Scars

Figure showing scars after a 5.5 cm femoral lengthening. The scars migrate upwards along the femur by 3.5 cm. The position of the screw (which was at the level of the scar during the surgery) is now lower than the scar. The skin of the leg has been pulled upward, creating a "lifting" of the leg as ratcheting maneuvers are performed.

Figure showing scars after a 5.5 cm femoral lengthening. The scars migrate upwards along the femur by 3.5 cm. The position of the screw (which was at the level of the scar during the surgery) is now lower than the scar. The skin of the leg has been pulled upward, creating a “lifting” of the leg as ratcheting maneuvers are performed.

Size and position of the scars

The operation is percutaneous, meaning that it uses stab incisions to go through the skin. These incisions are small, though larger than those from arthroscopic surgery. The skin is sealed using intradermal suture – covered with surgical ‘superglue’.
 
For femur lengthening, there are 3 skin incisions:
 
One at the top of the buttock (1.5 to 3 cm) to introduce the nail.
One on the top lateral side of the thigh (1 to 2.5 cm) to set the screw, anchoring the top of the nail to the femur.
One on the lower lateral side of the thigh (3 to 4.5 cm long), which introduces the 2 screws for anchoring the lower part of the nail to the lower femur.
 
To lengthen the tibia, there will be a greater number of scars, however each one of these is small.
 
Even when a patient is naked, the scars are not visible from the patient’s front due to their posterior and lateral positions. Depending on skin type, thickness and coloration, a closer, lateral examination of the patient may be necessary in order to see the scars.

Lower lateral scar 2 months postoperatively.

Lower lateral scar 2 months postoperatively.

 
In major femoral lengthening, the procedure collectively pulls up skin of the leg and thigh, as the body envelope behaves as a single “sheet”. Consequently, the incisions are moved upward from their original points on the body. This may require a new incision in front of the screws when the inferior screws are removed.
 
Likewise, during surgery to lengthen the lower leg, skin from the knee is pulled downwards and the foot skin pulled up.

 

Simultaneous femoral and tibial
lengthening on the same side

A simultaneous lengthening of the femur and tibia will reduce motion in the joints, due to necessitating the stretching of a large portion of skin.

scars 1 year (right) and 18 month after surgery (left).

scars 1 year (right) and 18 month after surgery (left).

A stretching of the nerves, including those within the skin, is also induced. This is felt as a burning sensation, or an escalation in skin sensitivity. Therefore, it is not recommended to undergo simultaneous bilateral lengthening of both femurs and tibias. Sequential lengthening of femora and tibias is generally performed, however the patient is allowed a recovery period in between the two operations, in order to allow the skin to heal and soft-tissue to regain its suppleness.

Possible treatments to decrease scars

Treatments are available which can reduce the appearance of scars. These include: postoperative local creams such as Ketum®, corticosteroids applied locally after the operation, or, once the nail is removed, dermal abrasion or laser treatments may be viable. Mechanical or chemical treatments that induce an inflammatory reaction of the skin will make the scarring more noticeable before the treatment does its work. In the event of Keloids or other more difficult scarring issues, surgical revision or cosmetic surgery may be performed.

The early post-operative phase

Electro-stimulation machine (Compex®).

Electro-stimulation machine (Compex®).

Early post-operative phase

Recovery depends predominantly on the procedure’s early operative phase and capacity.
 
According to the institution of the inventor of the Albizzia® nail, the following advanced protocol is followed:
 
In the recovery room, the patient is set on an electric machine, which allows continuous, passive motion (Kinétec®). By Day 1, almost all range of motion in the knee (130° to 140°), is recovered.
 
Oftentimes, the patient will be able to lift his or her leg a few hours following the surgery. Recovery of muscles by suppression of muscle inhibition is also swiftly achieved.
 
 
 

Patient on an electronic continuous passive motion machine.

Patient on an electronic continuous passive motion machine.

The leg should be raised in order to lower or avoid any clotting, and reduce risk of postoperative edema.
 
Stretching exercises are begun on Day 1.
 
Electrotherapy for muscle rehabilitation follows soon after, with the aid of a machine such as a Compex®.
 
On the first day after the operation, the patient can begin walking with full weight-bearing, under strict instructions on how to avoid hyperloading the nails. This stops the nail or screws from rupturing, and reduces risk of ratchet wear.
 
Ninety minutes of cycling is recommended each day, with other sports being introduced steadily.

