We provide initial information by electronic means, but it is always essential to evaluate the patient during a consultation process. This allows us to optimally prepare the patient’s journey leading up to the surgery and perform all the necessary procedures.
How is the consultation process shaped?
A consultation visit starts with a special X-ray scan performed at Paley European Institute.
First, the patient meets with a medical assistant. A detailed history is collected. Height, weight and arm span measurements are also taken.
Then a medical team joins the process to review X-ray scans and evaluate the patient, e.g. check the range of motion and muscle tone in a physical examination. The team explains the procedure and provides advice on the best lengthening strategy for a given patient, taking into account their individual expectations and body proportions. The medical team calculates the bone length ratio on the basis of an X-ray scan. A normal tibia to femora length ratio is 0.80 +/-0.02. A ratio above 0.82 indicates that tibial bones are relatively long when compared to femoral bones and thus femoral lengthening will be recommended; if the ratio is below 0.78, the recommendation would probably be the tibial lengthening. Expectations about the number of additional centimeters are an additional criterion, as femoral bones can be safely lengthened by up to 8 cm, while for tibial bones it is only 5 cm. The medical team will discuss these and other aspects of the procedure in detail and try their best to answer all questions.
After the consultation, the medical assistant stays with the patient to answer any additional questions. Together with the patient, they visit the physical therapy department. If possible, this is also an opportunity to talk to other patients undergoing the limb lengthening procedure. This cannot be guaranteed, as the schedule of physical therapy is independent of the consultation schedule. Other patients would also have to agree to such a meeting. We respect the privacy of all patients and guarantee full discretion.
X-ray scans should be sent to Paley European Institute on a monthly basis so that Dr. Deszczyński and Dr. Albrewczyński can assess the bone remodeling progress. Ideally, they should be sent by e-mail to firstname.lastname@example.org. If attaching an X-ray scan to an e‑mail is inconvenient, the results may be sent on a CD to: Paley European Institute, Aleja Rzeczypospolitej 1, 02-972 Warszawa.
Lengthening the femurs by 8 cm lasts three months and the next 2–3 months are required for the bone tissue to heal to a condition allowing for full weight-bearing on the limb without crutches. So the entire process would be expected to take 5 months. Lengthening the femurs by 5 cm takes less than 2 months. In the case of the PRECICE nail, an additional month or two should be added. After this time, you will be able to bear full weight on your limbs without using crutches. Lengthening the tibia by 5 cm lasts three months, and the next 2–3 months are required for the bone tissue to heal to a condition that would allow walking with full weight-bearing without crutches. In the case of the STRYDE nail, the mandatory crutch use after the lengthening procedure is significantly shorter and the ability to walk without them is assessed radiologically during follow-up visits.
The extent of the lengthening is limited by the soft tissue capability. The risk of complications related to the lengthening procedure increases with the extent of the lengthening. Lengthening of up to 5 cm is a low-risk procedure. The risk is intermediate in the 5–8 cm range and high above 8 cm. For example, to gain an additional 10 cm of height, it is much safer to lengthen both the femora and tibiae by 5 cm than any single type of bone by 10 cm.
