Limb Lengthening Complications & Revision Surgery 

Evaluation and Treatment After Previous Limb Lengthening Surgery 

Introduction

Limb lengthening is a complex orthopedic treatment involving not only bone regeneration but also adaptation of the muscles, tendons, joints, nerves, blood vessels and other soft tissues.

Even when surgery is carefully performed, problems can occur during the distraction phase, consolidation phase or after completion of lengthening.

Some problems can be managed by adjusting the lengthening process or rehabilitation.

Others may require additional surgery.

Patients who have already undergone limb lengthening require a different evaluation from patients considering their first procedure.

The first question should not be:

“Can the leg be lengthened again?”

It should be:

“What exactly is causing the current problem?”

1. Problems, Obstacles and Complications

Not every unexpected event during limb lengthening has the same severity.

Some problems may be managed without surgery.

Others may require modification of treatment.

More serious complications may require additional procedures or revision surgery.

This distinction is important because successful complication management often depends on early recognition before a manageable problem becomes more difficult to correct.

2. Why Complications Occur

Limb lengthening changes several biological systems simultaneously.

The bone is progressively lengthened while the surrounding:

• Muscles

• Tendons

• Ligaments

• Nerves

• Blood vessels

• Fascia

• Skin

must adapt.

At the same time, the surgeon must maintain:

• Bone formation

• Alignment

• Rotation

• Joint motion

• Implant stability

This combination explains why close follow-up is necessary throughout treatment.

3. Common Problems During Limb Lengthening

Potential problems include:

Bone

• Poor regenerate formation

• Premature consolidation

• Delayed union

• Nonunion

• Regenerate fracture

Alignment

• Varus

• Valgus

• Flexion/extension deformity

• Rotational deformity

Muscles & Joints

• Muscle tightness

• Joint contracture

• Knee stiffness

• Ankle equinus

Nerves

• Numbness

• Tingling

• Neuropathic pain

• Weakness

Infection

• Pin-site infection

• Deep infection

Implant

• Nail malfunction

• Screw failure

• Implant breakage

• Loss of fixation

These categories are well represented in the orthopedic limb-lengthening literature.

Femoral and Tibial Lengthening Have Different Considerations

The pattern of complications may differ depending on whether the femur or tibia was lengthened. Learn how the two procedures differ in joint mechanics, muscle adaptation, alignment and rehabilitation.

[ Compare Femoral vs Tibial Lengthening ] 

4. Joint Contracture

As the bone length increases, muscles crossing adjacent joints are progressively stretched.

If the muscles cannot adapt sufficiently, joint motion may decrease.

Examples include:

• Reduced knee flexion during femoral lengthening

• Reduced ankle dorsiflexion during tibial lengthening

Contracture can interfere with walking and rehabilitation and may eventually limit further lengthening.

5. Equinus After Tibial Lengthening

One of the important problems during tibial lengthening is ankle equinus.

The calf and Achilles tendon complex may become relatively tight as the tibia lengthens.

The patient may have increasing difficulty bringing the ankle upward.

Early management may involve:

• Stretching

• Physiotherapy

• Bracing

• Adjustment of distraction

• Additional treatment when clinically necessary

The objective is to recognize progressive tightness before a fixed deformity develops.

6. Nerve Symptoms

Nerves also adapt during distraction.

Warning symptoms can include:

• Tingling

• Numbness

• Burning pain

• Electric-shock sensations

• New weakness

These symptoms should not simply be ignored as normal pain from lengthening.

A review of leg-lengthening concepts notes that nerve palsy can occur and that excessive distraction or compartment-related problems can contribute to neurological injury.

7. Poor Regenerate Bone Formation

The newly forming bone in the distraction gap is known as regenerate bone.

In some patients, regenerate formation may be slower or weaker than expected.

Potential contributing factors include:

• Distraction rate

• Bone biology

• Smoking

• Nutrition

• Age

• Previous surgery

• Vascularity

• Mechanical stability

Treatment should be based on the underlying reason rather than simply waiting indefinitely.

8. Premature Consolidation

The opposite problem can also occur.

The regenerate may mature too quickly before the planned length has been achieved.

If the distraction gap consolidates prematurely, further lengthening may become difficult or impossible without additional intervention.

Regular X-rays are therefore necessary during distraction.

9. Delayed Union

Delayed union means the bone is healing more slowly than expected.

The patient may require a longer period of protected activity and fixation.

