Internal limb lengthening is when the device used to lengthen the bone is inserted inside the bone. The lengthening device has a small magnetic motor inside it. When the motor is activated by an External Remote Controller (ERC), the device slowly lengthens, and this causes the bone to slowly lengthen.
Before Internal Limb Lengthening Surgery
How to Prepare
The surgical team will provide you with more detailed instructions on what you need to do in the days and hours before the surgery. It is recommended that you stay active, eat a healthy diet, and stop smoking prior to any operation to promote optimal healing and a smooth recovery.
You may need to stop taking certain medications in the days leading up to the surgery to prevent excess bleeding or interaction with anesthesia during the operation. Always consult with your doctor about all prescriptions, over-the-counter medications, and supplements that you are taking.
After the operation, you will typically stay in the hospital for two to three days. You will not be allowed to drive to or from the hospital before or after your surgery, so make sure to make arrangements for a friend or family member to provide transportation for you.
Minimizing stress and prioritizing good mental and emotional health are also important to lowering levels of inflammation in the body to aid in your recovery. The healthier you are when you go into surgery, the easier your recovery and rehabilitation will be.
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What to Expect
Internal Limb lengthening surgery will be a procedure decided between you and your doctor and will be scheduled in advance depending on the availability of your surgeon and the operating room.
Before the Surgery
On the day of your Internal Limb lengthening surgery, you will be taken to a pre-op room where you will be asked to change into a gown. You will undergo a brief physical examination and answer questions about your medical history from the surgical team. You will lie down on a hospital bed, and a nurse will place an IV in your arm or hand for delivering fluids and medications. The surgical team will use the hospital bed to transport you in and out of the operating room.
The osteotomy, or bone cutting, and placement of an internal lengthening nail can be performed under general anesthesia, which will put you to sleep during the operation, or under epidural anesthesia, where the anesthesia medication is injected into your low back and numbs you from the waist down. With epidural anesthesia, you may be awake during the surgery, but should not feel any pain from the procedure.
During the visit with the doctor, ask for our guide to prepare for surgery. When planning for Precice surgery, you should also be aware of the following:
. Schedule any necessary MRI scans before surgery: The patient may not be allowed to have an MRI scan after the Precice is inserted. An MRI scan could de-magnetize the Precice nail, making it unable to lengthen.
. Learn about the precautions that should be taken with the ERC: If any family members have a cardiac pacemaker, the ERC will need to be kept away from them. The magnet in the ERC could affect the functioning of some pacemakers. The magnet in the ERC can also adversely affect items such as credit cards, magnetic room keys and cell phones.
. Prepare for the ERC to be loud: When the ERC is being used to lengthen, it is loud! Parents may want their children to become familiar with the sound before the surgery.
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Internal Limb lengthening surgery helps correct significant Limb length discrepancies, but it carries a number of risks, including:
. Bone infection (osteomyelitis)
. Poor bone healing
. Bone growth restriction
. Nerve damage
. Injury to surrounding muscles and blood vessels
. Excess bleeding
. Adverse reaction to anesthesia
. Blood clots
. Nausea and vomiting
. Joint stiffness
. Bone length may not be exact, such as longer or shorter than planned
. Muscle contraction (muscle shortens)
. Problems with the new bone forming
Always discuss with your doctor about the possible risks of Internal Limb lengthening surgery to determine if it is an appropriate option for you given the extent of your leg length discrepancy and how it is affecting your daily functioning.
Purpose of Internal Limb Lengthening Surgery
Many patients who are candidates for Internal Limb lengthening surgery have two legs/arms of different lengths as the result of:
. A congenital birth defect
. Growth plate injury to a leg/arm bone as a child
. Malunion of a previous fracture where the leg/arm bone heals out of alignment
. Nonunion of a previous fracture where the leg/arm bone does not heal at all
Patients with skeletal dysplasias or other bone disorders may also qualify for Internal Limb lengthening surgery if there is a significant difference in leg lengths between the right and left sides, affecting their ability to walk and move properly.
