Abstract
Background
Cosmetic limb lengthening has been rapidly growing ever since the advent of the external fixators magnetic lengthening nails. Similar to all surgical procedures, cosmetic limb lengthening is not risk free. This paper presents a series of complications encountered and treated at a specialized limb lengthening and deformity correction center, along with an analysis of potential risk factors.
Methods
A series of referred patients for complications after limb lengthening using IM nails were identified. Collected variables included demographics, place of index surgery, complication, and treatment of choice and outcome of treatment.
Results
22 limb lengthening procedures were identified. Most of these cases were done outside of the U.S. Hardware failure occurred in 23 % of index surgeries, primarily affecting femurs. Mal/nonunion rates were high (45 %), with femurs most affected. Iatrogenic deformities, primarily tibial, and soft tissue complications including contractures and nerve entrapment were observed. Treatment strategies included hardware exchange, bone grafting, and soft tissue release. All patients were successfully treated without any patients suffering from serious long term irreversible outcomes.
Conclusion
This study examines the surgical management of complications arising from cosmetic limb lengthening procedures at a single institution. We provide insights into effective treatment strategies and highlight the risks associated with medical tourism for these procedures. Our findings demonstrate a rising incidence of complications linked to international limb lengthening centers.
1. Introduction
Limb lengthening has been a rapidly expanding practice since the development of distraction osteogenesis by external fixation first described in 1951 and introduced to the western world in 1989.1 This technique has been associated with several complications including pin-site infection, ankle equinus, delayed consolidation of regenerate, fracture of regenerate, osteomyelitis, etc..2 Distraction osteogenesis over a motorized intramedullary nail (MILN) has subsequently grown in popularity due to its considerably lower complication rate and high precision,3, 4, 5, 6, 7 but still presents with substantial risk.1
As limb lengthening techniques are better understood, the popularity of limb lengthening for cosmetic purposes has also grown, but this has not come without significant pushback regarding ethical concerns.8 Some consider the invasive procedure for cosmetic purposes to be an unnecessary risk without adequate reward, but others consider “height dysphoria” as a psychological condition which can be treated with lengthening and contribute to patient satisfaction.5,8 Given this controversy, access to this kind of service is extremely limited, often motivating patients to seek this procedure at different national and international centers where there is incongruity among accepted practice. Additionally, medical tourism is a rapidly growing practice for U.S citizens to receive lower cost cosmetic procedures typically not covered by insurance.9 This potential cost advantage, however, comes with an inherent risk of several severe complications including infection, abscess, and skin necrosis among others.10,11
These factors, in the sphere of distraction osteogenesis, leave room for several debilitating post-operative complications that must be addressed.2,5
Only a handful of medical centers across the world possess the capabilities to amend these complications. Our institution is one dedicated center that receives many of such cases and has the potential to improve the quality of life of patients with unfavorable cosmetic and functional outcomes. Three surgeons at this center possess the relevant knowledge and experience vital to addressing these unfavorable outcomes. On average, our center provides cosmetic stature lengthening surgery and care for more than 50 patients yearly. The present study sought to provide initial observations on our experience correcting complications following cosmetic procedures at other limb lengthening centers. Specifically, we sought to evaluate relationships between location of index surgery, demographic considerations, common complications seen, and approaches to mending these complications.
2. Methods
2.1. Patient selection
After IRB (institutional review board) approval, we conducted a retrospective review of medical records of all patients referred to our center for revision surgery following complicated cosmetic limb lengthening procedures between January of 2021 and December of 2023. Patients who underwent index procedures, intramedullary limb lengthening, including bilateral femoral, tibial, and fibular lengthening for height dysphoria and received secondary intervention by a surgeon at this institution were included in the study, complications of grade III on the modified Dindo et al. system were included.12 Patients seeking secondary intervention for an index surgery performed for any reason other than height dysphoria were excluded. The remaining cohort included nine patients, eighteen limbs, and twenty-two long bones, tibia and/or femur.
