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Complications.

Autologous cancellous bone grafting from the iliac crest was undertaken for atrophy of the new bone at the distal distraction site in two patients. In one patient a repeat fibular osteotomy was performed for early consolidation. In three patients (four limbs), collapse of the regenerate occurred after removal of the frame with proximal varus in one and proximal anterior bowing and distal valgus in the other two. This was corrected by the application of a new Ilizarov frame.

Other complications included proximal anterior tibial bowing (4° and 5°, respectively) resulting in a minor loss of knee extension (two), slight recurvatum of the proximal tibia of 3° which did not affect the movement of the knee (one), distal varus of 4° (two), distal valgus (between 3° and 5°) resulting in pronation and minor stiffness of the subtalar joint (five), limitation of dorsiflexion of the ankle to 20° (two) and a leg-length discrepancy of 10 mm (one). In 26 patients (48.2%) there was superficial infection at the pin site. No patient required hospital admission because of a pin site infection.

Most responded to local pin-site care and oral antibiotics. In some cases, wires or pins had to be removed without compromising the stability of the frame. Although a further surgical procedure was required in 25 patients (46.3%); this did not significantly lengthen the time in the frame or result in further complications.

In all cases, neither the public-health system nor the patients’ medical insurance covered the cost of treatment, since constitutional short stature is not considered to be pathological. The mean cost of the operation, including hospital fees was € 12 000, plus an additional € 3000 for bilateral tendo Achillis lengthening.

During treatment 30 patients (15 students and 15 office workers) continued to attend school or work full time, four (three physicians and one engineer) delegated some of their work, 19 (manual and factory workers) took sick or unpaid leave for ten to 12 months; and one was unemployed. All patients resumed fully their previous sporting activities, with the exception of the patient who refused lengthening of tendo Achillis.

At the latest follow-up, all the patients were satisfied with the improvement in self-esteem, distress or shyness and quality of life. They all stated that they would recommend the treatment to others of similar stature. When asked if they would have the procedure again, 48 said that they would and the remaining six were undecided.

Based on the parameters of patient satisfaction, axial deviation, restricted joint movement, pronation of the foot, leg-length discrepancy and scars, the clinical results were excellent in 49 patients (90.7%) and good in five (9.3%). The final aesthetic effects were satisfactory in all cases (Fig. 2).

Discussion

Limb lengthening with the Ilizarov apparatus has been used for pathological conditions such as dwarfism, hemimelia and other congenital or acquired limb-length discrepancy 4,5,10,11 in our unit for the past 24 years and in recent years we have broadened the scope to include cosmetic and psychological indications based upon patient demand.

We selected only patients with constitutional short stature which is defined as a height which is below the fifth percentile for age and gender and caused by illness, hormonal deficiency or dysmorphism. 3 Although not considered an illness, the condition can cause psychological 1-3,12 and functional disadvantages. 13

Selection of patients for cosmetic leg lengthening requires careful psychological investigation. Those who undergo this procedure must be highly motivated, fully informed and understand the procedure and possible complications. Moreover, they should be aware that the cost of treatment is not covered by medical insurance or the public-health system.