Evaluation should consider:

• Regenerate quality

• Mechanical stability

• Alignment

• Nutrition

• Smoking

• Infection

• Metabolic factors

10. Nonunion

Nonunion is a more significant failure of bone healing.

Treatment depends on the specific problem and may involve:

• Revision fixation

• Bone grafting

• Biological augmentation

• Correction of alignment

• Treatment of infection

Revision planning should identify why the bone failed to unite before selecting the next procedure.

11. Malalignment

Lengthening must occur while maintaining the correct mechanical axis.

Possible deformities include:

• Varus

• Valgus

• Flexion

• Extension

• Translation

• Rotation

Even when the desired length has been achieved, poor alignment can affect gait and joint loading.

Therefore:

Length alone is not the definition of a successful result.

12. Rotational Deformity

Rotational deformity may be less obvious than bowing on a simple front-view X-ray.

Patients may notice:

• Feet pointing inward or outward

• Abnormal gait

• Knee orientation differences

• Functional discomfort

Assessment may require detailed clinical examination and additional imaging.

13. Infection

External fixation introduces pins or wires through the skin and therefore can be associated with pin-site infection.

Internal implants can also become infected.

The clinical significance ranges from superficial infection to deeper bone or implant infection.

Treatment depends on:

• Depth

• Organism

• Implant stability

• Bone healing

• Patient condition

14. Implant Failure

Lengthening implants experience repeated mechanical loading.

Potential problems include:

• Nail breakage

• Screw breakage

• Failure of the distraction mechanism

• Loss of fixation

A large series examining magnetic intramedullary lengthening nails reported mechanical failure in 9.5% of nails, and many failures required additional surgery.

This does not mean that every modern lengthening nail has a 9.5% individual failure risk; the figure comes from a particular retrospective series involving different nail generations and indications.

15. Complications With PRECICE and Other Internal Nails

Internal lengthening nails avoid some problems associated with external fixation, particularly pin-related issues.

However, they are not complication-free.

A systematic review covering 983 segments treated with FITBONE or PRECICE identified complications in approximately one-third of segments. In approximately one-quarter of segments, complications substantially altered treatment, prevented the intended goal, or produced a new pathology/permanent sequela according to the authors' classification.

These figures should not be interpreted as an individual's predicted risk because the studies included different:

• Ages

• Diagnoses

• Bones

• Lengthening amounts

• Devices

• Surgical techniques

But they demonstrate why postoperative monitoring remains essential even with modern internal devices.

16. External Fixator Complications

External fixation has different potential problems, including:

• Pin-site infection

• Pin loosening

• Scarring

• Muscle tethering

• Joint stiffness

• Patient discomfort

• Alignment problems

However, external fixation remains valuable in complex reconstruction because it can provide substantial control over length and deformity correction.

The choice between external and internal fixation should therefore be based on the clinical problem rather than aesthetics alone.

17. When Should Revision Surgery Be Considered?

Revision surgery may be considered when there is a structural or functional problem that cannot be adequately corrected with observation or rehabilitation alone.

Examples may include:

• Nonunion

• Significant malalignment

• Rotational deformity

• Implant failure

• Persistent joint deformity

• Severe contracture

• Infection

• Residual limb-length discrepancy

• Excessive lengthening

• Failed previous reconstruction

The appropriate procedure depends on the cause.

18. Revision Surgery Is Different From Primary Surgery

Revision limb-lengthening surgery is often more complex than the original procedure.

Previous surgery may have altered:

• Bone anatomy

• Medullary canal

• Blood supply

• Muscles

• Tendons

• Nerves

• Skin and scars

• Joint motion

Previous implants may also remain in place.

For this reason, the original operative history is important.

19. Evaluation Before Revision Surgery

Evaluation may include:

Previous treatment

• Original diagnosis

• Date of surgery

• Bone lengthened

• Lengthening amount

• Device used

• Previous complications

Current imaging

• Full-length standing X-rays

• Bone union

• Mechanical axis

• Implant condition

• Joint orientation

Clinical examination

• Leg lengths

• Joint range of motion

• Muscle strength

• Neurological examination

• Gait

• Skin and scars

CT or other imaging may be considered when rotational deformity, nonunion or complex anatomy requires further assessment.

20. Revision for Nonunion

Revision treatment should address both biological and mechanical causes.

Depending on the individual situation, treatment may involve:

• Improved fixation

• Bone grafting

• Correction of deformity

• Treatment of infection

• Modification of mechanical loading

Simply replacing one implant with another without identifying the cause may be insufficient.

21. Revision for Malalignment

When the bone has healed in an unacceptable position, corrective osteotomy may be considered.