2.2. Data collection
Variables of interest included baseline demographics, location of index surgery, hardware used in index surgery, laterality, operative bone, type of complication, nature of hardware failure, corrective surgery, replacement hardware, and outcome of corrective surgery. Complications following index surgery included hardware failure, mal/nonunion, abduction and flexion contractures, nerve entrapment, and anatomic deformity. Intraoperative complications included foreign hardware without matching surgical equipment. Postoperative complications included DVT requiring IVC filter.
2.3. Statistical analyses
Categorical variables, including comorbidities and complications, were analyzed using chi-square (X2) tests in bivariate calculations. Continuous variables were evaluated using Student's t-tests. All analyses were performed using R Studio (Statistic Department of the University of Auckland, Auckland, New Zealand) with significance set at P < 0.05.
3. Results
3.1. Demographics
Of the nine patients, undergoing bilateral cosmetic limb lengthening, (eighteen limbs) and presenting to our practice, eight patients were male and one female with no listed medical comorbidities. The average patient's age was thirty-four years old, ranging from nineteen to forty-five. Three (33 %) patients received their index surgery in Turkey, two (22 %) in Greece, one (11 %) in Germany, one (11 %) in continental U.S., and two (22 %) were unknown.
3.2. Surgical characteristics
Surgical attributes of the cohort included eighteen limbs and twenty-two long bones, all patients had bilateral femoral lengthening with 2 of them had undergone concomitant tibial lengthening. Two of the nine patients presented to our center during their lengthening phase, while 7 presented post lengthening and during consolidation. Of the twenty-two bones receiving index surgery, five (23 %) sustained hardware failure including three (14 %) plastic deformities and two (9 %) hardware breakages. Nine (45 %) bones sustained non/malunion and four (25 %) bones sustained iatrogenic deformities. Of the eighteen limbs evaluated, two (11 %) sustained abduction contractures of the hip and flexion contractures of the hip and knee. One (6 %) limb sustained common peroneal nerve entrapment. Fig. 1 show a case of non-union post lengthening, while Fig. 2, Fig. 3 shows bone healing after exchange nailing.
Fig. 1.
Case of bilateral femoral non-union post lengthening after limb lengthening.
Fig. 2.
Right femur with complete resolution 3 months after exchange nailing.
Fig. 3.
Left femur with complete resolution 3 months after exchange nailing.
Of the five hardware failures, five (100 %) occurred in femurs. Four (80 %) were treated with femoral exchange nailing, and one (20 %) was treated with nail removal. Of the nine instances of mal/nonunion, five (56 %) occurred in femurs, two (22 %) in tibias, and two (22 %) in fibulas. The five femurs were treated with autograft and exchange nailing, and both fibulas and tibias were treated with autograft and plate fixation. One fibula was treated with bioactive glass. Three tibias and one femur sustained iatrogenic deformity. All three tibias were treated with computerized circular external fixators and malunion repair, and one femur was treated with lateral open wedge osteotomy and plating. Both abduction/flexion contractures were treated with iliotibial fasciotomy and the common peroneal nerve entrapment was treated with fascial release.
3.3. Outcomes
During surgery one (4.5 %) bone had an intraoperative complication regarding unknown screw dimensions and difficult nail removal. One patient had a post operative complication (DVT) requiring an IVC filter. There were no complications relating to recovery and function following surgery. Table 1 shows different types of initial presentations that required further surgical intervention.
Table 1.
Different types of complications and surgical approach for treatment.
