Leg lengthening process

- First consultation with our leg lengthening specialists Dr. Axel Becker. The consults take place in our clinic in Freiburg (Kaiserstuhlstraße 28). The duration of which is about 2-3 hours:

- General information, presentation of different methods of leg lengthening, explanation of the principle of callus distraction.

- Medical history, physical examination, photo documentation, X-rays of the long bone and discussion of the X-rays. Personal photo simulation of an extension, creation of a preliminary operation plan with selection of an individually-optimal implant. Information about therapy procedures, rehabilitation options, accommodation options, treatment and any additional costs.

For legal purposes the surgical clarification must take place at least 48 hours before the surgery, otherwise it cannot take place at all. For this reason, the patient must be at the location of operation two days before the planned operation date.

- One day before the operation: Pre-op check-up and labs, anaesthesia clarification.

- Operation & First mobilisation on the evening of the day of the operation.

- Hospital stay for about 4 days with subsequent transfer to rehabilitation. Beginning of physiotherapeutic measures in the hospital.

- Rehabilitation phase

After moving to our rehabilitation center (Mooswaldklinikum), there is a phase of intensive physiotherapy and the beginning of clicking-mechanism under supervision.

Rehabilitation in the Mooswaldklinik is included with a stay of up to the 14th postoperative day. Afterwards, each patient is free to extend the rehabilitation at their own expense or to go home. We recommend to stay another 2 weeks in the rehab center to get fit and start the training to walk without crutches.

- Going home

Patients are not discharged to go home until they can safely use the lengthening or click mechanism on their own and have mastered the physical therapy and gait exercises. At home, physiotherapy and gait training must be performed every day. Swimming, massages, training on the ergometer etc. have a supporting effect. Safety, exercise discipline and personal consistency on the part of the patient are very important for the success of the treatment!

- Every six weeks an X-ray should be taken and sent to our institute. At the end of the extension phase, you will see our specialists again as an outpatient. If there are still functional deficits at this point, the physiotherapy plan is individually adjusted.

- If any problems or complications arise, it is crucial to contact our office in Freiburg at once.

- After one and a half to two years, the nail should be removed.

- An appointment can be done by mail or via phone call, after the last X-rays have been controlled. Check-in into the clinic is one day before the operation. The stay afterward is usually one to two days.

All information is provided without guarantee and without liability for the content of websites referred to here.

Surgical leg lengthening with fully implantable intramedullary distraction nails

Bone healing and callus formation

Bone is living tissue that is subject to constant remodelling and growth processes, even in adults.

In the case of a broken bone, what is known as primary bone healing only occurs if the fracture gaps have adapted to the finest of hairs and have been completely immobilised. This means that small tunnels of approx. 0.2 to 0.3 mm are resorbed by so-called osteoclasts. These so-called Haversian canals extend from one fragment end to the other. Subsequent so-called osteoblasts form concentric new bone deposits in these cavities and thus narrow the channels again. In this way, Haversian remodelling (the coordinated activity of osteoblasts and osteoclasts to resorb and replace existing cortical bone) spreads from one bone fragment to the next, resulting in a bridging of the bone fracture directly with that bone corresponding to the original bone in terms of structure and orientation.

However, normally, a broken bone cannot usually be set up in such a way that contact points are created everywhere. There are places with more or less fine gaps. If these gaps are supported by adjacent contact points, they are also subsequently immobilised. In such gaps, lamellar bone (bone substance arranged in layers) can initially form and later tubules are also formed, which grow through from one fracture end to the other and are built up with bone deposits.

In the case of larger crevices and gaps the so-called secondary fracture healing takes place. In the process of this bone healing, a so-called callus is formed. First of all, the action of the osteoclasts on the ends of the fractured fragment creates a rounded fragment end and temporarily widens the fracture gap. Starting from the periosteum, a so-called callus “sleeve” then grows at the fragment ends, which then gradually grows towards the fragment ends and at the same time widens, thus increasing the cross-section in the fractured area.

This precursor of bone tissue, the so-called callus, initially consists of the initial blood clot that formed due to the fracture of the bone, later it turns into granulation tissue, and eventually becomes connective tissue. A fibrocartilage framework develops in this connective tissue, which is further stiffened by the storage of lamellar bone in the meshes. The callus gradually bridges the hernial cleft. The fibrous cartilage that has formed in the fracture gap increasingly calcifies and is gradually built-up through the activity of osteoclasts and osteoblasts.