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Other conditions that can cause a significant Limb length discrepancy requiring Internal Limb lengthening surgery include:
. Cerebral palsy
. Legg-Calve-Perthes disease
If you suspect you have a limb length discrepancy, you should receive a physical examination from an orthopedic physician to determine if there is a true limb length discrepancy due to different leg/arm bone lengths or if there is an apparent limb length discrepancy where one leg/arm appears to be shorter even though both leg/arm bones are the same length.
Apparent limb length discrepancies can result from problems with the spine, hips, or sacroiliac joints. Physical therapy is often effective for restoring proper alignment of the muscles and joints to correct the issue. If your doctor suspects you may have a true limb length discrepancy, x-rays will be used to confirm the difference in bone length.
Will the Precice be a good option for every person who needs limb lengthening?
The Precice nail is offered in several lengths and diameters, but a person’s bone may still be too small for it. The diameter of the bone must be wide enough so that the Precice can fit inside the bone canal. The doctor will measure the diameter of the bone on an X-ray. The Precice is offered in three diameters: 8.5, 10.7 and 12.5 mm (0.33, 0.42, 0.50 inches).
The bone also needs to be long enough to fit the Precice. The shortest nail is 6.3 inches (160 mm) for the tibia and 6.7 inches (170 mm) for the femur. The doctor will measure the length of the bone on an X-ray to see if it is long enough to accommodate the Precice nail.
Young children and people with very small stature whose bones cannot accommodate the Precice nail can now reap the benefits of internal lengthening.
Another factor that must be considered is whether the ERC can be placed close enough to the Precice to make it lengthen. Soft-tissues (muscle, fat, skin) can be so thick that the ERC cannot be placed close enough to the Precice to activate lengthening. To see if the Precice will work for a patient, the doctor will measure the distance from the bone canal to the skin on an X-ray.
People are not good candidates for the Precice if they have a pacemaker or know that they will need an MRI scan in the next year. It is generally not recommended to have an MRI scan when a person has a Precice nail implanted. Therefore, we routinely recommend removal of the Precice about one year after surgery, provided that the lengthened bone is fully healed.
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How much will the Precice lengthen a bone?
The bone is lengthened in very small amounts each day until the lengthening goal is achieved. The maximum amount that can be lengthened depends on which model of the Precice is used. Different Precice models can lengthen the bone a total of 1.2 inches (30 mm), 2 inches (50 mm) or 3 inches (80 mm). For example, if the shortest Precice is the only one that fits in the bone, the patient may be limited to lengthening a total of 1.2 inches. In most cases, we can implant the models that allow 2 to 3 inches of length.
During Internal Limb Lengthening Surgery
What is the Precice and how does it work?
The Precice Lengthening System consists of a telescoping metal rod, called a lengthening nail, with a magnetic motor inside of it. The nail is inserted through a small incision into the bone canal where the bone marrow is found.
The patient is given a special device called an External Remote Controller (ERC) that is used to make the Precice nail slowly lengthen. The ERC has a magnet inside it that rotates. When the ERC is placed against the leg or arm and turned on, the movement of the magnet inside the ERC causes the magnetic motor inside the Precice to slowly lengthen. When the Precice lengthens, the bone also lengthens.
How is the Precice inserted during surgery?
The doctor needs to make space for the device to fit inside the bone. The outer part of a bone is made up of hard tissue, but the inside of a bone is made up softer marrow tissue. The doctor will use an orthopedic drill to create a canal in the marrow cavity in the center of the bone. This canal will be large enough for the Precice to fit inside it.
The way the Precice is inserted depends on the bone and the patient’s unique situation:
. For the femur (thigh bone), the device may be inserted in two different ways:
. One way that the Precice can be inserted is through the top of the femur that is closest to the hip. This insertion from the hip towards the knee is called antegrade insertion. The illustration below shows how the nail is inserted, the skin incisions that are made, and where the bone may be cut (osteotomy) and lengthened.
