Page 12 - The Outcome Question Continued

(3) The fibula in our study did not migrate in any patient due to proximal and distal fixation of this bone. A common error is due to the misperception that the fibula does not need to be fixed to the tibia proximally and distally. Lack of distal fixation leads the fibula to migrate proximally. Even incorrect fixation leads to the same problem. For example, fixation distally, with a transverse instead of an inclined screw, will resist the tendency toward proximal migration less than the distally inclined screw fixation we recommend.
(4) There were no contractures of the hip, knee, ankle, subtalar, foot, or toe joints. Physical therapy and bracing are important to prevent contractures. Lengthening for stature without these measures may lead to significant stiffness and contractures of joints.
(5) There were no infections in any of the PRECICE SSL patients. This is due to the fully implantable device, minimal invasive surgery, meticulous sterile technique, and the use of preoperative and perioperative antibiotics.

At our center we have seen patients from all over the world who arrive with disabling complications after failed SSL. These include: equinus deformity due to Achilles tendon contracture (ballerina feet); fascia lata contractures with hip flexion contracture and hyperlordosis (duckass); partial or complete failed regenerate bone formation, including fixators that cannot be removed due to failed healing; bent and broken hardware; malunions and nonunions of the tibia, fibula, and femur; proximal migration of the fibula; and many more. We must remind ourselves that these patients start functionally at 100%. The treatment goal is to end up with the same 100% functional level. Anything less than this is neither a good outcome nor a reasonable tradeoff for a few centimeters. Disablement is too often an outcome of this surgery when performed by unqualified or inexperienced surgeons, which leaves patients with debilitating conditions and gives this surgery a bad reputation.

A few years ago the senior author (D.P.) saw 7 patients in the course of 2 years who were disabled by complications from bilateral tibial lengthening. All of these had been treated by a single surgeon. This resulted in 7 separate malpractice lawsuits and ultimately the loss of that surgeon’s medical license. Such cases give SSL and undeserved bad reputation.

Stature lengthening raises many questions: Should we agree to lengthen anyone for stature? Should we base this decision on a height threshold? Should we base this decision on psychological factors? Should we base this decision on ability to pay, as with other cosmetic surgeries?

Height threshold is arbitrary and judgmental (Fig. 6). Risk is not dependent on initial height; benefit is not necessarily greater for shorter individuals. Therefore the risk/benefit for shorter individuals is no different than for taller individuals. Stature dysphoria is a real entity. As documented, there is ample psychological evidence for this condition. However, motivation may be due to more benign reasons (eg, fashion models who want to have longer legs, individuals who desire access to jobs with minimal height requirements, etc.) Is it the surgeon’s job to judge the patient’s motivation as long as they are realistic about what can be achieved and aware of what the surgery and rehabilitation entails?

Cost is a major consideration. Insurance providers consider SSL to be a cosmetic procedure and therefore will not pay for it. The implants alone are very expensive. Added to the cost of hospitalization, operating and recovery room costs, anesthesia fees, surgeons fees, physical therapy, durable medical equipment (wheelchairs, walkers, crutches, commode), drugs (anticoagulant, analgesics, sleeping medications, muscle relaxants), office visits, x-rays, etc., the total cost is formidable and unaffordable to most. Ultimately cost is the limiting factor for most patients. Of concern, is that as this surgery is exempt from third party payers and because most surgeons and hospitals are paid up-front in cash, pricing is widely variable. Patients may acknowledge there are differences among providers related to skill and outcomes, but price can become an influential decision-driver.