The goal may include correction of:

• Varus/valgus

• Flexion/extension

• Rotation

• Translation

Full-leg alignment should be considered rather than focusing only on the local deformity.

22. Revision for Implant Failure

Implant failure does not have a single treatment.

Management depends on:

• Whether lengthening is complete

• Bone regeneration

• Bone union

• Alignment

• Type of implant failure

• Patient's weight-bearing requirements

Options may include replacement, additional fixation or another reconstructive strategy.

23. Can Excessive Lengthening Be Corrected?

In selected patients, excessive previous lengthening may result in problems involving:

• Body proportions

• Soft-tissue tension

• Joint motion

• Gait

• Alignment

• Function

Evaluation should determine whether symptoms arise primarily from length itself or from another associated problem.

In selected situations, corrective osteotomy or shortening may be considered.

However, this is highly individualized.

24. Can a Failed Limb Lengthening Be Lengthened Again?

Sometimes, but not automatically.

Before considering additional lengthening, it is necessary to evaluate:

• Bone quality

• Previous regenerate

• Joint motion

• Muscle flexibility

• Nerve function

• Alignment

• Infection history

• Existing implants

The priority is to establish a stable and functional limb before pursuing additional centimeters.

25. Old Complications Can Still Be Evaluated

A complication does not necessarily become untreatable simply because many years have passed.

Patients with longstanding:

• Malunion

• Limb-length discrepancy

• Rotational deformity

• Joint contracture

• Previous failed reconstruction

may still undergo evaluation.

However, treatment options depend on the current condition of the bone, joints, muscles, nerves and soft tissues.

26. Why Previous X-Rays and Operative Records Matter

For revision patients, previous records can be particularly valuable.

If available, international patients should provide:

• Preoperative X-rays

• Postoperative X-rays

• Operative report

• Implant information

• Lengthening records

• Previous complication history

• Current X-rays

This can help reconstruct what happened during the original treatment.

27. The Goal of Revision Surgery

Revision surgery should not be judged solely by:

“Did we obtain the desired number of centimeters?”

The goals are broader:

Bone Union

Appropriate Alignment

Joint Motion

Muscle & Nerve Function

Stable Fixation

Balanced Limb Length

Functional Walking

In some patients, achieving these goals may be more important than additional lengthening.

28. Frequently Asked Questions

Can nonunion after limb lengthening be treated?

Potentially, yes. Treatment depends on bone biology, fixation, alignment and whether infection is present.

Can a broken PRECICE nail be treated?

Implant problems can be evaluated for revision, but treatment depends on the type of failure and the state of bone healing.

Can crooked legs after limb lengthening be corrected?

Some post-lengthening angular or rotational deformities can be evaluated for corrective osteotomy or other reconstructive treatment.

Can ankle equinus after tibial lengthening be treated?

Treatment depends on severity, duration, muscle-tendon tightness and joint condition.

Can I undergo further lengthening after a complication?

Possibly in selected cases, but restoration of bone stability, alignment, joint motion and soft-tissue function generally takes priority.

Can complications be treated years after the original surgery?

Some longstanding complications can still be evaluated, although chronic changes may make reconstruction more complex.

Do I need my previous operative records?

They are very helpful but not always available. Current imaging and examination remain essential.

29. International Patients Seeking Revision Surgery

Patients who underwent limb lengthening in another country can undergo preliminary review before traveling.

Useful information includes:

• Current height

• Original height

• Amount lengthened

• Femur or tibia

• Surgical method

• Implant type

• Date of surgery

• Current symptoms

• Current X-rays

• Previous operative records

Complex revision cases often require more information than primary limb-lengthening consultations.

30. Our Approach to Limb Lengthening Complications

The objective of revision treatment is not simply to perform another operation.

The first step is to determine:

What went wrong, why it happened, and what structures are currently affected?

Treatment planning should consider:

Bone + Alignment + Implant + Joint + Muscle + Nerve + Infection + Limb Length + Function

Only after these factors have been evaluated should a revision strategy be selected.

Limb Lengthening & Revision Surgery in Korea

For comprehensive information about limb lengthening, PRECICE, external fixation, complication treatment, rehabilitation and international consultation:

Official Limb Lengthening & Revision Surgery Page → [ Gangnam Champion Hospital ]

This page provides general educational information about complications and revision surgery after limb lengthening. Treatment depends on the original procedure, current anatomy, bone healing, alignment, joint condition, neurovascular status, infection and individual clinical circumstances. An individual medical evaluation is required.