Principle of callus distraction:

Callus Distraction is when such a callus is stretched by controlled traction on the severed bone and results in length growth. The same processes of new bone formation takes place as it would in bone growth during childhood or in bone healing after fractures. The possibility of callus distraction has been known since the middle of the 19th century, but it only gained importance with the Siberian doctor Prof. Ilizarov (1921-1992). He developed the ring/ external fixator, in which the leg or arm is pierced with thin wires and metal rings are stretched around the limb and connected by spindles, joints and rods. The treatment begins with cutting through the long bone to be lengthened from the outside with a bone chisel. Then the ring fixator is applied and fixed in both halves of the bone with pin wires that are passed through the skin, muscle and bone. The rings of the apparatus are then moved apart with the help of adjusting screws, so that the fracture gap widens. As long as a constant pull is maintained daily, new bone will be created.

The bone itself is not the limiting factor in callus distraction, but rather the soft tissue is. Muscles, blood vessels and nerves also grow with it, but the less stretchable tissues, such as ligaments and tendons, lead to, in the case of large lengthening distances, temporary functional losses. The worst case being displacements and stiffening in the adjacent joints.

When the distraction is too fast, this can also lead to damage to the nerves that are being stretched.

Lengthening with an external fixator causes considerable pain, ugly scars, and a high risk of infection due to the connection of the bone to the outside via the pin wires. This risk of infection exists not only for the duration of the lengthening phase itself, but also during the subsequent strengthening of the bone, which lasts for months.

The reason being that during this time the fixator ensures the sole stabilization of the healing bone and cannot be removed. The apparatus is heavy and cumbersome and prevents early and adequate physical therapy. Commonly, the patients suffer from significant limitations in joint functions. Nowadays there are also so-called monolateral external fixators. Although these fixators are usually somewhat more comfortable than the ring systems, they tend to lead to malposition such as bending, twisting and axis deviations of the bone, basically due to their one-sided arrangement on the outside of the extremity (e.g., when used on the thigh in bending of the bone in the “O" sense). Attempts have since been made to solve this problem by additionally implanting a rigid intramedullary nail (LON=lengthening

Over Nail) to stabilize the bone. This procedure also allows the fixator to be removed after the end of the lengthening phase, thus reducing the risk of infection. Efficient all-encompassing physiotherapy is not possible with this procedure either.

Fully implantable intramedullary distraction nails:

In order to use the characteristics of callus distraction without having to accept the disadvantages of external fixators, fully implantable intramedullary distraction nails have been developed since the 1980s. Conventional intramedullary nails made of steel or titanium have been used in the treatment of fractures for over 50 years. All distraction intramedullary nails available on the world market today are based on such intramedullary nails. These have sophisticated inner workings that allow them to be distracted.

Electrical Nails

The Fitbone II® was developed by Prof. Dr. Med. Betz. It is a further development of the Fitbone I® developed by Prof. Dr. Med. Betz and Prof. Dr. Med. Baumgart. However, Fitbone I® is only rarely used. The nail is lengthened by an electric motor inside the nail, which is supplied with energy from the outside (a transmitter placed through the skin). Fitbone II® appears easy to use without active patient cooperation and is to date the only nail for simultaneous quadruple lengthening. The nail is expensive, stability and controllability are limited and frequent clinical, sonographic and X-ray controls are also required. It allows the shortest maximum distraction of all available intramedullary nails.

Mechanical Nails

The Albizzia® is a mechanical distraction nail developed by Drs. Guichet and Grammont in which lengthening is achieved by rotating the affected leg back and forth by 20 degrees until an audible click is heard. The nail used by Dr. med. A. Becker - the Betzbone®, is a further development or better said, a modification and improvement of the Albizzia®. The material of the nail is stronger and the interlocking in the bone has been better adapted to the anatomy of the bone. The Betzbone® has the highest stability and extension capacity (up to 12 cm) of all intramedullary distraction nails currently on the market. The high stability allows an early full-bearing load and unrestricted physiotherapy directly after the operation. It also allows a reliable feed with secure function and requires only a few clinical and

X-ray checks. The initial activation of the extension mechanism requires sensitive guidance from the surgeon.

