Treatment techniques
Lower limb length discrepancy is not always a problem. However, if this causes the patient to limp or feel pain, or prevents them from participating in activities they used to enjoy, they have several options to choose from. This section provides information about limb length discrepancy treatment methods and how to prepare for your consultation with a specialist.
Choosing an appropriate strategy for dealing with a limb length discrepancy is quite the challenge. It should be borne in mind that not all options will be the right choice for each case and that the information provided on this site cannot replace a direct visit with a specialist.
Our physicians have experience in treating limb length discrepancies that allow them to explain in detail the individual treatment methods, their advantages and related risks. They will discuss with you the treatment methods available and present those most suitable for your case.
Limb lengthening is possible and has been successfully performed for about 50 years in Kurgan, Russia. Gavriil Abramovich Ilizarov formulated the procedure in 1951 when he treated many WWII veterans with lower limb nonunions.
In the beginning, Ilizarov developed external fixators mounted around the limb. Knowing that exerting surface pressure on a fracture enhances bone healing, he built fixators that allowed compression. He instructed one of his patients to gradually increase the pressure in the nonunion area by tightening a rod. However, the patient turned the rod in the wrong direction, which caused a distraction (separation) of the bone fragments. Ilizarov noticed that the gap between bone fragments was filled with newly formed bone tissue. It was the beginning of large-scale research and development activities that proved that limb lengthening is possible, safe and effective.
Ilizarov and his colleagues performed thousands of limb lengthening procedures in Kurgan. Unfortunately, Russian politics significantly limited the exchange of information with the West. Finally, at the beginning of the 1980s, surgeons from Italy became interested in the procedure, started perfecting it and founded a large center in Lecco. The first limb lengthening procedure in the USA was performed in 1988. Initially, American orthopedic specialists were very reluctant and skeptical of that method, but its effectiveness spoke for itself.
Limb lengthening and reconstruction methods can used to fill bone cavities and lengthen and/or correct the shape of bone segments. The procedure may be performed in both children and adults with a limb length discrepancy due to birth defects, diseases or injuries. Limb lengthening and limb deformity correction processes are based on distraction osteogenesis. It is a revolutionary concept, debunking the earlier conviction that bone tissue cannot regenerate. The bone is cut surgically and then its fragments are gradually separated (distraction), which leads to the formation of new bone tissue (osteogenesis) at the lengthening site. It allows for forming between 15% and up to even 100% of the original bone length. We use a number of different techniques, e.g. clamp (unilateral) and spatial (ring) fixators allowing for correcting angular deformities and bone lengthening at the same time. During the procedure, the physician also mounts or implants an orthopedic bone lengthening fixator. Fixators may be placed inside the bones, such as the PRECICE nail. External fixators remain outside the body, such as the Vilex Hexapod, SmartCorrection, DialMedicali Frame or even ordinary Ilizarov fixators.
The newly formed bone tissue is normal and has not been used up over time. Muscles, nerves and blood vessels also grow through the slow stretching, just like during pregnancy or childhood growth spurts. The procedure itself is minimally invasive and requires spending only one or two nights at the hospital. The pain is not severe because the distraction process is very slow; patients can also walk normally during treatment.
Both children and adults are suitable candidates for the procedure.Lower limb length discrepancy, sometimes accompanied by deformity, frequently occurs in children with birth defects, such as congenital absence of the fibula (hemimelia), congenital short femur or hemiatrophy. Over the years, such conditions lead to chronic back pain and hip joint inflammations. Causes for the discrepancy may also include epiphyseal plate fracture or osteitis in childhood, leading to inhibition of the growth processes.
In the course of injuries, the bone may heal in a shortened and deformed position (malunion). A complete nonunion can occur as well (pseudarthrosis). Limb lengthening procedures solve all of the above-mentioned problems. We have successfully corrected significant deformities and aligned the length of limbs in cases where discrepancies reached more than ten centimeters. Another issue may be a bone cavity resulting from a bone neoplasm, osteitis or a severe fracture.We are able to fill the cavity with new bone tissue through bone transport.