. Another way that the Precice can be inserted is through the bottom of the femur that is closest to the knee. This insertion from the knee towards the hip is called retrograde insertion. Note that the location of the magnet in the femur when the Precice is inserted retrograde is different than when the Precice is inserted antegrade. The location of the magnet will affect where the patient places the ERC on the thigh. When the ERC is turned on and placed against the skin of the thigh, it causes the Precice to slowly lengthen.
. For the tibia (shin bone), the device will almost always be inserted from the top of the tibia that is closest to the knee.
. For the humerus (upper arm bone), the device will be inserted through the top of the humerus that is closest to the shoulder (from the shoulder towards the elbow).
How is the ERC used to lengthen the bone?
When the ERC is turned on and placed against the skin of the leg or arm, it causes the Precice to slowly lengthen. When the Precice lengthens, the bone also lengthens. The ERC will stop when the patient has completed the correct amount of lengthening for that session.
When the arm or leg is swollen or has thick soft tissues, the doctor may instruct the patient to place the ERC against the skin and apply pressure to compress the soft tissues so that the ERC is closer to the Precice. Magnets work better when they are closer.
How often will the patient need to use the ERC?
The surgeon will prescribe how many separate lengthening sessions need to be done each day and the amount of lengthening for each session. Typically, patients are asked to lengthen the bone 0.75 to 1 mm each day (0.03 to 0.04 inches; there are 25 mm in 1 inch).
For example, a patient could be asked to lengthen 0.25 mm during four different sessions throughout the day, which would result in a total of 1 mm of lengthening each day. Each session with the ERC would takes about 2 minutes to lengthen the bone 0.25 mm. Four sessions would take a total of 8 minutes per day.
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After Internal Limb Lengthening Surgery
What happens after Precice insertion surgery?
After the Precice is inserted, the patient will stay in the hospital for 2 to 3 days. While using the ERC to lengthen the Precice (called the distraction phase), the patient will need to return for postoperative visits approximately every 10 to 14 days. After the distraction phase of treatment is completed, the consolidation phase starts where the bone solidifies and heals.
Physical or occupational therapy is critical during the distraction and consolidation phases of treatment. During therapy, the muscles, tendons and ligaments are stretched in order to ensure that the arm or leg will have full movement after treatment. Patients will need physical therapy if they are lengthening the bones in the legs or occupational therapy if they are lengthening the humerus (upper arm bone). Our doctors may or may not allow this to be done in the patient’s home town, since some people need more specialized physical therapy, which is available at our center. In many cases, we also prescribe special braces/splints. These are generally made for the patient during the week after surgery.
The patient will be allowed only limited weight bearing on the leg with the Precice in it. The doctor will determine how much weight bearing is allowed on the leg based on each unique situation and the size and type of the Precice nail that is implanted. If both legs will be lengthened, the patient will need to be in a wheelchair.
Please talk to the surgeon if the patient needs to visit the dentist for routine cleaning or dental surgery during treatment. After the Precice is inserted, special antibiotics may be necessary in order to have dental work.
When to Call a Doctor
Contact your doctor if you experience any of the following:
. Signs of infection, such as fever or chills
. Redness, swelling, increasing pain, excessive bleeding, or discharge around the incision.
. Pain and/or swelling in the feet, calves, or legs
. Pain that you cannot control with the medication you were given
. Cough, shortness of breath, chest pain
. Severe nausea or vomiting
. Numbness, tingling, or loss of feeling in your leg, knee, or foot
. Problems or concerns about the fixation devices
When can the Precice be removed?
Typically, the Precice is removed approximately 1 year after insertion. The removal procedure is an outpatient surgery, which means that the patient does not need to stay in the hospital overnight after the removal. The lengthened bone should be fully and circumferentially healed before considering removal of the Precice.
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