In lengthening surgeries, surgical intervention is performed especially on the bones. Muscles, nerves, vessels and other soft tissues accompany the lengthening process together with the bones. The tissues that are most difficult to adapt to lengthening are muscles. When physical therapy is added to the treatment procedure during extension, the process becomes more comfortable.

Limb lengthening surgery can be performed on children from the age of 5-6, when they can adapt to the surgical procedure. If applied to children; the number of additional operations that may be required in the future; The amount of shortness present is determined by age and growth potential.

(FIGURE 1a-b)

2– Who is eligible for limb lengthening surgery?
Genetic factors or various diseases during childhood can lead to short stature. Conditions causing short stature include:
•Genetic diseases affecting the bones: achondroplasia, multiple enchondromatosis, multiple osteochondromatosis, etc.
•Childhood and adult diseases affecting growth in one or both legs or arms (hemimelia, sequelae of poliomyelitis, polyostotic fibrous dysplasia, post-tumor surgeries, sequelae of osteomyelitis, etc.)
•Nutritional disorders
•Hormonal disorders

These diseases may result in shortening, angulation, or rotation deformities in one or both legs or arms. The decision to perform bone lengthening, deformity correction, or limb equalization surgeries depends on factors such as the patient’s age, the cause of the disease, the extent of shortening, and growth potential.

3– What are the techniques used in limb lengthening surgery?
Limb lengthening techniques are classified into three groups based on the devices and methods used:
•External fixation (Ilizarov technique) (FIGURE 2)
•Computer-assisted external fixation (FIGURE 3)
•Internal fixation (motorized nails) (FIGURE 4)
•Combined technique (combination of internal and external fixation) (FIGURE 5a-b)

The basis of limb lengthening surgery lies in the Ilizarov external fixation system, gradually extending the bone. This method can be combined with internally applied nail systems or solely using expandable nail systems within the bone. The choice of the method depends on factors such as the patient’s age, the bone region to be lengthened, the planned lengthening amount, the degree of deformity, and the physician’s experience.

4- How are the preparations for limb lengthening surgery done?
Detailed examinations of the patient planning limb lengthening surgery are conducted initially. The amount of shortening in a single bone or total shortening, the degree of angulation if present, and the disease causing the shortening are identified. Muscle strength, joint range of motion, and nerve damage are assessed. Detailed length x-Rays are created to plan the amount of lengthening and determine which bone to start with. Ideally, performing simultaneous lengthening surgery on four bones (two tibias and two femurs) is not recommended due to the load it would impose on the body and the coordination issues with muscles.
Considerations include the patient’s expectations, overall health, and smoking status (smoking is a significant factor affecting the formation or delay of new bone in lengthening surgeries). Patients should be thoroughly informed about these aspects.

The final step is selecting the appropriate method based on all gathered data. Questions to be considered include:
-Which bone or bones will be lengthened?
-What is the planned lengthening amount?
-Is there any angulation?
-What is the patient’s age and weight (leg circumference)?
-What are the patient’s expectations (duration, cosmetic concerns, etc.)?
For instance, if lengthening is to be performed on the femur and the patient is overweight with no angulation, either unilateral external fixation + internal nail or an expandable nail alone might be preferred.

If the lengthening procedure will be performed from the shin bones (tibia), if the patient is of appropriate weight and there is angulation, Ilizarov or computer-assisted external fixators may be preferred.

5- How is limb lengthening surgery performed?
Limb lengthening surgery is conducted by an experienced orthopedic specialist under general or spinal anesthesia. The procedure begins by medically breaking the bone that is planned to be lengthened using controlled transverse (horizontal) osteotomy. After osteotomy, the bone lengthening/fixation systems are securely applied to the bone, as explained earlier. All these surgical procedures involve small incisions. (FIGURE 6a-b)
On the first day after surgery, the patient’s general condition is stabilized using antibiotics and pain relievers. Depending on the overall health of the patient, partial weight-bearing is allowed using supports such as a walker or crutches for daily activities and isometric muscle exercises begin on the same day. Hospitalization generally lasts two to three days.
Lengthening procedures start on the 5th day for children and the 7th day for adults after surgery. The preferred lengthening rate is an average of 1 mm per day, divided into four equal increments of 0.25 mm each. (FIGURE 7a-b)

Once lengthening is complete, the consolidation phase, where the newly formed bone hardens, begins. This period is approximately twice the length of the actual lengthening. During this time, patients can bear more weight while walking with support. FIGURE 8a-b)
Periodic X-ray checks ensure proper bone union, and once consolidation is sufficient, the externally applied fixation device is removed through a surgical procedure.