The first generation PRECICE technique was developed by Ellipse Technologies in collaboration with a team of orthopedic surgeons that included Dr. Paley. This method was intended for treating limb length discrepancy. Dr. Paley was the first physician in the United States who implanted the P1 nail. This took place on 1 December 2011. The second generation PRECICE nail (P2) was created as a result of the collaboration between Dr. Dror Paley and Ellipse Technologies, taking into account first and foremost the needs of patients looking to gain stature. It is therefore the first intramedullary nail designed with the specific requirements of a cosmetic procedure in mind. The P2 model was used for the first time by Dr. Paley in November 2013. P2 enables lengthening by 8 cm with an implant that is available in 3 sizes: with diameters of 8.5 mm, 10.7 mm and 12.5 mm. The 8.5 mm diameter nail is intended for smaller bones normally present in children, patients with dwarfism and petite adults. The design of the P2 nail is nearly four times stronger and enables a higher weight-bearing capacity. Furthermore, the durability of the telescopic junction was increased almost three times, reducing the risk of a mechanical nail failure in the event of bone tissue overproduction, preventing the complications of premature consolidation (bone tissue healing) which may arrest the lengthening process. In short, Precice2 enables a larger extent of lengthening due to a stronger design with a more durable piston. P2 is available in several sizes and accounts for different types of patient anatomy. The most recent modification of this model was to reinforce the junction between the two telescopic ends of the nail. There is a special welded junction there, called a crown, that would fail occasionally, increasing the risk of nail breakage. It was Dr. Paley who identified this flaw and contributed to its elimination in collaboration with the manufacturer, while also reinforcing the device design. The P2.1 model was released in December 2014 and P2.2 in May 2015, replacing all previous P2 models. The P2.2 nail is even stronger and more resistant to any failures or breakages. Ellipse was acquired by Nuvasive. The device is currently sold by Nuvasive Specialized Orthopedics. The next generation is the STRYDE nail. Its distinguishing feature is the use of medical-grade steel which makes it more resistant to compressive forces and allows increased weight-bearing in the distraction phase, which in turn was limited in the P2.2 generation Precice nail.
The price of femoral and tibial lengthening includes all the associated additional procedures, such as a plastic surgery on the iliotibial tract and lengthening of the biceps femoris tendon when lengthening the femur or possibly locking screws when lengthening the tibia. The purpose of these procedures is to PREVENT complications. The first consultation visit serves to determine whether performing them is justified. Dr. Paley performs four tests (Ober’s test, popliteal angle test, Ely test when lengthening the femur and Silverskiold test when lengthening the tibia) to evaluate muscle function and assess for potential contractures of the iliotibial tract/fascia lata, hamstring muscles and the rectus femoris when lengthening the femur or the triceps surae muscle when lengthening the tibia. It is not possible to determine whether the procedures are necessary (and which ones) without examining the patient. The more extensive the lengthening, the higher the probability that plastic surgeries on soft tissues will be required. To illustrate: every patient undergoing bone lengthening by 8 cm requires plastic surgery on the iliotibial tract, while with a 5 cm lengthening this is only necessary in 50% of cases. In the case of tibial lengthening, if the Silverskiold test (during a physical examination) reveals excessive tightness of the Achilles tendon, the procedure may result in contracture of the triceps surae. Although plastic surgeries can be performed on it, these may lead to a permanent reduction in spring force. We avoid this kind of situations and we limit the extent of tibial lengthening.
If excessive tightness is already present before surgery and a prophylactic plastic surgery is not performed, then muscle/joint contractures will require more costly procedures at a later time. A prophylactic plastic surgery on the anterior compartment may be carried out simultaneously with tibial lengthening to prevent compartment syndrome.
Fortunately, complications requiring surgical intervention are rare. Approximately 4% of patients experience those related to unscheduled interventions.
Health insurance does not cover any esthetic medicine procedures. The cost is the most important barrier for patients looking to undergo bone lengthening for esthetic reasons. Not only does insurance not cover the costs of the procedure itself, but in the event of complications requiring additional surgical procedures, insurance will not cover the costs of treating complications.
Paley Institute is the SAFEST and MOST RELIABLE center in the world when it comes to this kind of procedures.
Prices vary by country, center, specialist and method. Costs of purchasing the device constitute a significant portion of the price of the entire procedure. The alternative is to use external fixators which, although expensive, are suitable for multiple use. The prices of used external fixators are very low. However, it should be emphasized that the experiences associated with placement of a massive external fixator and then wearing it, with all the typical complications such as infections, joint stiffness or scars, cannot be compared to a procedure which utilizes the safest, cutting-edge technology to minimize scars, adhesions and stiffness, risk of infection and pain. Many patients decide to undergo treatment abroad precisely because of the costs. At many facilities, the patient is at risk for permanent disability. It is very difficult for consumers to select the right facility. The specialists who perform limb lengthening procedures are not equal, and this is also true for the centers which employ them. If something is cheaper, it does not mean the patient will achieve the same desired result. In our opinion, the principle “the price reflects the quality” is true in many cases. Precice is the most advanced and safest cosmetic limb lengthening procedure ensuring lower levels of pain and complications than other procedures.
