Lengthening strategy and technique 

Lengthening for stature in normally proportioned persons with short stature but without dysphasia (dwarfism) requires a different strategy than does lengthening in patients with disproportion and dysphasia (dwarfism). Most patients with constitutional short stature or low normal stature require only modest increases in stature compared with the extreme amount of lengthening required by patients with dwarfism.

When assessing distribution of height in the population, we consider the normal bell curve. We divide people by distribution around the mean (average). Normal height is considered ± 3 standard deviations (SD) from the mean. Stature below 3 SD from the mean in persons without a medical condition such as dwarfism or growth hormone deficiency is considered constitutional short stature. The lower limit of so-called normal stature for Caucasian men is 5'5" (166 cm) and for women is 5'0" (153 cm). ( These info were taken from a published article by dr. John Herzenbreg from USA. )

Patients with constitutional short stature or low normal stature are not treated until they have completed growing. They usually do not have deformities of the bones.

 

Percentile SD Height Women (in) Height Women (cm) Height Men (in) Height Men (cm)
95 +3 68.5 174 74 188
90 +2 67.5 171 73 185
75 +1 66 167 71.5 181
50 Mean 64.5 163 69.5 176
25 -1 63 160 68 172.5
10 -2 61.5 156 66.5 169
5 -3 60 153 65 166

 

We prefer the lengthening using ring fixator ( Ilizarov or Taylor Spatial frame by aid of computer software ). This because when using ring fixator in our technique of maximum stability, this mentioned the highest success rate without problems or complications in more than 1000 patients we did since 1996 untill 2006. Also, it is the safest method according to the scientific publications. As many new methods are available until the moment, but all are not fully developed yet and the scientific researches mentioned some complications with these new methods. This include LON or ( Lengthening over nail method ) and fully implantable lengthening nails ( ISKD, Albizzia and Fitbone ). The usual goal of lengthening for stature for most patients with low normal stature is 2 to 3 in (5 to 7.5 cm). More than this amount of lengthening cannot be achieved safely in one pair of bones during one lengthening procedure. For more lengthening, one needs to repeat the process in a second pair of bones.

 

 

The usual strategy is to lengthen both tibiae (includes the fibula) 2 to 3 in. If a second lengthening is desired, then both femora are lengthened the same amount. Most patients do not choose to have the femora done because of the added time commitment and the doubling of the expense. Furthermore, doing too much lengthening in the lower limbs in normally proportioned people could lead to disproportion. Up to 3 inches of lengthening produces no obvious disproportion.

Recovery duration

One can assume that it will take approximately 1 month for every inch (2.5 cm) of lengthening. Lengthening does not begin until 1 week after surgery. Therefore, 2 to 3 inches of lengthening takes 2 to 3 months. Then we have to wait until the newly formed bones are fully consolidated before frame removal. This take few months later ( the duration depends upon many factors including how many centimeters we lengthened ). Usually for 6 centimeters, it take approximately about 6 months. In some patients it took 5 months and in others took up to 7 months. When using my new technique of maximum stability, Weight bearing is permitted very early after the procedure. At the end of lengthening, the external fixators are removed from outside without need for further surgery to do this. Most patients begin weight bearing 2nd day after the surgery. Physical therapy continues, mostly to keep full ankle motion and foot push-off strength. daily exercises are recommended after the procedure for the ankle motion. This to keep the ankle always dorsiflex up to 90 degrees (minimum).

In many centers of limb lengthening all over the world including USA, they usually do not allow the patient to walk or weight bear after the operation. And the patient has to use a wheel chair for at least 4 months after the op. Then start very hard physiotherapy program to regain the lost muscles power ! As I did 3 fellowships in the best centers for limb lengthening in the world including USA, Italy and Russia and I learn a lot from Dr. Catagni in Italy, Dr. Herzenberg and Dr. Paley in Baltimore as well as in Ilizarov institute in Kurgan, I have developed my own technique in applying the ring fixators which increased the stability of the frames and minimized the common complications with external fixation as pin tract infection to be almost 0 %. In this way, I allow my patients to weight bear and walk from the second day after the operation. As my patient start to walk early, so he or she does not loose his leg muscles power and there is no need to do any special hard physiotherapy program later on.

Lengthening Cost

  1. The cost of bilateral leg lengthening using external ring fixator start from 15,000 Euro. This cost cover: 
  2. Consultation fee before operation and all pre operative evaluation from the surgeon and anasthesia. 
  3. External devices usage. 
  4. All follow up visits. 
  5. Frame removal procedure in the outpatient clinic. 
  6. All follow up X rays for up to 6 months after the operation. 
  7. All dressing tools needed during the procedure for up to 6 months after the operation. 
  8. All hospital cost encountered with the operation for up to 4 nights of stay in the hospital.

