The risks and rewards of limb lengthening
Limb lengthening is an established treatment which literally means extending the length of your arms or legs.
There are many reasons why people would want this surgery – they include conditions that shorten bone length such as skeletal dysplasia and growth plate fractures, trauma that has resulted in shorter limb length or simply a desire to be taller.
The procedure usually has a high success rate but when it goes wrong, the consequences can be physically and mentally traumatic.
The whole issue of limb lengthening hit the headlines recently with the news that the Royal College of Surgeons is conducting a review of 721 cases Great Ormond Street Hospital in London after concerns were raised about one of its former surgeons, Yaser Jabbar.
Out of 39 cases examined so far, 22 children were said to have suffered a degree of harm, and the hospital said it is taking the concerns “incredibly seriously.”
Limb lengthening surgery is a complex orthopaedic procedure that involves cutting and separating the bone of the affected limb, then gradually lengthening it over time while also stretching the surrounding muscles and tendons.
The process originally pioneered by Gavril Ilizarov, a Soviet doctor treating injured soldiers returning from World War Two can be expensive and painful and it carries a risk of complications from nerve injuries and blood clots to the possibility of the bones not fusing back together.
Stuart Matthews, TLA Director, Co-founder and Consultant Trauma Surgeon, has broad experience in the field of the Ilizarov technique. Prior to becoming a full-time Surgeon in Trauma and Orthopaedic Surgery within the NHS, Stuart served 18 years in the British Army where he was a Consultant Orthopaedic Surgeon to the Defence Medical Services dealing with the surgical rehabilitation of severely injured service personnel. His specialism in trauma involves limb salvation surgery such as the Ilizarov technique amongst other methods. Stuart built up a substantive medicolegal practice in serious personal injury and clinical negligence over this period.
In addition to preparing medical reports for the legal profession both in personal injury and clinical negligence cases, he has also been preparing screening reports for decades and so has also overseen the expansion of TLA’s pro bono service thanks to his in-depth medical knowledge and understanding of medicolegal.
Stuart said: “There have been a number of recent articles in the press and social media recently regarding limb lengthening surgery.
“This is the forced creation of new tissue created by pulling apart a surgically produced division of bone (corticotomy) at a specific controlled rate under a mechanically stable environment achieved by an orthopaedic device.
“This produces a new tube of bone in the gap in the bone that has been surgically divided as well as the creation of a new amount of surrounding soft tissue.”
Ilizarov’s technique used fine wires to transfix bone through the skin and soft tissues via safe anatomical corridors which he then tensioned onto encircling metal rings. These were connected by threaded rods with the rings being held in position by nuts.
By turning the nuts, the relative position of the rings could be altered so manipulating the position of the underlying bone. In the gap created by pulling the corticotomy apart, a tube of new bone very similar to normal bone is formed if the rate of distraction and the mechanical environment was properly controlled.
The new bone is referred to as “regenerate” and the production of good quality bone not only depends on the rate of distraction but on a number of patient-related factors including medication, tobacco consumption and other secondary medical conditions.
Stuart added: “The correct rate of distraction of the corticotomy differs from patient to patient but averages 0.25mm three to four times a day on average.
“Too fast and new bone may not form or nerves and blood vessels maybe damaged by overstretching. Too slow, and the corticotomy may heal before correction is achieved.”
Ilizarov’s circular frame method of orthopaedic bone fixation is still in use along with a similar hexapod frame with cross calibrated clickers. The sequence of turning the clickers is generated by a computer program allowing not only correction of length but also deformity.
It can also be achieved by external fixators or nails inside the bone which are lengthened by the patient twisting the leg or through an externally applied magnetic motor with the correction under the control of the patient.
“Psychological assessment of the resilience and motivation of the patient is important to determine the suitability of enduring and co-operating with what is an arduous procedure. This is especially true in cases of congenital deformity or correction of short stature,” said Stuart.
“This technique is most powerful in treating cases of post-traumatic deformity where bone is missing due to either open fractures or removal of bone because of infection.
“However, there are alternative surgical procedures that can achieve the same objectives, and the reconstructive surgeon must be conversant with the entire range of available methods to offer the best solution according to the individual patient’s needs.”
Established in 2006, TLA offers lawyers and insurers direct access to thousands of internationally renowned medical experts in the UK both in the NHS and private practice. A named, designated TLA Case Manager will liaise and manage the case from onset to conclusion for both expert and client.
The majority of our instructions are for clinical negligence claims and moderate to complex/multi-track personal injury claims and our sister company, 3D Health UK, provides investigations and diagnostics, surgery and rehabilitation during the medicolegal case.