The exact analysis of the leg geometry is based on X-rays of the whole leg and, if necessary, computer tomography. Based on this diagnostic imaging, the various treatment options are discussed with the patient and the operation is planned. Due to blood-saving, minimally invasive surgical techniques, blood transfusions are not necessary. The operation takes place under general anesthesia and lasts, with simultaneous application, several hours. The nail is inserted through a single small incision after the medullary cavity has been prepared. Long tubular bones have a solid, compact outer layer of bone. The inside consists of bone trabeculae near the joint, in the shaft area there is the marrow cavity for the bone marrow. These bone trabeculae enable a stable lightweight construction.

After drilling, the nail

During the preparation of the medullary canal to implant the lengthening nail, a small hollow needle, which is screwed into the lower part of the bone and which is later removed, prevents the pressure in the medullary canal from increasing too much thereby reducing the risk of bone meal and bone marrow washing into the bloodstream.

The artificial growth plate is done by using a special internal saw at the inside of the bone, i.e., via the same cavity into which the nail is then inserted. Usually, it is created from the outside with the help of bone saws or bone chisels, with the soft tissues at the site of the transection also having to be injured. This is what can be avoided by using an internal saw.

A single dose of antibiotics is administered intraoperatively to prevent infection. On the day of the operation, latest on the following day, the patient gets up for the first-time using support.

In the following post-operative rest phase, there are only isolated lengthening impulses.

After 5-7 days, the actual lengthening process begins with a distraction speed of up to 1 mm per day on the thigh and up to 0.5 mm on the lower leg. Careful and regular physiotherapy is essential for this process, possibly supported by individually adapted pain therapy.

Patient Name:

Cost breakdown of the length lengthening procedure

First consult with Dr. Axel Becker

Anamnesis, physical examination, X-rays, X-ray analysis, operation planning, photo simulation, detailed information about the optimal procedure, alternatives, rehabilitation, and organization.

Possible additional costs for pain therapy, alternative methods and/ or naturopathic treatment

Individual additional costs, e.g. use of a swimming pool, medication, telephone, internet, laundry, taxi, car rental, language course, excursions & food and accommodation for companions, etc. as and when required.

If unforeseen complications occur, further costs may be added.

The prices can change at short notice. The information provided is without guarantee.

If necessary, please contact the office of Dr. Becker for further information.

Stretching exercises in preparation for leg lengthening

The following exercises are used for muscle and tendon stretching before a planned leg lengthening process. This preparation reduces muscle resistance and simplifies the first few centimeters of lengthening. It is important not to spring back when stretching, but to hold the tension for about 120 seconds and then go 30 seconds deeper in the tension. After that slowly release the tension again. Please carry out these exercises on a daily basis. This will make the post-operative phase easier. After the implantation of the distraction nail, these stretching exercises should built the basic foundation for the muscles to catch up with the distraction of the bone. And should be done in repeated cycles for at least 3-4 hours a day. This counteracts the relative shortening of the musculature and to thus ensure that the soft tissue grows in a gentle manner. This in turn relieves the adjacent joints. However, when performing the stretching exercises after the operation, please make sure not to put your full body weight on your legs and to protect your joints.

1. Stretching of the Achilles tendon

Lie one leg on the bed or table and put the other leg on the floor. The bed or table supports your body weight. Now bend your upper body forward over the horizontal leg until you feel a pull on the back of your leg. Hold this position for about 120 seconds. Repeat this exercise 3-5 times.

2. Quadriceps stretching exercises

Stand on one leg and bring the heel of the other leg to buttock-height. You may hold on to a wall or stable chair with one hand. With the other hand, grasp the heel of the leg to be stretched, or use a towel to stretch more gently. Now pull your heel up When you feel a pull, hold this position for 120 seconds and repeat 3-5 times. Be sure to keep your pelvis straight, your knees together, and your supporting leg slightly bent.

3. Stretching the hamstrings, outer thighs and glutes

Sit up straight and bend one leg crossing it over the other extended leg. Put your foot down at thigh level. Support yourself with one arm and press the bent leg as close as possible to your upper body with the other arm. Hold this position for 120 seconds and then slowly release the tension. Repeat the exercise 3-5 times.