Patient the evening of surgery. He was able to keep his leg elevated 10 minutes above the bed level. On right, knee flexion obtained by the patient on the evening of surgery. The patient is well covered with pain killers.

Patient the evening of surgery. He was able to keep his leg elevated 10 minutes above the bed level. On right, knee flexion obtained by the patient on the evening of surgery. The patient is well covered with pain killers.

Patient initiating on Post-Operative Day 1 to walk with full weight-bearing with a walker.

Patient initiating on Post-Operative Day 1 to walk with full weight-bearing with a walker.

Left: Patient performing 20 min of bike... 2 hours after operative room discharge (bifemoral cosmetic lenghtening)! Right: Patient 2.5 hours after discharge from the operating room for a femoral derotation and lengthening surgery.

Left: Patient performing 20 min of bike… 2 hours after operative room discharge (bifemoral cosmetic lenghtening)!
Right: Patient 2.5 hours after discharge from the operating room for a femoral derotation and lengthening surgery.

Pain

Although each patient will feel a different level of pain, there will be a strong link to stress level in every case; some patients will feel very little following the surgery, whilst others will find it intolerable. Painkillers should reduce any discomfort.

Early postoperative pain

If a patient feels pain near the start of the postoperative period, the anesthesiologist can treat this with medication.

 

Painkillers can be administered via a femoral catheter or epidural, however any drug offered to reduce the pain will not interfere with muscle action, in order to prevent any suspension of the recovery process. Choice of medication be administered on a patient-by-patient basis.

Morphine patches are also beneficial. The pain following the operation will take a few days to reduce.

Pain linked to the ratcheting and the lengthening procedure

It is possible that pain during ratcheting could occur at the start of the lengthening procedure, if the patient has regained normal mobility or is psychologically unprepared. Generally, when the patient is prepared for the process, any pain seems minimal, if present at all, but will always be concurrent with the patient’s psychological stress. The pain can be felt with either the internal or external fixators. Although some patients opt to abandon the treatment at this stage, the pain itself is an infrequent feature at this stage of the procedure.

Minor pain linked to muscle adaptation may occur, and this does remain for a while. One could compare it to the “growing” pain felt as young peoples’ bodies develop, or to pain from excessive exercise. Likewise, this pain is generally experienced during procedures relating to lower limbs, which are naturally limited to a maximum gain of 5 cm per year (3 cm/year on the femur).

 

In the case of surgical lengthening, a 10cm femoral gain can be obtained in 3 months. It takes longer for the femur to get used to this unnatural gain, which consequently causes pain, particularly at nighttime, during periods of low activity and stimulation.

 

Pain which occurs 2-3 weeks following the procedure can be associated with strong bone formation, which can be a sign of premature bone fusion. At this point, ratcheting can be hard, if not impossible, to perform. A general anaesthetic may be needed for between 3 and 5 minutes in order to reduce the painful reaction and allow the strong bone to form. If this is not identified in time, another operation may be required to cut into the new bone. In the majority of cases, one operation, done under general anaesthetic, is able to solve this problem, and your surgeon can usually anticipate any signs of this happening.

 

At roughly 5 or 6 weeks after the operation, the pain level should be minimal. By then, only stiffness, night pain and some minor skin irritation remains. When possible, lowering the rate of distraction helps decreasing the pain.

 

Ratcheting Maneuvers

 

Pictures of alternative inwards and outwards maneuvers for ratcheting the nail.

Pictures of alternative inwards and outwards maneuvers for ratcheting the nail.

Maneuvers to lengthen the leg – alternating inward and outward leg rotations – can be performed by the patient, their family, surgeon, or physiotherapist.
 
A patient who executes these maneuvers will often be able to find the position which suits them best, and consequently allow them to relax. Ratcheting is usually performed with the knee partially flexed and the hip completely flexed. It is also possible to totally extend the knee, allowing the patient to “roll” their leg. For patients with ligament laxity, the joint should locked first, before being rotated a further 20 degrees.
 
Fifteen “back-and-forth” ratcheting lead to 1 mm of length gain. Three times a day, the patient should performs 5 clicking maneuvers, starting on the fifth day after the operation. This should be performed when the muscle is in a relaxed state, usually following a session of physiotherapy.
 