| Presenting complication | Treatment |
|---|---|
| Femoral Non-union, hardware breakage | Exchange nailing |
| Femoral non-union, Hardware bend of 8° or more | Exchange nailing |
| >5 cm bone defect in femur following lengthening | Tibial proximal tibia metaphysis bone harvest. Femoral non-union bone grafting |
| Severe abduction contracture of hip, Flexion contracture of hip and knee | Iliotibial fasciotomy at superior pole of the patella |
| Femoral non-union | Nail removal, non-union repair with bone graft, prohpylactic fixation with intramedullary nail |
| >8 degrees of plastic deformity with malunion | Exchange nailing |
| Tibial non-union | External fixator application |
| Iatrogenic tibia malunion | Hardware removal, application of computerized circular external fixator, malunion repair |
| Valgus deformity with broken tibial nail | Tibial hardware removal, application of computerized circular external fixator, malunion repair |
| Valgus knee deformity with broken femoral nail | Nail removal, open wedge lateral osteotomy and plating |
| Anterior lateral proximal tibial pain | Nail removal |
| Common peroneal nerve entrapment | Fascial release to free common peroneal nerve. |
During follow-up, 3 patients, 1 undergoing 4 segment lengthening and 2 undergoing femoral lengthening had flexion contractures of no more than 20° that resolved with intensive physical therapy. At 1 year follow-up all patients were full weight bearing, ambulatory with 1 patient suffering from tibial tubercle knee pain after tibial nail removal.
4. Discussion
While several studies have elucidated outcomes and complications of cosmetic limb lengthening, none have investigated the techniques or experiences in surgical revision of these complications. Our main objective was to detail our institution's initial experience revising complications arising from cosmetic limb lengthening at other institutions. Our main finding was that most complications derived from non/malunion, hardware failure, and skeletal deformity following lengthening. Main surgical interventions included autograft, exchange nailing, and external fixator application respectively. While these results require further corroboration and confirmation with a larger patient population and more robust statistical analysis, this study serves as a novel outline for an important topic not yet addressed by the current literature.
We acknowledge potential limitations of our study. The retrospective design of the study makes it difficult to control confounding variables. While we did collect data regarding other contributing factors, such as pre-existing deformities and comorbidities, we did not account for them in our outcomes. The small patient number and limited availability of follow-up data hinder the generalizability of the findings. Due to the lack of literature in this area, however, the novelty of the current study justifies the preliminary reporting of our findings. Additionally, we did not include a control cohort of patients who underwent similar procedures performed by nonspecialized surgeons. Data was obtained from chart review of medical records and may be subjective or incomplete. The value of our study lies in the novel nature of our preliminary results. We can now derive insights about limb lengthening complication revisions and institution-specific knowledge about specialized, hospital-based limb lengthening and deformity services.
The paucity of data regarding cosmetic limb-lengthening complications is likely secondary to its relatively rare use in practice as well as controversial opinions on the practice itself.8 However, limb lengthening techniques have been used frequently for the past two decades to address functional deficits resulting from limb deformities. These data can help provide insight into expected potential complications that arise when performing distraction osteogenesis for cosmetic limb lengthening. A review of the topic has provided an extensive list of these complications which include failure of distraction, insufficient regenerate and non-union, device breakage, iatrogenic deformity, joint contracture, and joint subluxation among several others.13 Addressing these specific complications is paramount in limiting undesirable consequences and establishing a consistent protocol when they do arise.
4.1. Demographic considerations
Of the nine patients sampled in this study, eight were males, and seven of nine were under the age of forty. Unfortunately, due to lack of literature on the topic, it is difficult to analyze the demographics of height dysphoria and determine trends in patients seeking cosmetic limb lengthening intervention. However, it is a common presumption that males place greater importance on height as part of their identity. This increased load may contribute to greater social pressures and cognitive dissonance around their stature, motivating them to seek surgical intervention. Given this anecdotal notion, one may assume that most limb-lengthening complications occur in men because they comprise an overwhelming majority of participants. Similarly with age, predominantly younger men place greater stress on their stature and appearance, leading to a great number of young men seeking limb lengthening procedures, leading to a greater number of complications occurring in younger populations.
