Reaching Greater
Heights
Limb Lengthening
Julie An
Ms. Mary Curtin
Dr. Daniel Tang
3 March 2015
Julie An
Ms. Mary Curtin
Intern/Mentor Program
9 March 2015
Reaching Greater Heights: Limb Lengthening
In this world, there are thousands of people ranging in different heights. Some are very short,
some are very tall, and some are just in between. Once one is past its adolescence and growth
period, it is known that its height will be a permanent physical characteristic that cannot be
changed. Without the use of external objects such as shoes, one’s height cannot be changed
because his or her bones have finished its development. However, an innovation of a concept has
conquered the impossible. Limb lengthening is a concept that was constructed with an idea that
new bone will develop in between segments when enough stress and separation is applied. It
involves a complex orthopedic procedure that allows the creation of new bone even in adulthood.
Born about 50 years ago, it is a fairly new concept that many people do not know of. Since its
inception, it constructed new ways to treat irreparable fractures, deformities, and bone shortening.
The procedure contains the ability to repair illnesses that doctors could not treat and thought
irremediable. This opens a door to thousands of possible patients that could receive treatments
for their illnesses and finally have a life that involves normalcy and peace. In fact, it is recently
becoming more widely known and increasing in usage even solely for cosmetic reasons. The
procedure started with the Ilizarov method, but more new techniques have been developed to
overcome prominent issues such as infection (Paley, Dror.) This deviation from the classic
original method is provoking people to question the effectiveness of the new techniques. Though
research and observation of clinical studies, certain methods appear to stand out when their
advantages and disadvantages are compared. The PRECICE method is the more effective limb
lengthening method than Ilizarov and IKSD because there are fewer complications, more
comfort experienced, and more successful results produced.
Limb lengthening procedure involves a procedure called distraction osteogenesis. It is
comprised of multiple steps/phases: osteotomy, latency period, distraction phase, and
consolidation period. During osteotomy, the bone is surgically spilt into segments. After the
operation, the patient goes through a couple days in the latency period where the bones are left to
rest until the distraction begins. Then, the two segments are gradually separated during the
distraction phase. Finally, during the consolidation period, the separation stops and the bones are
left to heal and grow into solid connected bone (Natu, Subodh Shankar). This separation of bone
allows new bone to form and create a new shape and length for the limb. The choice of which
method/device to use is especially important during the distraction and consolidation phase
because the device determines how the bone will be separated and how the device will hold the
two segments of bone together to ensure a successful union. Limb lengthening techniques can be
separated into two categories: internal or external. The PRECICE and ISKD method are both
internal devices that are implanted inside the patient’s bone (Schiedel, Frank M.) On the other
hand, the Ilizarov fixator is an external device that is constructed surrounding the patient’s limb
in a cylindrical shape. All of these techniques are held in place with screws or rods that connects
to the bone. While each device and method is different, they all embody the same principal of
creation of bone using distractions (Paley, Dror.)
First, due to the fact that the PRECICE method is an internal device, it dramatically
decreases the likelihood of complications that could rise during the procedure. Like any surgery,
there are many risks and complications involved. Infection, refractures, and stiffness can be
acquired through the procedure. Using PRECICE reduces the risk of pin tract infection which
can create additional amount of problems into the procedure. Infection is a frequently appearing
problem when using an external fixator like Ilizarov because the pins are going through the skin
and exposed to the outside environment. Infection can add to the pain that the patients are
already suffering with and bring “mild swelling and redness around the pin site,” and “clear,
yellowish discharge and even frank pus, with general symptoms such as fever and chills”
(Medscape General Medicine). In order to avoid further problems, “there is a constant need for
cleaning of pin sites to prevent infection,” with the Ilizarov method (New Technique for.) It
creates unnecessary stress and obstacles that deviates the patient from getting a faster successful
result. However, with the PRECICE method and its internal rod, the “usual complications related
to the external fixators, such as pin-track infections and mobilization difficulties were not
encountered” (Dinçyürek, H.) The decreased chance of infection alleviates the extra worries and
deviation from getting the best treatment.
In addition to the reduced risk of infection, the internal rod provides stability to the separated
bone segments during distraction and consolidation. Because there is a rod in between the bones,
it has the ability to hold the separated segments together and aligned more effectively. However,
the Ilizarov method only supports the bones from outside which can create a higher amount of
instability. “Forty three patients experienced problems with non or delayed union, mal union,
incomplete osteotomy, premature consolidation of the regenerate or fracture through a pin site”
(Adair, A). It is more likely to refracture the bone with the Ilizarov method. A refracture can
interrupt and even halt the lengthening process and its treatment might need another surgery. It
decreases the rate of recovery and contains the possibility of not achieving a successful
completion and result of the procedure.
