Page 4 - Results Continued

According to Paley’s criteria, 102 difficulties were observed—42 problems, 54 obstacles, and 6 complications (Table 2).

Regarding pin tract infection, we reported 12 grade 1 (pain, erythema, or tenderness around the pin site), 8 grade 2 (characteristics of grade 1 infections plus serous drainage) and 5 grade 3 (characteristics of grade 1 infections plus purulent drainage) according to Gordon’s grading system [13]. Pin-site infections were treated by oral antibiotics (amoxicillin) [14, 15] except for one, which required intravenous antibiotics and one half-pin removal without compromising the frame’s stability. No cases of radiographic osteolytic changes at the pin site (grade 4) or ring sequestrum/osteomyelitis (grade 5) were reported.

Two cases of atrophy of the new bone formation at the distal distraction were treated with autologous cancellous bone grafting from the iliac crest.

Due to early bone consolidation, a revision of the fibular osteotomy was necessary in four limbs.

In five limbs, collapse of the regenerate bone was observed after removal of the frame—a proximal varus deformity occurred in two, and a proximal anterior bowing with distal valgus deformity occurred in the other three. Application of a new Ilizarov frame was performed until complete bone healing and correction were obtained.

Hinges were applied for correction of all axial deviations observed such as a proximal anterior tibial bowing (4 degrees and 5 degrees) resulting in a minor loss of knee extension (4 limbs), a slight recurvatum of the proximal tibia of 3 degrees which did not affect the movement of the knee (2 limbs), a varus of the distal part of the tibia of 4 degrees (2 limbs), a valgus of the distal part of the tibia (3 degrees–5 degrees) resulting in pronation and minor stiffness of the subtalar joint (5 limbs), and a limitation of the ankle dorsiflexion of 20 degrees (4 limbs). A leg length discrepancy of 10 mm was observed in only one case and a new external fixator was applied.

Foot pronation was observed in six limbs and a subtalar joint fusion was necessary to stabilize the foot in three cases.

No fat embolism, deep vein thrombosis, or pulmonary embolism was observed during the entire follow-up period. At the latest follow-up, all patients were satisfied with improvements 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 whether they would have this surgery again, 53 answered positively, and the remaining 10 were undecided (Figs. 2, 3, 4, 5).

Based on the parameters of patient satisfaction, axial deviation, restricted joint movement, pronation of the foot, leg length discrepancy and scars, the outcome was excellent in 56 patients (88.8%), good in 5 (7.9%) and fair in 2 (3.1%).

The final aesthetic effects were satisfactory in all cases and all patients continued with their previous sport activities.

Discussion
In our study we surgically treated patients with constitutional short stature, defined as a height under the 5th percentile for age and gender, without any dwarfism and/or skeletal deformities and/or hormonal deficiencies [5, 6]. Although short stature is not considered as a disease, it can cause psychological [6, 7, 16] and functional disadvantages, and can have a radical influence on a person’s life [17, 18].

Patients with dysmorphophobia or body dysmorphic disorder are not suitable candidates for this type of cosmetic surgery. This disorder is a distressing and impairing preoccupation with an imagined or grossly exaggerated defect of appearance. It is associated with high rates of occupational and social disability, hospitalization and suicide attempts [19, 20]. Patients with dysmorphophobia usually seek cosmetic surgery to alter their subjective perceived abnormality. Psychological evaluation before surgery is mandatory to exclude such patients, even if some surgeons do not take this particular aspect into consideration and proceed with surgery [7]. A scrupulous preoperative psychological evaluation can help the surgeon to better understand the patient’s body perception and their expectation after surgical cosmetic lengthening.