Short stature may be a serious problem in patients with dwarfism. We are able to lengthen both lower limbs at the same time, to increase the patient’s stature. We have successfully lengthened the lower limbs by 30 cm and the upper limbs by 13 cm in patients whose short stature was caused by achondroplasia. This allowed them to become more independent and they are able to reach e.g. the phone, toilet or car accelerator pedal on their own.
Young people with lower limb deformities are at a higher risk of developing degenerative changes due to the mechanical axis deviation. The techniques described here are suitable for the safe correction of severe deformities, which helps prevent the necessity to implant joint endoprostheses.
During the procedure, the physician cuts the bone into two fragments. The procedure is called osteotomy. Additional soft tissue procedures can be performed simultaneously to prepare muscles and nerves for lengthening. For example, surgical lengthening of the calcaneal tendon facilitates the tibia (calf) lengthening. During the procedure, the physician also mounts or implants an orthopedic bone lengthening fixator. A fixator may be placed inside the bones, such as the PRECICE nail. There are also external fixators, which remain outside of the body, such as the Vilex Hexapod, SmartCorrection, DialMedicali Frame or even ordinary Ilizarov fixators.
After the procedure, there is a waiting period of 5–7 days, during which repair processes between bone fragments begin. This time is called the lag phase. Afterward, the patient (or their caregiver) alters the settings of the fixators, slowly separating the bone fragments from each other. This process is called the distraction phase, i.e. the lengthening phase. The gap is filled with newly formed bone tissue during the separation of the bone fragments. This way the bone is lengthened. The newly formed bone tissue is called bone regeneration.
During the distraction phase, the patient (or their friend/family member) alters the fixator’s settings every day so that the bone fragments are slowly separated at the rate of about 1 mm per day. The duration of the lengthening process may differ slightly, depending on the bone. For instance, the treatment plan may estimate a tibia distraction rate of 0.75 mm per day and a femur or humerus distraction rate of 1.0 mm per day. Gradual stretching forces the body to constantly form new bones and soft tissue, such as skin, muscles, nerves, or blood vessels. The distraction phase lasts until the desired bone length is reached. Possible additional bone length amounts to approximately 2.5 cm per month. In the distraction phase, the patient has several follow-up visits per month to check if the lengthening rate is adequate. Based on an X-ray assessment of the bone regeneration, the physician may increase or decrease the distraction rate. During the process, the patient must undergo rehabilitation 2–5 times a week and exercise at home every day as per the instructions they receive.
The distraction phase is followed by consolidation, during which the bone regenerates, gradually hardens, and transforms into bone. A typical bone lengthening procedure, where the additional length to be achieved is 5 cm, takes approximately 2 months, whereas the mineralization of the new tissue takes another 2–3 months.
In such a case, the lengthening fixators remain in place for at least 4–5 months. The healing process is considered to be completed only when the new tissue is remodeled and calcified. To support the healing process, patients should avoid nicotine in any form, follow a healthy diet with a high protein intake and take vitamin and mineral supplements. In the consolidation phase, the physician will instruct the patient to gradually place more weight on the limb (using crutches or a walker), facilitating bone remodeling. At the end of treatment, the patient may stop using crutches.
Following complete bone regeneration consolidation, the lengthening fixators may be removed in the outpatient setting (usually, the patient does not need to stay at the hospital overnight). To ensure additional protection for the new bone tissue, the physician may put the limb in a cast or instruct the patient to wear an orthosis for 3–4 weeks following external fixator removal. After removing the internal implant, there is no need to put the limb in a cast.
At Paley European Institute, we use various orthopedic apparatuses for bone lengthening. We use the most suitable equipment for each individual patient. We are the most skilled in Europe in using both external and internal apparatuses for limb correction and lengthening.