Of the nine patients in this cohort, six received their index surgery at non-U.S. institutions, one at a U.S. based institution, and two at unknown institutions. Medical tourism is a rapidly growing practice for United States citizens14 with some countries offering affordable procedures for as low as a tenth of the price.15 Despite worrying trends in complications and dissatisfaction rates in patients opting for medical tourism, the practice is expected to continue expanding.16 Current literature suggests that medical tourism outside the United States, despite its lower up-front costs, come with higher risk for costly complications and financial strain for both the patient and the hospital system.17,18 Our preliminary results seem to corroborate these findings and highlight a health and financial concern associated with medical tourism for cosmetic limb lengthening. Furthermore, in reviewing the cases of the two patients who did not disclose the location of their initial limb lengthening procedures, it is essential to consider the underlying reasons for this omission. It is highly unlikely that these patients are genuinely unaware of where they received their surgical interventions. Rather, their reluctance to provide this information may stem from a fear of judgment or potential repercussions. Patients who seek medical care outside of the United States, particularly for elective procedures such as cosmetic limb lengthening, may fear being perceived as reckless or uninformed. They may also worry about the reaction of their primary surgeon upon discovering that they sought corrective treatment elsewhere, particularly if complications have arisen. This situation is further complicated by the stigma associated with cosmetic limb lengthening, a procedure that is often viewed with skepticism and concern due to the risks involved and the perception of it being an unnecessary enhancement.
4.2. Hardware failure
Of the twenty-two bones receiving index surgery, five (23 %) sustained hardware failure including three (14 %) plastic deformities and two (9 %) hardware breakages. All of these occurred in femurs. All hardware failures displayed concomitant mal/nonunion at the osteotomy site, and there was no association between type of hardware used and failure. In four out of five cases, the surgeon opted for exchange nailing with Smith and Wesson brand MILN's, and in one case opted for plating with Synthes Tomafix. All cases were additionally treated with bone autograft at the osteotomy site.
Hardware failure is an uncommon but feared complication of distraction osteogenesis.19,20 Current literature states that risk factors for hardware failure in typical intramedullary nails include smoking, diabetes, trauma, and improperly sized nails.21 However, magnetic intramedullary lengthening nails (MILN) pose a greater risk for hardware failure given their telescopic structure and mobility.13 A similar study from this institution reports a 9.5 % failure rate in MILNs, with 63 % of those cases amendable by additional surgery.22 Many techniques exist for removal of broken intramedullary nails,23 but hardware retrieval can prove to be a difficult task. In our preliminary study, two complications arose removing broken hardware in five femurs (40 %). Additionally, all techniques for broken hardware removal assume that the nails are cannulated. In one case a portion of the distal femoral nail was found to be incarcerated in a femur, and the portion of this nail was not cannulated. The surgeon made the decision to tap the incarcerated piece in a retrograde manner from the hip to the knee and use a bone hook to hook into one of the locking holes. Another paper employed a similar technique for removing broken hardware,24 but other case reports have reported other techniques.22,25, 26, 27 None the less, removing broken, non-cannulated femoral nails is a topic of discussion requiring further investigation.
4.3. Non/malunion and deformities
Nine (45 %) bones sustained non/malunion and five of these bones were associated with hardware failure. The type of non-union typically displayed secondary to distraction osteogenesis is categorized as hypertrophic non-union,20 and is often caused by instability at the osteotomy site.28 In cases other than hardware failure, hypertrophic non-union may be caused by too swift of a lengthening regimen or may be iatrogenic. In case 2, the patient lengthened as much as 1.5 mm per day for two months, resulting in bilateral femoral 5 cm bone defects. Technique for non-union repair relies heavily on extent of non-union, bone affected, and surgeons’ preference. In all five cases, femoral non-unions were treated with nail exchange, and four out of five employed temporary external fixator stabilization to prevent rotational deformity during exchange nailing. One of four (25 %) tibial/fibular non-unions were treated with exchange nailing, while three of four (75 %) were treated with nail removal and plating. Poutoglidou et al. provide a comprehensive treatment algorithm in cases of fracture non-union,29 but this kind of resource is yet to exist in non-union following distraction osteogenesis.
Four bones sustained iatrogenic deformity, with three occurring in tibias and one in a femur. All three tibial deformities were multiplanar and complex, requiring use of a computerized circular hexapod for gradual deformity correction. Intrinsic to the MILN is the inability to address rotational deformities should they arise, necessitating the use of external fixators for gradual deformity correction30,31 in these cases. In case 8, the previous surgeon had attempted multiple exchange nailing procedures in attempt to correct anterior and valgus deformity prior to presenting to this institution.