4. Stretching of the deep hip flexors

Take a long lunge forward while keeping your upper body upright. You can place your hands on the thigh of the front leg for support. Hold this position for 120 seconds and then release the tension. Repeat the exercise 3-5 times.

5. Stretching of the hamstrings and glutes

Lie on the floor with your legs stretched flat. Bend one leg and pull the knee to your chest with your hands. The other leg remains stretched out on the floor. Hold the stretch for about 120 seconds and then slowly relax. Repeat the exercise 3-5 times.

6. Stretching the adductors and inner thigh muscles I

From a wide straddle position with your upper body upright, bend one leg and shift your body weight to the bent leg. The feet remain parallel and the toes point forward. You can either raise your arms or support yourself with them on your thighs. Hold the stretch for 120 seconds, then slowly release. The exercise is repeated 3-5 times.

7. Stretching the adductors and inner thigh muscles II

Sit on the floor and place the soles of your feet together. Pull your feet close to your body with your hands, keeping your knees as close to the floor as possible. Hold the stretch your individual pain threshold for 120 seconds and slowly release the tension. The exercise is repeated 3-5 times.

8. Stretching the adductors and inner thigh muscles III

Sit upright on the floor and spread open your stretched legs. The toes should be drawn up and the knees should be fully locked. With a straight torso lean forward towards the floor. Hold the position at your individual pain threshold for 120 seconds and then slowly release the tension. The exercise is repeated 3-5 times.

Stand about 30 cm away from a wall and lean against it with your hands. Make sure that you do not put too much body weight on your legs after the operation. Now slowly let your body fall diagonally towards the wall by bending your arms and leaning against the wall. The wall carries most of your body weight. Keep your heels on the floor, knees locked and hips locked. When you feel a pull in your calf, hold this position for 120 seconds and repeat 3-5 times.

10. Hamstring and calf stretching exercises II

Take a big backward lunge step with one leg. The heel is completely on the ground. Keep your back leg straight. Bend your front leg and keep your torso upright. As soon as you feel a pull, hold this position 120 Seconds and repeat the exercise 3-5 times.

In this packet you will find the important stretching exercises leading up to your surgery and how to execute them properly.

Stretching

Limb lengthening is not only lengthening of the bone, but the soft tissue surrounding the bone as well. Therefore, the flexibility of your muscles and tendons play a crucial role in limb lengthening.

It is strongly recommended to carry out stretching exercises throughout the entire procedure. Patients may also benefit greatly by doing stretching exercises before the operation.

The main muscle groups that require your attention are listed below in the order of priority;

1. Hip Flexor (Very important)

2. Quadriceps (Very important)

3. Hamstring (Very important)

4. Calves

5. Adductors

6. Buttocks

On the following pages we will go through how to stretch each muscle group. Please read the text on each page before executing the exercises.

Basic rules of stretching

Warm up first. Stretching muscles when they're cold increases your risk of injury, including pulled muscles. Warm up by walking while gently pumping your arms, or do a favourite exercise at low intensity for five minutes. Always use the opportunity to stretch after you exercise (when your muscles are warm and more receptive to stretching).

Stretching exercise: Every area (ventral/dorsal/lateral/medial) should be stretched in two cycles. Begin with the ventral area. Do the stretching exercise until the tension hurts and hold this for 2 min. Then go a bit further for another 30 sec. After that change to the next area. Once the cycle is finished (stretching was done in all four areas), start the second cycle.

How often: As a general rule, always stretch whenever you exercise. Prior to the surgery, try to do at least one session of stretching (all muscle groups) 4-5 times per week. Remember; the more flexible you are before the surgery the easier your lengthening will be

Exercise 1.2.3: Push your hip forward in order to increase the tension while maintaining a straight back.

Exercise 1 can also be performed lying on your stomach.

3. Hamstring

Exercise 2

Exercise 3

Exercise 1: Keep your legs completely straight. In time, try to stand on something elevated while trying to touching the floor. The goal is to try and increase your flexibility at a distance that represents the amount of centimetres/ inches gained.

Exercise 2: In order to increase the tension; try to stretch the knee of the elevated leg and bring your head towards the knee. Keep the other knee completely stretched.

Exercise 3: Move your upper body towards the foot while maintaining a straight knee