Not only can it bring more complications during the lengthening but it can bring further,
long-lasting problems after the procedure. The recovery time could be shortened with PRECICE
because the absence of an external fixator allows the patient to lose less flexibility during the
procedure. Because the limb is free of any constriction on the outside, it can move in more vast
motions. However, the Ilizarov fixator involves a cylindrical metal device surrounding the limb
which constricts the limb from bending or even moving it with ease. When a muscle is not used
or exercised, it can lose its strength and motion. Therefore, muscle contracture can occur easily
when an external fixator prevents the patient from having a wide range of motion (Medscape
General Medicine). The recovery process of gaining flexibility back is long, difficult and can
delay the patient from fully attaining the limb’s normal functions. These complications can
decrease a patient’s satisfaction rate and increase the pain and amount of time needed to see the
successful result.
Furthermore, PRECICE provides a more comfortable experience for the patient through the
procedure. Compared to other methods, less pain will be inflicted during the distraction phase
due to the lengthening technique of the equipment. While IKSD is an internal device, it requires
the patient to rotate the limb to a certain degree in order to lengthen the nail inside (Rozbruch, S.
Robert). Sometimes it involves the patient getting into an uncomfortable position and angle of
the limb which incites pain and discomfort. Rotating a sensitive limb every day in order to
lengthen it can amplify the pain and dissatisfaction with the procedure. There is no awkwardness
of the bulky external fixator (New Technique for) as well. Also, more pain can arise through
neurovascular complications which can occur when the pins are inserted through the soft tissues
into the bone (Medscape General Medicine). Nerve pain is intolerable and the worst type of pain
of all because it is very deep rooted and hard to treat. However, without the need to puncture skin
and muscle tissues, the PRECICE method offers less likelihood of developing neurovascular
complications such as weakness, numbness, and the inability to control the limb’s function
effectively. This advantage is especially more crucial in determining the effectiveness of the
technique because the possibility of more serious complications are greater.
Its internal structure allows the patient to move freely during the procedure. Having to carry
the extra weight of metal pins and bars attached to a sensitive, broken limb compile greater pain
and discomfort. Therefore, PRECICE patients can have a higher activity level (Herzenburg,
John). They are free of any external constrictions and demonstrate a higher ability to move freely.
The patient will be able to have a faster recovery during and after the consolidation phase
because of the ability to move freely. Many Ilizarov patients have “difficulty of doing physical
therapy with the frame on” (New Technique for). Riding a bike or walking can be uncomfortable
and difficult due to the weight and size. Thus, the progress of physical therapy will be slow and
long. This would delay the time the limb is back to its normal function, strength, and range of
motion. Therefore, using the PRECICE method will allow the rehabilitation period to be shorter
because less time is needed for physical therapy. In less amount of time, the patient will be able
to integrate back into the world and start living his or her new life.
Overall, PRECICE offers more successful results with its modern and efficient technology.
The method is one of the newest devices that was developed to overcome the previous
complications. The use of the magnetic device to lengthen the bones in specific increment
amounts allows the lengthening to be more accurate. Patients have great control over the
lengthening with the external magnetic device which interacts with the magnet inside the rod.
(Magnetic Lengthening with Dr. Rozbruch). The machine will show exactly how many
millimeters the rod has lengthened while using the magnet. The device is very convenient and
easy to use that the patient himself can perform the lengthening at home. The PRECICE method
had a higher reliability and accuracy rate than ISKD (Schiedel, Frank M.). It has a better rate
control because ISKD depends on movement (Limb Lengthening) which is unreliable and
inaccurate. Depending on the patient’s rotation of the limb, the bones can be lengthened too
much or too little. The possibility for errors is unknown and risky. ISKD presents no exact way
of ensuring the desired lengthening of the bones.
For areas dealing with real patients, it is important that they were satisfied in the end. It is
one of the most important ways to judge the excellency of a procedure. When using the PREICE
method, the patient’s satisfaction rate is higher at the end of the procedure because all of its
intended goals were met. The PRECICE ensures that the initial desired length is achieved. If the
goals are not met at the end of the procedure, all the pain and stress the patient experienced
would have been a waste. If the results are positive, it is more likely for a patient to see the
procedure as a good, worthwhile investment. The patient can quickly bear full weight due to the
stability of the rod in between the bones and faster progress in physical therapy. On the other
hand, there is less superficial scarring because no external pins were used for the external fixator.