If a patient is concerned about performing these rotary maneuvers, a general anaesthetic can be administered for between 5 and 10 minutes, which allows the surgeon to assist with ratcheting. However, if the knee is capable of its complete range of motion, and the patient is relaxed, it should otherwise be painless. Care during surgery, and adequate physiotherapy, can reduce ratcheting problems and eradicate the need for general anesthesia to allow ratcheting to occur.
 
ratcheting-maneuvers2
 

Joint Motion

The Table above shows the motion obtained (lines, in degrees of flexion) according to the postoperative weeks, with the Albizzia technique with Dr. Guichet (continuous lines) and with external fixators (discontinued lines) for the same gain of 6 cm on femurs. The advantage of the Albizzia is obvious.

The Table above shows the motion obtained (lines, in degrees of flexion) according to the postoperative weeks, with the Albizzia technique with Dr. Guichet (continuous lines) and with external fixators (discontinued lines) for the same gain of 6 cm on femurs. The advantage of the Albizzia is obvious.

 

With an external fixator, femoral lengthening drastically reduces the motion of the knee to only 50 degrees, though this is sometimes less. Full 120 degree motion is recovered around 17 months after the surgery.

 

A lengthening nail also impairs knee motion, particularly when rehabilitation has not been correctly completed, or in the case of isolated problems. In Dr. Guichet’s experience, being able to bend the knee 120 degrees is usually possible if motion was normal before the operation.

 

The table below depicts how motion is recovered (in degrees of bending) with each week following the operation, in the case of the Albizzia® nail, compared to motion obtained with external fixators.

 

Hip and ankle motion can also be impacted following the procedure. Other than some specific cases, thejoint-motion joints themselves are not affected, though, the surrounding tendons are rendered too short for the length of bone to which they are attached, which reduces motion range in the joints.

 

Joint motion, often relating to muscles which cross joints (biarticular muscles), is not permanently reduced, but improves gradually as the muscles and tendons adapt to the procedure. Bending does not generally cause problems; hip extension is reduced temporarily, but this brings on an an anterior pelvic tilt which can be rectified by resuming walking. The knee can be left with a mild bend, but full recovery is achieved in the majority of cases. Strong abdominal and lumbar muscles can enable the patient to maintain pelvic straightness, which allows them to avoid any further tilting.

 

Flexion and Extension of the knee at a 50 mm gain.

Flexion and Extension of the knee at a 50 mm gain.

 

Rehabilitation

 

Patient performing stretching exercise of anterior rectus of the quadriceps. She is tensioning an elastic band and then contracts glutei muscles to extend the hip, which in turn tenses the anterior rectus.

Patient performing stretching exercise of anterior rectus of the quadriceps. She is tensioning an elastic band and then contracts glutei muscles to extend the hip, which in turn tenses the anterior rectus.

The reactions and adaptations of muscles during the procedure adheres to general physiological rules, which frequently run counter to those taught at traditional recovery facilities. That is to say, it is specific, and must go along strict guidelines in order to stop muscles and tendons from demonstrating inflammatory reactions, and could consequently lead to bending deformities, stiffness, and complications.
 
The lengthened muscle behaves similar to the adolescent muscle: it takes time to get used to bone growth. In an adolescent, 3 cm of growth in the femur may take 1 year of adaptation. In surgical lengthening, this gain takes 1 month, but the process continues and may need a further 11 months, depending on the status and age of the patient.
 
Active stretching exercises are highly recommended. Once the patient has learned the different methods of exercise from the physiotherapist, they will be able to perform them themselves. Any passive stretching is prohibited.
 

Flexion deformity of the hips and of the knees after a 65 mm femoral lengthening. An intensive rehabilitation will allow recovery of full extension after muscle and tendon relaxation (loosening).

Flexion deformity of the hips and of the knees after a 65 mm femoral lengthening. An intensive rehabilitation will allow recovery of full extension after muscle and tendon relaxation (loosening).

Rehabilitation and exercises are dependent on the biological phase of healing.
 
Rehabilitation is designed to achieve the following aims:
 
• Recovery of muscle force and joint motion before the operation.
• Maintenance of the maximal joint motion permitted during lengthening.
• Program of strengthening, with an emphasis on instant force and endurance.
• Active stretching exercises.
• Anti-inflammatory action.
 
The rehabilitation program pioneered by Dr. Guichet and implemented in the rehab Centers – Mr Serge Conesa in Marseille, and the Isokinetic Center in Milan – enables maximum recovery depending each patient’s biological reactions.
 