Paley European Institute has THE BROADEST EXPERIENCE in the world in these kinds of procedures thanks to a constant collaboration with Dr. Dror Paley.
Dr. Dror Paley has the most extensive experience in limb lengthening surgery performed both to increase height and to equalize limb length. Since 1986, he has performed over 20,000 limb lengthening procedures. He can pride himself on the highest procedure success rate for all methods. This is of major importance for patient safety.
We believe the choice should be based on analysis of 4 aspects. These aspects are:
Surgical pain occurs immediately after surgery. Most patients receive epidural anesthesia. We often inject a long-acting topical anesthetic, which persists in the body for up to 96 hours, into the wound. These methods are excellent for treating surgical pain. Patients start taking oral analgesics when they are still hospitalized. Upon discharge, all patients receive a prescription for analgesics with recommendations for use. In the first two weeks after surgery, most patients still feel some degree of surgical pain. When it stops, patient comfort is significantly improved. The most intense pain occurs during the stretching exercises which are a part of physical therapy, and when falling asleep. For this reason we sometimes prescribe hypnotic agents. Most patients do not complain of pain during the day. The Precice lengthening process itself is usually painless. The people who have undergone the lengthening procedure indicate they have experienced only slight pain.
Inform your employer you will be absent from work (arrange time off/sick leave) so that you don’t feel pressured to return to the workplace.
Following a consultation at Paley European Institute, the PEI Medical Care Coordinators will be happy to answer any organizational questions, present the further management path, schedule subsequent consultations and the surgery and develop the entire post-operative management plan.
A pre-operative appointment with the surgical team takes place before the procedure to complete consent forms and other necessary documents. The patient also has an appointment with an anesthesiologist. Furthermore, surgical anesthesia and post-operative pain management methods are discussed. The patient also receives recommendations concerning the procedure. This visit usually takes place several days before the operation.
Hospitalization usually lasts 3–4 nights. At Medicover hospital, patients aged above 18 are accommodated in the Department of Surgery rooms, while minors are accommodated at the Department of Pediatric Surgery.
After the procedure, the patient is transferred for 1–2 hours to the recovery room and then to their own room. If your family or friends are present, our Medical Care Coordinators provide them with information on an ongoing basis during the procedure and arrange a meeting with Dr. Deszczyński and Dr. Albrewczyński after the procedure is completed. Then they lead the family/friends to the recovery room if the patient wishes so. The person who underwent surgery has a vascular access and a Foley catheter (urinary catheter) inserted. The catheter stays in place until the epidural catheter is removed. If epidural anesthesia was not used, the Foley catheter is removed one or two days post-procedure. During hospitalization, we initiate the administration of anticoagulants. The nurses take care of the patient’s comfort and positioning to prevent pressure ulcers from developing. Each morning, we collect blood for testing. If the parameters are unsatisfactory, a transfusion may be ordered; however, this is rare. Epidural anesthesia is usually discontinued after two days. Physical therapist visits the patient every day to teach them how to move and regain independence. The patient learns new skills, such as getting into a wheelchair or commode chair, returning to bed etc. When the patient regains a satisfactory level of performance and the pain recedes, the patient is discharged with recommendations.
Some patients lose so much blood that they require a transfusion even before the procedure. Depositing blood for your own use is possible but not required. If required, we use blood from a blood bank. Blood loss occurs not only during the operation but also during the next several days. If a need for a transfusion arises, this usually happens during the first or second day post-procedure. The associated risk is minimal. Fewer than 10% of our patients require a blood transfusion.
Yes. The patient receives a wheelchair and a walker that they take with them. These aids are arranged by the PEI Medical Care Coordinators. The physical therapists employed at the department teach the patients to move from the bed to the wheelchair and to the toilet. The patient starts to walk using the walker, and then crutches, only after they leave the hospital.
