For a femur bone to grow 6cm during adolescence takes 5 years; after a surgical procedure, it only takes 2 months – 30 times more quickly! Imagine the pressure on your joints and body while running 300 miles per hour (500 km/h)! Without preparation, after a surgical lengthening, it can take a patient between 2 and 3 years to recover – and sometimes more. If well prepared, it can take less than 1 year.

Preoperative steps

 
If you are not prepared, you wouldn’t be able to climb the Himalayas or run the New York Marathon. The lengthening process is more of a shock to the body than climbing or a marathon, so the undertaking necessary preparations is even clearer. You must accept taking the time to prepare your body.
 
Lengthening is a long procedure. A patient should understand that they will need to take many weeks off from work, and bear in mind the risks of temporary complications, such as infection over pins with external fixators, transitory stiffnesses, and the difficulties that this scientific procedure may bring.
 
Accepting that some temporary problems may arise, as well participating in thorough preoperative preparation, will be the cornerstone of a successful lengthening procedure.

Personalized pre-operative training

A muscle evaluation before the operation will inform all preoperative training and physiotherapy. An examination at the start of the training course, and prior to the operation is recommended. Muscle and tendon preparation will ensure the best functional recovery after the operation. This will take place in a gym, under the guidance of a personal trainer, at a venue which is convenient for you.
 
Depending on your own individual bodily properties – flexibility, stiffness, joint motion, muscle force, etc. – a custom training package will be designed for you.
 

Type of report provided after an isokinetic test

Type of report provided after an isokinetic test

Isokinetic Testing

Electronic muscle testing (Cybex®) gives an exact measurement of the energy and force developed by muscle groups. Muscle deficiency before or after surgery is accurately determined, and any rehabilitation is geared towards making up for deficiencies in other areas. In limb lengthening with the Albizzia® nail, Cybex® testing demonstrates that endurance muscles, which operate against gravity – such buttock muscles, quadriceps, and calves – are lost. Specific protocols for reinforcing these muscles are put in place, which provides early recovery of functionality, and allows improved overall muscle strength.
 
Gain in muscle force will be measured by tests before and after preparation – both of which take place prior to surgery. A further test before the nail is removed will determine the extent of recovery once the lengthening has been completed, and also whether further training is necessary before the nail is taken out.
 

Psychological evaluation

Psychological evaluation is extremely important. Any limb reconstruction procedure will alter a patient’s self-image as well as the perception of their body image by others. The patient must accept this new vision of their body; a change in self-perception will reduce its psychological impact on the patient, if their the desire for growth is oriented around the physical lengthening process rather than resolving problems with their domestic and social relations.
 
Psychological evaluation also determines those who wish to acquire a physical ‘centimetric gain’. For patients whose demands are less certain, such as those seeking to improve their social relationships, an increase of several centimeters cannot resolve psychological problems. These patients will be assessed, and directed towards psychotherapeutic treatment, which will be more appropriate to resolving their difficulties.
 
Lengthening, or major axis correction, is an intense experience. The process is painful, requiring an extended time commitment, and necessitates a determined and motivated patient to complete it. Patients will feel transitory joint stiffness for several months before they can expect a return to their previous activity and function. Fragile, weak and unstable people will encounter more problems, and will not succeed in the same way during the lengthening process than strong and stable people.
 
The patient’s personality and their ability to deal with this experience will play an important part in the successful lengthening process. Some patients may wish to prematurely halt their lengthening before they reach their original target.
 
The actual surgery and healing process will require a patient to withdraw from everyday professional and scholastic activities; furthermore, transitory complications such as pin infections may also occur. A patient should completely understand and accept these challenges before finishing the lengthening process.
 
The psychological evaluation will include a discussion, tests, and psychological support before or during the procedure, as needed.
 
 
 

Evaluation of Bone Quality

A thorough biological blood check and a DEXA will determine bone quality and improve any medical recommendations following the operation.

Anaesthesia Consultation

The Anaesthetist will make sure that no problems arise which could disturb the anaesthesia, or will preempt any potential issues which may occur. He will also determine which type of anaesthesia and post-operative pain killers would be right for each patient.

Complementary preoperative tests

These include:
 
• Special long-leg x-rays (using ideally EOS technology)
• Cardiological consultation
• Dental consultation
• Blood test and medications to be taken for one month before the operation
• Motivation letter



Preoperative Preparation

Table showing postoperative evolution of muscle force without and with preparation (preoperative gain).

Table showing postoperative evolution of muscle force without and with preparation (preoperative gain).

Unilateral external fixators

One side of the limb will be set with a unilateral external fixator. At the thigh, the fixator is set on the outer lateral side; at the leg, it is set on the inner, internal, or medial side.

 
Devices currently in use include Orthofix®, Heidelber®, Judet®, Wagner®, and FSA®.
 
The main section of the external fixator is linked to the bone using screws or half-pins, which are large in diameter (4 mm to 6 mm). Patients are generally tolerant of the fixator.
 
Therefore, an intensive preoperative training program will be needed to allow for full functional recovery to take place. The training will concentrate on increasing muscle mass – in order to gain in strength – as opposed to remodeling or endurance.
 

Tendon Preparation:
prevention of retractions

Postoperatively, a patient uses a stepper to train. Similar training can be done preoperatively.

Postoperatively, a patient uses a stepper to train. Similar training can be done preoperatively.

A stretching program takes place, which focuses on any stiff or retracted muscles and tendons.
 
Main tendons and muscles to stretch are:
• Hamstrings
• Anterior rectus of quadriceps
• Lateral band of the thigh
• Calves


pre-Operative-last-pic