 The previous cost must be paid in advance before item 1. This cost does not include the following: 

  1. Insurance money that come back to the patient after frame removal. This is an additional 1100 euros. 
  2. Cost of physiotherapy which is about 200 $ to 250 $ per month for the first 3 months and should be paid direct to the physiotherapist based on at least two visits per week. 
  3. Cost of accommodation in a furnished apartment in case the patient prefer to stay in Cairo after the operation either for 3 months which is the lengthening period or even till finish all the procedure till frame removal which may take totally 6 to 9 months + care taker to help. This cost depends upon the season and the standard of the rental apartment. The average cost per month for this item is 550 Euro and should be paid in advance for the first 2 months then renovated monthly 15 days in advance only before the proposed date. 
  4. Cost of food and utilities of living as electricity bill or phone bill...etc. this is generally much lower than in Europe or USA which is about 50 % or less comparing to there.

Hospital & accommodation

The first week after the operation, the patient stay in the hospital. This include 3 meals per day.

The hospital is a very modern and well equipped medical center lies in Cairo close to the international airport. The patient stay is in a double room, air conditioned room with TV, toilet and shower.

If the patient wish to stay in a single room, so he or she has to pay 500 US $ for the whole week of the hospital stay. Then the patient is transferred to a luxurious furnished apartment with all amenities he or she needs during the following period including Satellite TV and wireless ADSL internet…etc During staying in the apartment, the patient has to pay only for the cost of his food as he or she like. Generally, food cost in Cairo is 25 % the same in any European or American city although the high quality of the restaurants and also the naturalists of it. Food will never cost more than 200 US $ per month to order food from different kind of restaurants around either by phone or via the internet where some web site available to access all local restaurants. All kind of restaurants are available: MacDonald’s, Burger King, Hardees, Pizza Hut, Papa Johns, KFC and many nice local fast food available. In addition, the lady who is the care taker can cook any kind of food the patient like.

The cost also includes using original ( FDA approval or CE certified frames ) and pins. The pins we use are the most expensive and best pins available in the medical market HA coated pins of Orthofix. Please, browse: www.orthofix.com to understand more about. This kind of pins decrease the incidence of pin loosening or infection down to 0 %. All kind of frames we use should be marked by CE and or FDA. This means that the company produce the frame are sailing them to hospitals in USA and Europe. We never use any material that is locally made or made anywhere and is not marked by CE or FDA approved. Many other centers for limb lengthening everywhere in the world are using low cost frames either locally made or not CE marked or FDA approved. This kind of cheap frames can affect the results. We do not like to provide a cheaper cost over the quality of the material or the service provided. The quality of our work and results as well as used devices could be compared only to the same in USA and West of Europe, not to any other place over the earth where they produce more expensive operation for a much cheaper materials. Even if the final results of some other centers are good, but patient cannot know what could happen in the future for his body who had a bad quality metal for a long time which could be absorbed to the blood and make future problems.

La cosa piu importante è la tecnica utilizzata e la qualità degli apparecchi. Personalmente, preferisco utilizzare i chiodi di Orthofix coperti con HA che contribuiscono all’ottenimento di risultati migliori rispetto al 1998, quando iniziarono a essere utilizzati.

Payment methods

Payment is either in cash or using travel checks ( in your doctor name). Other possibility is to use Bank transfer. As the system here in Egypt is different from USA or Europe, Your doctor is responsible financially about you. There is no financial deal between the patient and the hospital, but between the patient and the doctor and between the doctor and the hospital. This is very frustrating for doctors here as the doctor has to pay for the hospital, companies sailing devices and pins. He also has to pay for fees of others involved in the procedures as nurses, anesthesia doctor…etc. So, here the doctor is the responsible about everything.

Follow up

The pain sensation is different from a person to another, however 90 % of patient has no actual pain after 3 days from the operation or during the lengthening procedure. For the first 3 days post operative, the pain management specialist like to give my patients a regular dose of Bethedine or Morphia for his or her comfort. The patient should not feel pain at any time after the surgery by using pain medication. Also, it is preferred to inject regular continuous dose of marcain or xylocain ( anesthesia ) injecting into the epidural catheter when the patient has epidural local anesthesia during the operation for the next 3 days after the op . using a special electric syring pumb. This guarantee no pain after the operation. Regular anti – inflammatory pain medication as Voltaren, Brufen…etc are not allowed to be used after the surgery. This because it affect the quality of the new bone formation, This because the new bone formation is an inflammatory process and this medicine is anti – inflammatory!

 

Although this surgery is considered cosmetic, we recognize that most people seeking this type of surgery are driven to do so for psychological reasons. This is clearly related to individual body image. Our psychological testing after lengthening compared with before lengthening has convinced us that in the majority of cases, stature lengthening alleviates or eliminates the neurosis the patient has before doing the operation. This neurosis is due to his or her wish to be higher. Having stated that, we have had to make an arbitrary cutoff of maximum height for which we feel comfortable offering this service. Please recognize that we are approached by individuals who are just as distressed by their perceived short stature independent of their measured height.

Other lengthening techniques

Different methods for lengthening are available. As we mentioned that we prefer external fixation method as Ilizarov ring fixator or TSF for legs and Orthofix LRS device for thighs. This because of the highest rate of success ( which reached to 100 % in our patients ). However, there are other new devices of lengthening is available as internal leg lengthening via Precice Nail , for more information about internal leg lengthening please visit our new website from here..