You will take the following medications:
Vitamin D and anti-inflammatory medications are administered as well.
There are several options. Contacting the Medical Care Coordinator is recommended.
The patient has to stay in Warsaw until the end of the distraction (lengthening) phase. The duration of the distraction phase for femoral lengthening is one day per each planned extra millimeter of stature, e.g. 80 mm = 80 days. Lengthening starts within 7 days post-procedure, depending on the age of the patient. Therefore, if we don’t start the activities until e.g. day 7, these 7 days must be added to the 80 days needed to achieve 80 mm, so 87 days are needed to achieve 80 mm. The rate of tibial lengthening is ¾ mm per day. The distraction phase in order to achieve 50 mm is 10 weeks. Add one week prior to the start of lengthening for a total of 11 weeks.
Yes, assistance will be necessary during the first 2–3 weeks. The patient should come with an accompanying person who will take care of them. Optionally, they can hire an assistant for the first 2–3 weeks following the operation. We can help arrange that. A higher number of assistance hours is required in the first week after discharge than in subsequent weeks. If the patient arrives unaccompanied, they have to secure the funds for this purpose. Everyone needs assistance for at least two weeks after discharge. If the patient does not have company, they will require several hours of assistance daily.
During distraction, the ends of the bone are held separate by the implanted intramedullary nail. It is affixed to bone tissue by screws on both ends. The nail diameter is 8.5, 10.7 or 12.5 mm. The screw diameter is 4–5 mm. Every implant ultimately bends or breaks due to repeated weight-bearing. No implant, regardless of the manufacturer or technology, is resistant to this. The risk increases with the patient’s body weight. This applies to all limb lengthening nails, regardless of the material they are made of and the promises made by the manufacturer or physician.
At our center, we only permit full weight-bearing on the limb when an X-ray shows the gap is completely filled with bone tissue. Then the bone takes over the weight and relieves the implant. During lengthening, we allow weight-bearing on the limb with support using crutches or a walker, which allow transferring the body weight onto arms. The permitted weight-bearing level depends on several factors: the patient’s body weight, nail diameter and the bone being lengthened. For the largest diameter Precice2 nail (12.5 mm), we allow weight-bearing of up to 34 kg per leg. This means if the patients is standing on both legs supported on a pair of crutches, they can bear a weight up to 68 kg. Nevertheless, when walking or transferring body weight from one leg to the other, the patient MUST USE TWO CRUTCHES and reduce the weight to 34 kg with every step. In the distraction period, the patient must NEVER walk using one crutch, regardless of body weight. The same rule applies during the consolidation period, until the physician allows increasing the weight-bearing threshold. The patient can check the level of weight-bearing on the limb by standing on a bathroom scales, supporting themselves on crutches and attempting to achieve the required weight, e.g. 34 kg. For the smaller diameter 10.7 mm and 8.5 mm nails, no more than 23 kg per leg is allowed. If a STRYDE nail is used, the limb can bear full weight directly after the operation; however, we recommend using elbow crutches for safety.
Patients with implants undergoing the limb lengthening procedure can only drive after they discontinue narcotic analgesics used during the day. They also have to be able to get in and out of the vehicle independently, as well as stand using crutches or a walker and get into a wheelchair to gain full independence. All of these activities must be done within the allowed limb weight-bearing limit, as described above.
Rehabilitation takes place at Paley European Institute 5 times a week throughout the lengthening period, under the supervision of a designated physical therapist. In addition, the patient performs rehabilitation at home at least 3 times a day every day, according to a protocol they receive from us.
Rehabilitation has to be continued during the consolidation period, albeit less frequently (2–3 times a week). We also change the scope and nature of exercises in this period: we focus on motor training to speed up the return to full activity.