Once the lengthening procedure has taken place, patients are recommended to perform between 4 and 7 hours of rehabilitation per day, in order to let them go back to their day-to-day activities more quickly.
 

Gait

Unilateral lengthening

In unilateral lengthening, patients can begin to walking with canes again from the day of the operation. They may also be allowed to bear their full weight, under protection. Many sports activities will also be allowed before the end of the lengthening process.

Bilateral lengthening

In bilateral lengthening, weight-bearing recommendations are dependent on the specific patient and their unique constraints. Unconstrained weight-bearing and walking may begin to wear down the nail mechanism, and impede further lengthening.
 
Dr. Guichet will offer full recommendations to avoid any problems linked to full weight-bearing in these cases.
 
Over an hour of walking per day is not recommended during the early stages of the rehabilitation process, but by the end, there should be no limitations. If a patient does not walk enough, a pelvic tilt may be induced, leading to a lapse in the full recovery of their previous gait. One hour’s daily walking on a flat surface is generally recommended.
 
When the lengthening has finished – if the procedure has been a success – the patient should be able to walk without restriction. In the ensuing months, their ambulatory capacity should improve greatly, and some patients can walk from 8-10 hours a day roughly 2-3 months once the operation has taken place – generally in the case of increases of 4-9cm.

Patient walking with no limping and no crutches on the last day of a 8.5 cm bifemoral lengthening (she prepared for 2 years). She left Marseille leaving her crutches in Marseille...

Patient walking with no limping and no crutches on the last day of a 8.5 cm bifemoral lengthening (she prepared for 2 years). She left Marseille leaving her crutches in Marseille…

Walking pattern of a patient after a lengthening procedure with a nail

After the lengthening, particularly in the cases of shorter patients, their gait can be briefly disturbed, but returns to normal following bone fusion.
 
In other centres, this can take between 30 and 40 days per cm. However, Dr. Guichet has reduced this to 15-20 days per centimetre.
 
An extremely well-prepared patient can expect to walk visibly ‘normally’ up to 6 months after a 6-7 cm gain, but 12-16 months after a 10 cm gain. For less trained patients, recovery can take up to 12-14 months for a 6 cm gain.
 
Gait reflects the change in muscle and soft-tissue, particularly in biarticular muscles.
 
Lower limbs can frequently be stiff, even when a patient continues to exercise a range of motions in their individual joints. Stiffness of the lateral band can bring on a gait with minor internal rotation of the hips, causing the legs to appear a little further apart. The percutaneous surgery does not induce limping, though pelvic stiffness may lead to a minor waddle; the pelvis tilts forward, on account of a stiffness in the quadriceps’ anterior rectus. This will take longer to go away, as this muscle takes more time to stretch.
 
When seated, a patient will also be able to notice the results of the lengthening: due to a comparative stiffness in the hamstrings, they will not be capable of tilting their pelvis and torso entirely forward while their knees are straightened. These signs will generally vanish a few weeks after completion of the procedure.
 

Sports

Apart from contact sports, and activities involving jumping, patients who have undergone bilateral and unilateral lengthening can resume many sports soon after surgery.

Swimming

Swimming is reintroduced early following a bilateral lengthening procedure, as an integral part of Dr. Guichet’s rehabilitative protocol, with the intention to swim lengths of the institution’s Olympic-sized swimming pool, rather than simply floating in the water. Generally, thirty to sixty minutes of swimming will make a patient tired.

After 5 cm lengthening, this patient could swim for one hour beginning the third week after surgery.

After 5 cm lengthening, this patient could swim for one hour beginning the third week after surgery.

Static Bike

static-bike
Static cycling is often introduced the day after the operation; to begin with, the bike will be set with no resistance, and is encouraged to last for 90 minutes daily.
 
Muscle reinforcement is initiated 2 to 3 weeks following surgery, without rotator stimulations. Resistance is gradually increased up to 80% of the maximal resistance.

Stepper

A stepper is generally introduced before the end of the procedure, though it is closely monitored in order to avoid the nail being too greatly strained. Use of the stepper restores the instant and endurance muscles, permitting the patient to regain their ability to take long walks.

Patients in thepostoperative period on steppers.

Patients in thepostoperative period on steppers.

