Page 8 - The Selection Question Continued

Rorschach findings for prospective patients indicated both accepted and declined patients tended to view the world in idiosyncratic and unconventional ways, impairing their adjustment, and felt a need to defend their self-image. Accepted patients were more emotionally reserved, whereas declined patients tended to feel overwhelmed. These individuals displayed excessive degrees of subjectively felt distress, and had a greater proneness to experience mixed emotional states and ambivalence.

Overall, these findings may appear to raise the question whether all persons seeking SSL should be referred for psychological evaluation and/or treatment. Assessing the suitability of a patient to undertake this procedure has merit. However, psychotherapy as an intervention to remedy insecurities related to stature often does not suffice. Although various forms of psychotherapy can help patients adjust to personal limitations and life circumstances, they cannot undo the ongoing stigmatization that often accompanies short stature. Indeed, many patients who seek SSL have already undergone substantial psychotherapy, only to find that environmental feedback and entrenched attitudes temper treatment outcome, leaving them to experience ongoing distress and frustration. When an individual perceives his or her short stature to be debilitating, it can diminish the success and fulfillment experienced occupationally and interpersonally across the life span. A surgical solution, often offers the best hope for self-actualization and contentment.

The Outcome Question

Do postpsychological evaluations support the proposition that these patients become satisfied with their new body and perceive themselves differently? To date, there are no published studies on the effect of stature limb lengthening on psychological adjustment. In the Paley and Windisch study 9 patients (8 males, 1 female), completed a follow-up questionnaire an average of 4.8 years after their initial surgery date (see Box 1 below for sample questionnaire items). The mean height gain of these 9 subjects was 2.9 inches (preoperative height averaged 62.6 inches; postoperative height averaged 65.5 inches).

The data from Paley and Windisch indicate that patients are generally pleased with the stature they gain with SSL, despite the fact that their height gain was relatively modest, often leaving them at the lower percentiles on a height chart.

Two to 3 inches of additional height appears to have had a more profound impact on the patients’ psychosocial well-being than their relative approximation of the normative height range. Psychological factors may contribute to their satisfaction, even after they have increased their height by only 2 or 3 inches. Letting the issue go finally, irrespective of the amount of height gain may just be related to having finally done all that can be done. Several respondents indicated they felt no need to pursue further lengthening because they wished to focus their energies elsewhere and move forward in their lives. In this connection, Haley38 coined the term “ordeal therapy” to describe a therapeutic intervention, which places the patient in a difficult or painful situation that tests character and provides the patient an opportunity to gain important insights that change attitudes and behaviors.

The outcome question is also dependent on both the physical outcome of the surgery (ie, whether the patient was able to return to previous activities of daily living and sports activity at the previous level of function) and whether it changed how they felt and saw themselves. Paley et al39 investigated a group of 11 patients treated by bilateral femoral lengthening with the ISKD between 2002 and 2006. All were males with average age 29 years (range, 15 to 53 y) with preoperative height of 163 cm (range, 156 to 170 cm) [64.2 inches (range, 61.4 to 66.9 inches)]. After lengthening the mean height was 169 cm (range, 155 to 178 cm) [66.5 inches (range, 61 to 70 inches)]. Four also had undergone bilateral tibial lengthening. There were 8 soft tissue contractures resolved by physiotherapy alone. There were 11 obstacles that required additional surgical procedures, including 4 soft tissue releases for contractures, 4 nerve decompressions for peroneal nerve symptoms, and 3 reosteotomies for premature consolidation. Three sequelae were observed: one was a minor complication where, despite a reosteotomy for premature consolidation, the remaining 1 cm could not be achieved. The other 2 sequelae involved nonunion. One case of nonunion healed after exchange nailing alone, and the other case healed after femoral allograft placement. Despite these complications, there was full restoration of function with return to preoperative activities and occupation. Enneking scores (evaluating pain, function, gait, walking distance and supports, and emotional acceptance) were normal preoperatively and showed no deterioration postoperatively.