Overview

There are serious risks involved in the lengthening process, due to the duration of surgery, and because it affects important bones as well as joint and muscle functions. Unlike soft-tissue cosmetic procedures, unilateral and bilateral lengthening are not simply superficial. This means the risk can vary depending on the type of surgery and the extent of the lengthening. It is also important to consider the psychological impact the surgery could have on the patient.

Risk of Lengthening

Less problems arise with the use of nails than with external fixation. However, it is still important to know the associated risks.
As a patient, it is always important to research any surgical procedure you are considering very carefully. It is essential to be given a full explanation of the procedure including detailed risks in order to give informed consent.

Dr. Guichet’s uniquely developed techniques ensure a lower level of risk, because patients can access advances as soon as they become available, ensuring the highest quality limb-lengthening procedures.

So, what are the general risks?

• Infection
• Fracture (bone or material)
• Paralysis
• Premature bone fusion
• Delayed bone fusion
• Joint stiffness

While it is important to be aware of what could go wrong. It is important to note that no instances of deep infection (osteitis, osteomyelitis), paralysis or lasting stiffness have occurred as a result of Dr. Guichet’s femoral lengthening practice to date.

Other possible effects include skin complaints, vascular problems, weight loss, depression or further psychological issues. In some cases occupational ramifications are also worth considering. While a certain level of pain is affiliated with this type of surgery, this is likely to be less of an issue than with external fixators.

Unilateral

A Patient with an initial hip instability. Prior to lengthening with the Albizzia® nail, stabilization of the hip was performed to help reduce risk of dislocation and subsequent complications.

A Patient with an initial hip instability. Prior to lengthening with the Albizzia® nail, stabilization of the hip was performed to help reduce risk of dislocation and subsequent complications.

Other than the risk of advanced healing, general complications will depend on the patient’s history and requirements. For instance, in cases where joints are unstable, there is a considerable risk of dislocation. In patients with a history of bone infections, there is a higher risk of infection post-surgery. With no previously diagnosed bone infections, a patient has less than a 1% risk of infection from a femoral lengthening procedure (under Dr. Guichet.) This is 15% less than the average practice who would be using external fixators.

To further reduce the risk of any possible complications, detailed clinical evaluation and meticulous follow-ups are scheduled. After an initial evaluation the patient will be advised of the more likely risks based on their individual circumstances compared to previous case studies.

Bilateral – Dwarfism

Bone formation 2 months postoperatively in an achondroplastic patient. General anesthesia for ratcheting was required, then a percutaneous bone section for too rapid early healing.

Bone formation 2 months postoperatively in an achondroplastic patient. General anesthesia for ratcheting was required, then a percutaneous bone section for too rapid early healing.

In cases of dwarfism a large amount of length is usually gained (15cm to 18cm per bone segment with the Albizzia®). Risks traditionally associated with lengthening with external fixators are strongly reduced but not entirely eliminated with this method.


Bi-joint muscles experience ‘retractions’, a phase of stiffness that impedes joint motion, which usually means a recovery period of weeks or months post-procedure.

 

In cases of very large lengthening (40% – 60% of the initial bone length), or of uncontrolled, passive stretching, flexion deformity can be noted. This is a deformity that will slowly recover post-procedure but is increased by the existing flexion deformity of achondroplastic patients (naturally occurring hip flexum within the bone).

 

Strong bone healing often follows biological kinetics, which means that healing increases two to three weeks after surgery and plateaus in the first two to four weeks. During this period, the bones may fuse prematurely. If anticipated, further procedures and general anaesthesia for ratcheting can be avoided. With diligent follow-up, this phase can proceed without need for further procedures. The risk of more surgery being necessary, in lengthening for constitutional short stature, disappears within four to six weeks after surgery, where in achondroplasia it may take up to eight weeks.

 

If an increased distraction rate is performed (such as 1.5mm per day) over a few weeks, an adverse nerve reaction may be observed. In this case, increased skin sensation can initially be detected over the ankle or foot. A decrease in sensitivity may also occur at a later stage.