The lengthening process is operated by the patient themselves or their friend/family member at their place of residence. The nail is lengthened each time by ¼ mm, 4 times per day for the femur and 3 times per day for the tibia. In the case of simultaneous femoral and tibial lengthening, lengthening is performed only 3 times per day. The whole process is enabled by a special transmitter or “control,” ERC (External Remote Control). Every patient is given training in operating the ERC by our orthopedic technician until they are familiar with it. Every patient receives an ERC for their own use. The device must be returned after the end of the lengthening phase.
Follow-up visits with a physician take place every two weeks at Paley European Institute. Additionally, if the patient exhibits any alarming symptoms, the patient’s Coordinator can be contacted by phone. During rehabilitation, our physical therapists also constantly supervise the lengthening process in consultation with the medical team.
X-rays of each bone being lengthened are done every two weeks before the follow-up physician visit.
After review of the patient’s X-rays, Dr. Deszczyński or Dr. Albrewczyński respond by e-mail with their interpretation of the examination and opinion as to whether full weight-bearing is possible. Full weight-bearing is usually possible 1–2 months after the end of the distraction phase. Most patients are able to walk with full weight-bearing one month after 5 cm femoral lengthening and two months after 5 cm tibial lengthening. In the case of 8 cm femur lengthening this is usually possible after 2 months.
Before taking up sports activities, the patient must first regain fitness and muscle strength. If intensive rehabilitation is ensured, returning to sports is possible even as soon as six months after the procedure. However, this issue is individual and depends on the physician’s judgement. Most patients are able to return to jogging approximately one month after they obtain permission to stop using crutches. You can take up other sports approximately one months after you start jogging. To speed up our patients return to sports activities, Paley European Institute has introduced a dedicated post-limb lengthening functional training protocol.
Yes, all nails need removing. The timeframe is not of crucial importance, but nails are typically removed one or two years after the initial procedure. It is necessary due to the fact that nails are made of titanium or steel and release metal ions over the years, and because they have mobile parts. The Precice is equipped with rare-earth magnet. It is shielded from the body inside a waterproof chamber. There is a risk that over the years, its tightness would be compromised and the rare-earth magnet would come into contact with body fluids. Removal of the device is indicated before this happens.
An interval of six months up to one year is recommended between the procedures. Femoral and tibial lengthening procedures can be performed simultaneously; you can discuss this option with Dr. Deszczyński or Dr. Albrewczyński.
There are multiple possible complications associated with the limb lengthening procedure. They are discussed in detail with the patient during the initial consultation and again at the pre-operative visit. They include non-union of bone, limb length discrepancy, nerve stretch injury, muscle/tendon contractures leading to joint stiffness and joint inflammation. Other possible complications include deep venous thrombosis and fat embolism. An incomplete union occurs in rare cases. Excessive nerve stretching may occur, which sometimes requires surgical nerve decompression. Tight muscles and tendons may require surgical lengthening. These types of problems are unlikely but if they do occur, Paley European Institute team has experience in diagnosing them and providing quick adequate treatment. Overly slow lengthening or incorrect placement of the ERC (not directly over the magnet inside the nail) may contribute to premature consolidation. If this occurs, a re-operation is required to perform a repeat osteotomy to enable further lengthening.
Most of our patients achieve excellent outcomes without major complications. If complications occur, the results of their treatment are usually good, provided the complications are diagnosed and treated quickly. The procedure requires long-term rehabilitation, and the full recovery, including returning to sports activities, may take over six months.
Limb lengthening procedures should be performed only by experiences specialists. Paley European Institute ranks high among centers with the most extensive experience in limb lengthening worldwide. Our previous patients have come to us from many countries in order to take advantage of the comprehensive orthopedic therapies offered by our renowned team. At our Institute, the treating physician provides a detailed explanation of all available treatment options and then adjusts the course of treatment to a person’s specific needs. Our patients are under the comprehensive care of an entire team of experienced orthopedic surgeons and specialized assistants, nurses and physical therapists. We enable the patients to achieve the best possible cosmetic limb lengthening outcomes.
Following a consultation at Paley European Institute, the Medical Care Coordinator will answer any organizational questions, present the further management path and schedule subsequent consultations and the procedure.
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