Page 5 - Discussion
We performed this study to evaluate the risk and benefits of cosmetic limb lengthening in terms of soft tissue and bone complications and functional and subjective clinical outcomes. Forty-eight patients (37%) experienced 59 complications and seven patients (5.34%) had more than one complication. There were 37 (28%) soft tissue complications and 22 (17%) bone-related complications during treatment. Twenty-three patients (18%) needed reoperations and residual problems occurred in six patients (4.58%); four patients had limitation of ankle dorsiflexion, one had a flexion deformity of the knee, and one had common peroneal palsy (Table 2).

This study has numerous limitations. First, this is a retrospective study of available medical records. We did not assess the patients directly. Seven patients were excluded owing to lack of required followup; this potentially could have biased the results. Some of these operations were performed before validated tools were used for outcome assessment. The physician-based and patient-based outcome scores that we used are unvalidated and because the surgeries were performed in the 1980s and 1990s, there was no way to use the outcome measures currently being used. The result also could have been influenced by bias of assessment as the surgeons documented the postoperative assessment of their own work, regardless whether it was physician-related or patient-related outcomes. All these factors could have exaggerated our results. There is a chance of selection bias as surgery was offered only to patients who were thought to be ideal candidates for this procedure. Proper patient selection is of paramount importance with this procedure which is a prolonged and arduous treatment modality. Despite proper patient selection, our experience with this technique, and the facilities for rigorous in-patient physiotherapy and rehabilitation, there were numerous challenges to overcome to ensure optimum results. We believe that extreme caution should be exercised in using this technique for cosmetic lengthening. Only studies from other institutes can clarify whether our results are replicable elsewhere. The patients came to us for various reasons (cosmetic, occupational, and social), and we do not have data regarding numerical gain in height translated as fulfilment of these objectives.

We recognize that performing surgery of this magnitude for cosmetic or avocational purposes (such as sport) is extremely controversial. Our institute has extensive experience with limb lengthening and many of our patients are from various parts of the world who come to us for cosmetic limb lengthening. These patients attend many counseling sessions with a psychologist and surgeon to determine whether they need this surgery. They are made fully aware of the nature of the treatment and the possible complications. Wherever possible nonsurgical solutions are offered and discussed. Many patients have changed their mind after these sessions and chose not to undergo the surgery. Some patients were rejected because of the psychologist’s recommendation as they showed features of dysmorphophobia or histrionic traits. Other patients persist, although their reasons may lack sense to us. Some patients, despite being rejected for surgery, have repeatedly requested we reconsider, and some to whom surgery was refused have gone to other centers with less experience with this technique and have returned to us for treatment of their complications. Therefore, in some cases, even when the patients were not rejected by the psychologists, we went beyond numerical values of height and the medical logic for cosmetic lengthening after ensuring motivation and compliance of the patients. Some patients have unrealistic expectations regarding the extent of lengthening and the counseling sessions have helped them to align their expectations with realistic levels. However, when the patients wanted to achieve the maximum possible lengthening, we obliged but with precautions and close monitoring to avoid complications. As an example, one of our patients was an intensely motivated 68-year-old man who could have 3.5 cm lengthening without significant complications despite concerns of bone regeneration owing to his age. The cost of this treatment is not covered by any medical insurance or public health system.

To our knowledge, the only published study of cosmetic bilateral lower limb lengthening was by Catagni et al. [6], who reviewed 54 patients with constitutional short stature in whom a mean length of 7 cm was gained. Twenty of their 54 (37%) patients had equinus of the ankle develop. Whereas we used extension of the Ilizarov apparatus to the ankle and gradual stretching with limited use of percutaneous tendoachilles lengthening, Catagni et al. performed tendoachilles lengthening in 19 of their patients (one patient refused surgery). Twenty-five of their 54 patients (46%) had pin tract infections that needed intervention. In our series, even though the incidence of pin tract infection requiring interventions was lower, we had deep infections requiring sequestrectomy, which was not seen by Catagni et al. This may be attributable to differences in pin tract care protocols.