The only scars it will leave on the superficial skin will be barely noticeable because PRECICE is
“a device that can be implanted with minimal incision surgery” (Limb Lengthening.) These small
incisions can heal faster and fade overtime. It is cosmetically better for the patient (Herzenburg,
John). Especially for women, scarring on the legs or arms can be worrisome and even stressful in
consideration of self-esteem and self-confidence. PRECICE eliminates any psychological issues
that could arise and deliver successful results that allow the patient to be content with the
procedure. How a patient feels at the end is most important than any other factors that contribute
to the success of the procedure. It is truly successful if the patient is fully satisfied with the
results.
Through such evidence, the conclusion can be made that the PRECICE method presents a
wide range of advantages over ISKD and Ilizarov method. Risk for complications are lower as
infections, refractures, and inflexibility appear in lower frequencies compared to other limb
lengthening techniques. Patients experience a more comfortable time with the procedure due to
less infliction of pain, more freedom in movement, and shorter duration. Finally, more successful
results are shown through its accuracy, satisfaction rate, and minimal scars. These comparisons
of different limb lengthening techniques emphasize the effectiveness of the PRECICE method by
installing confidence that it can achieve success and improve the limb lengthening field. In order
to initiate new beginnings, the knowledge of limb lengthening and the PRECICE method must
be spread for this knowledge will bring freedom and happiness. This discovery will dramatically
increase the quality of life of the people around the world. It will promise new futures and
inspiration to conquer anything. The impossible has been broken and a new perspective of life
rises. Limb lengthening is a revolutionary invention that will lead the orthopedic field into a
greater future curing millions of people of incurable diseases. There is finally a chance for new
beginnings, new lives, and new world for the hopeless.
Works Cited
Adair, A. "The Complication Rate in Ilizarov Surgery." Orthpaedic Proceedings. N.p., n.d. Web.
17 Feb. 2015. <http://www.bjjprocs.boneandjoint.org.uk/content/85-B/SUPP_II/139.3>.
Dinçyürek, H. "Functional Results of Lower Extremity Lengthening by Motorized
Intramedullary Nails." Acta Orthop Traumatol Turc (2012): n. pag. PubMed. Web. 18 Dec.
2014. <http://www.ncbi.nlm.nih.gov/pubmed/22441451>.
Herzenburg, John. "Satisfaction of patients who have undergone lengthening with both internal
and external fixation: a comparison study." Limb Lengthening and Reconstruction Society.
N.p., n.d. Web. 17 Feb.
2015. <http://www.llrs.org/PDFs/Annual%20Meeting%20Presentations/Friday%20Meetin
g/3.Herzenberg.pdf>.
Limb Lengthening: A New Breakthrough for Limb Length Discrepancy (LLD). N.p.,
n.d. Web. 18 Feb. 2015. <http://www.paleyinstitute.org/?q=node/48>.
Medscape General Medicine. "The Use Of The Ilizarov Method In Children for
Limb Lengthening." Medscape. N.p., n.d. Web. 17 Feb.
2015. <http://www.medscape.com/viewarticle/722302_4>.
Natu, Subodh Shankar, Iqbal Ali, and Sarwar Alam. "The Biology of Distraction Osteogenesis
for Correction of Mandibular and Craniomaxillofacial Defects: A Review." Dental
Research Journal (2014): n. pag. PubMed. Web. 30 Nov. 2014.
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3955310/>.
"New Technique for Tibial Lengthening Applies External Fixator, Intramedullary Nail
Simultaneously." The American Academy of Orthopaedic Surgeons 22 Mar.1998: n. pag.
Web. 20 Oct. 2014. <http://www2.aaos.org/acadnews/98news/tibial1.htm>.
Paley, Dror. "Progress in and from Limb Lengthening." Progress in and from Limb Lengthening
(2014): n. pag. Limb Lengthening. 21 Mar. 2014. Web. 9 Oct. 2014.
<http://www.limblengtheningdoc.org/files/Progress_in_and_from_limb_lengthening.pdf>.
Rozbruch, S. Robert. "ISKD Nail." Hospital for Special Surgery. N.p., n.d. Web. 23 Oct. 2014.
<http://www.hss.edu/files/LL-ISKD-nail.pdf>. PDF file.
Schiedel, Frank M. "How Precise is the PRECICE Compared to the ISKD in Intramedullary
Limb Lengthening?" Acta Orthopaedica 85 (2014): n. pag. NIH. Web. 29 Oct. 2014.
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062798/>.