose feelings in the lower leg or in extreme cases the loss of use of the leg.
- Unequal limb lengths. If one leg fails to heal properly, the doctor may need to reverse the direction of the external fixator device to strengthen it, causing a slight differential between the two legs.
- Final height may be less than expected. While most people expect to achieve a full three inches in height after recovery, it is not uncommon for the final height to be a half inch or more shorter than that.
To achieve a greater height, some patients opt for a second operation. Once the lower legs are strong enough, the femur bones of the thighs are broken and lengthened using a similar procedure. However, an additional six inches in the legs will make a person appear significantly disproportional. Add to that the additional expenses and recovery time of almost a year and it becomes obvious why the second operation is rarely performed.
At no time should you ever consider having both lower and upper legs lengthened at the same time. While some international facilities perform this variation, recovery is very difficult and physical therapy nearly impossible because of the pain. We spoke to one person who opted for this. A year after the operation he was still bedridden.
The next section describes New Procedures that improve upon the Ilizarov External Fixator.