During the rehabilitation process, any contact or impact sports are greatly discouraged in order to prevent mechanical failure and providing too much strain on the nail. Throughout the lengthening and healing phases of recovery, patients are allowed to engage in light sports, and your surgeon will provide rigid guidelines on when they can resume these. At least twelve months should elapse after the operation in order to ensure that the patient has grown accustomed to the new length of their limb.

a strong lumbar and abdominal walls muscle force prevents pelvis tilt.

a strong lumbar and abdominal walls muscle force prevents pelvis tilt.

 

Daily Life, Recovery and Removal Periods

During the lengthening phase, physiological modifications can impede a patient’s everyday activities; however, if a patient is careful to adhere to the surgeon’s instructions, the lengthening will be successfully completed.

Unilateral lengthening

Following unilateral lengthening, patients regain their capability to function on their own within a week.

Bilateral lengthening

After bilateral lengthening, it usually takes more time for a patient to recover their independence, due to the increased trauma from surgery. In general, the patient should be able to use the toilet within days.
 
The patient is generally discharged from the facility three days after the operation, and goes to live in the centre in Marseille, where daily activities are slowly reintroduced. The patient should remain near the hospital for the entire duration of the lengthening, or at least for 4 weeks in order to avoid any further complications.
 
During this period, it is important to have external help from a relative or friend, in order to perform tasks like cooking or shopping, which will be harder to perform independently. A list of home helpers is available from Dr. Guichet on request. By the end of the first week, patients should be able to begin shopping or walking to restaurants independently.
 
Patients are recommended to avoid driving until no more than six weeks after the procedure.
 
A patient can go back to work between 2 and 6 months after a procedure between 4 cm and 9 cm. How long it will take a patient to resume certain activities is related to their individual needs. For example, some patients who undergo a lengthening of up to 9 cm can resume work 5 months after surgery, while others only moderately tolerate a 5 to 6 cm lengthening.
 
Recovery will always be a time-consuming process, though it is important to remember that it takes 5 years to adapt to a natural 6cm lengthening, rather than one year with surgery.
 
Day to day activities can be resumed more quickly if the patient has not used external fixators, and ensures early weight-bearing exercises. However, some patients who anticipate a full lengthening gain, and can go back to usual activities the day after surgery.
 
Contact sports can be recommenced following full bone fusion – usually between 5-8 months after the operation.

Steps for standing-up from a chair, with initial unloading of feet.

Steps for standing-up from a chair, with initial unloading of feet.

daily-life

Follow-up after lengthening

When a patient suffers no post-operative difficulties, x-rays are taken on a fortnightly basis. Once healing is complete, and the bone has fused, a final clinical examination will be undertaken by your surgeon.

Nail removal

Nails can be removed between 1 and 2 years after insertion; this can be done as an outpatient procedure, though in some cases it takes place over a two-to-three day period of hospitalisation. The procedure is important, as it prevents long-term catalytic corrosion, and ensures that the bone entirely regains its mechanical properties.
 
Removal of the nail does a bone with holes, which will get replaced by new bone. After the removal, walking is encouraged straight away, though Dr. Guichet encourages the use of crutches for up to 3 weeks. Contact or impact sports can be undertaken once the bone has fused completely, which takes between 3 and 5 months.

 

Dietary intake

dded intakes which can be used in a lengthening procedure (proteines, glucosamino-glycanes, etc.).

dded intakes which can be used in a lengthening procedure (proteines, glucosamino-glycanes, etc.).

Since more calories are needed to help muscles grow, patients need to alter their diet before and during the procedure. For example, an 8 cm to 10 cm lengthening could require the consumption of up to 1000 additional Kcal/day – by comparison, an athlete in training for competition may require an extra 600 Kcal/hour. During lengthening, the muscles are strongly stimulated, so an improvement in their strength and adaptation can only go ahead if the muscles’ caloric needs are met.
 
Likewise, the muscles and bones require a greater level of calcium.
 
Vitamins, minerals, and amino acids are necessary to induce the body’s feeding and growth mechanisms, and iron is important in the event of of blood loss.
 
Dr. Guichet’s team will provide assistance around your dietetary intake during this time, and continue to provide help after the procedure.
 
For example, since new nerve membranes are 30% cholesterol, it is recommended to eat 3 eggs a day. Trying to suppress cholesterol intake is not recommended during a lengthening, and it is unlikely that you would be able to overload your body.
 
Weight loss during lengthening would suggest a negative metabolic balance, which would necessitate a change in diet.
 
Psychological distress during these procedures are frequently related to problems with muscles or insufficient caloric intake.