4.4. Contractures
One patient sustained bilateral abduction contractures of the hip and bilateral flexion contractures of the hips and knees secondary to failure of the index surgeon to perform IT band tenotomy. It is well documented in the literature that femoral lengthening over a MILN requires IT band release to prevent knee contractures.3,32 This complication was easily amendable with transverse transection of the IT band with immediate relief of abduction contractures and improvement in knee and hip flexion contractures.
4.5. Complications prevention
Preventing complications is paramount and is best achieved through close monitoring during the lengthening process. Bi-weekly followups are essential to detect early signs of problems. Poor regenerate, neurological deficit, particularly the common peroneal and saphenous nerves, joint contracture or implant failure are the most common problems faced. At the first indication of these issues, identifying and addressing risk factors and adjusting the rate of lengthening can solve the problem effectively. Should the regenerate remain inadequate after slowing down the distraction rate, interventions such as the accordion maneuver or acute shortening may be viable options for select patients. In cases of non-union, more invasive measures, like exchange nailing with or without bone grafting may be necessary. Neurolysis of the common peroneal nerve or tarsal tunnel can solve tractions neurapraxia when conservative measures fail. In the most recalcitrant cases where preventative measures fail to solve problems, the lengthening process must be stopped to ensure safety.
Throughout all stages, it is crucial to educate patients on the importance of adequate nutritional intake, adherence to weight-bearing protocols, and maintaining a physical therapy regimen that emphasizes both stretching and strengthening.
5. Conclusion
Our initial, single institution experience provides valuable insight for surgical management of these cosmetic limb-lengthening complications and offers a preliminary framework for approaches to these procedures. We also highlight the dangers associated with medical tourism for cosmetic limb lengthening procedures and demonstrate an increasing incidence of complications associated with international limb lengthening center. The field would certainly benefit from future research assessing cosmetic limb lengthening complication correction on a larger scale beyond the single institution level. With proven advances and benefits of MILN's. Limiting the occurrence and establishing research-backed framework for complications when they do arise should be a great priority for current research in this orthopedic subspecialty.
Source of funding
No funding was received in support of this investigation.
Potential conflicts of interest and funding sources
None are declared.
Ethical Statement for solid state ionics
Hereby, I Akram Al Ramlawi consciously assure that for the manuscript Complications after cosmetic limb lengthening, a specialized center experience the following is fulfilled.
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1)
This material is the authors' own original work, which has not been previously published elsewhere.
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2)
The paper is not currently being considered for publication elsewhere.
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3)
The paper reflects the authors' own research and analysis in a truthful and complete manner.
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4)
The paper properly credits the meaningful contributions of co-authors and co-researchers.
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5)
The results are appropriately placed in the context of prior and existing research.
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6)
All sources used are properly disclosed (correct citation). Literally copying of text must be indicated as such by using quotation marks and giving proper reference.
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7)
All authors have been personally and actively involved in substantial work leading to the paper, and will take public responsibility for its content.
The violation of the Ethical Statement rules may result in severe consequences.
CRediT authorship contribution statement
Akram Al Ramlawi: Conceptualization, Formal analysis, Data curation, Investigation, Software, Visualization, Writing – review & editing. Daniel J. Over: Data curation, Formal analysis, Writing – review & editing. Michael Assayag: Conceptualization, Writing – review & editing. Philip McClure: Conceptualization, Writing – review & editing, Supervision.
Declaration of competing interest
AAR – None; DJO – None MA – Kyowa kirin: Paid presenter or speaker; Nuvasive: Research support; Orthopediatrics: Paid consultant; PKM – Biocomposites: Other financial or material support; MHE Coalition: Other financial or material support; Novadip: Paid consultant; Research support; Orthofix, Inc.: Other financial or material support; Paid consultant; OrthoPediatrics: Other financial or material support; Paid consultant; Pega Medical: Other financial or material support; Smith & Nephew: Other financial or material support; Paid consultant; Stryker: Other financial or material support; Synthes: Other financial or material support; Paid consultant; Zimmer: Other financial or material support
Acknowledgments
None.
References
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