In a small number of patients, nerve reactions are noted and motor signs may appear delayed in terms of sensory signs which could slow the recovery of particular functions. These adverse nerve reactions are generally modest and do not result in definitive paralysis.

During lengthening, skin is stretched, which can result in a transitory burning sensation. If the patient has undergone previous lengthening with external fixators, contact with adhesive scars may cause discomfort. Cosmetic follow-up surgery can resolve or reduce this issue.

Generally, no deep infection, final stiffness or nerve paralysis have been observed where the Albizzia® nail has been used. But, this has not always been the case with external fixators. Osteoporosis has been linked with these, for example.

Internal lengthening nails can also cause osteoporosis. However, if the Albizzia® nail is used and the rehabilitation protocols (as devised by the inventor’s practice) are followed this can be avoided. No instances of osteoporosis have been observed in this instance, due to rapid bone loading.

Skin is stretched at the end of lengthening (see the actual position of the screws (ink crosses) which has migrated from its original position in line with the skin incision. At removal, the screws are again in front of the scar, after skin relaxation.

Skin is stretched at the end of lengthening (see the actual position of the screws (ink crosses) which has migrated from its original position in line with the skin incision. At removal, the screws are again in front of the scar, after skin relaxation.

Bilateral – Cosmetic

Complications in a 20 year-old patient who had a bifemoral lengthening performed in a surgical team not preparing patients and not inserting nails in a stab-incisions way: the bone formation at the regenerate is very weak in front of the place of skin opening (no use of intramedullary saw, left picture). She also presented a hyperossification over the hip which created a tremendous pain necessitating morphin for over one year, with secondary dependency (right). She also presented a foot drop with sciatic nerve paralysis which never recovered. She required 42 general anaesthesia for ratcheting and got no post-operative mobilization. She never recovered full function and limped for life.

Complications in a 20 year-old patient who had a bifemoral lengthening performed in a surgical team not preparing patients and not inserting nails in a stab-incisions way: the bone formation at the regenerate is very weak in front of the place of skin opening (no use of intramedullary saw, left picture). She also presented a hyperossification over the hip which created a tremendous pain necessitating morphin for over one year, with secondary dependency (right). She also presented a foot drop with sciatic nerve paralysis which never recovered. She required 42 general anaesthesia for ratcheting and got no post-operative mobilization. She never recovered full function and limped for life.

Under Dr. Guichet’s team complications are rare. This is due to a good understanding of the patient’s history and biology, preparation of the body and careful consideration of the gain that can realistically be achieved. Complications in unilateral lengthening tend to take place with various stages of involvement.

A reduced biarticular motion range and biarticular stiffness (of muscles that cross two joints) may occur naturally. Such instances of natural occurring complaints should gradually diminish without causing any lasting problems for the patient.

In order to avoid issues that may require secondary surgery, excessive bone formation can be controlled by a surgeon and the daily lengthening rate can be adapted. Doing so in the first few weeks to anticipate further issues will eliminate the necessity for further procedures.

Although very rare, low bone formation and nerve stretching can occur, but these issues generally resolve themselves. In the Albizzia® lengthening process, complications associated with external fixators such as osteoporosis, final stiffness and limping are virtually non-existent.

In summary, risks depend on surgical teams, the care provided and whether the recommended preoperative preparation and post-operative plan is followed. If one of the above elements fails, the results could be major.

The goal of a well planned elongation is that the limb functions either equally successfully or more so, with a short recovery period that allows the patient to get back to their daily routine.

Psychological risks

As with adolescent growth, a lengthening procedure can also have an impact on the brain and on the patient’s daily life.

Body-altering procedures can be likened to the growth of a child. The psychological impact of body changes can be difficult to deal with and patients can often experience aggression and frustration as a result of the pressure these changes put on the body and mind.

Personal trainers provide excellent support and rehabilitation to patients in this instance, and if this isn’t enough Anxiolytic medication may be prescribed.

A psychological evaluation is completed beforehand, but it is still possible that a patient may wish to stop the lengthening process early. This is difficult to predict, but can cause problem

Despite the potential for psychological issues to result, elongation can really transform a patient’s life, boosting self-esteem, strength and confidence and as having a positive impact on their well-being generally.