6– What is the treatment duration for limb lengthening surgery?
The treatment duration for limb lengthening surgeries varies based on the patient’s age, the bone being lengthened, and the amount of lengthening. In younger patients  lengthening procedures are generally have shorter treatment periods. It is crucial to note that smoking significantly slows down and inadequately supports new bone formation, making this an important consideration in lengthening surgeries.(For this reason, I generally do not recommend the cosmetic lengthening method for smoking. Prof Dr Bahtiyar Demiralp)
During the treatment process, physical therapy plays a vital role in maintaining joint flexibility and muscle strength. Patients should follow a nutritious diet and take calcium supplements to expedite the healing process.

7– What are the potential risks in limb lengthening surgery?
In these types of surgeries, if external fixation systems (external fixator) are applied, the most common issue is pin site problems. Regular pin site care is crucial, and often, dressing changes are sufficient.
Another potential risk is muscle contractures, which become more likely as the amount of lengthening increases. This issue is usually overcome with physical therapy and regular muscle exercises. In rare cases, problems can be resolved through applications of Botox to relax muscles or small surgical procedures.
“Delayed formation of the newly lengthened bone (consolidation insufficiency) is generally a problem seen in individuals with chronic diseases, extensions due to poliomyelitis sequelae, and smoking. Adjusting the lengthening pace can overcome this issue in individuals with additional health conditions.

8– What are the costs associated with limb lengthening surgery?
The costs of limb lengthening surgery are as frequently asked as the techniques themselves. Since technical aspects such as materials used, lengthening amount, and treatment duration vary from person to person, price ranges also show variability. Therefore, providing a fixed figure for limb lengthening surgery costs is not possible. To inquire about the prices for limb lengthening surgery, you can contact the physician who will perform the treatment for detailed information on the process.

9– Some questions about height growth:
-Are there exercises for height growth, and what are they?
Height growth exercises are among the methods that can be used to increase stature. Some of these exercises include:
• Stretching exercises: Activities like yoga and pilates can be performed for this purpose. Stretching exercises increase joint mobility by stretching muscles and ligaments, promoting flexibility, and correcting posture.
• Swimming: Regular swimming keeps the body flexible and helps maintain a straight posture, supporting the spine.
• Sports: Engaging in activities such as pull-ups, basketball, volleyball, and swimming can aid height growth by strengthening muscles.

-Do genetic factors influence height growth?
Genetic factors primarily influence height growth. The height of the parents are the main factors in determining the height of the child.

-What are the nutrients that support height growth?
Nutrients supporting height growth contribute to the healthy development of bone, joint, and muscle structures. These nutrients include calcium, protein, vitamin D, phosphorus, zinc, and magnesium, which should be rich in foods such as dairy products, leafy green vegetables, meat, fish, poultry, eggs, legumes, and nuts. However, the consumption of these foods should be controlled under the supervision of a dietitian.
-At what age is height growth more effective?
Height growth is more effective during the adolescence period. Adolescence is generally considered to be around 9-16 years for girls and 11-17 years for boys. Natural height growth is not expected beyond these ages.

More detailed information regarding the limb / bone lengthening procedure can be obtained face to face by contacting the institution where I work.

Wishing healthy days.

Yırtık gelişen hasta genellikle aşil tendonunun kemiğe yapışma yerinin yaklaşık5 cmyukarısında ayak bileğinin arkasında ani zorlanma sonucunda ani ve şiddetli bir acı ( hastaların ifadesine göre taş atılmış, tekme atılmış gibi) duyar. O andan itibaren yürümekte zorlanan hasta o taraf ayağının parmakları üzerinde yükselemez.

Muayenesinde, Thompson testi ( hasta yüzükoyun yatarken baldır kasının doktor sıkılması sonucunda ayak bileğinin hareket etmemesi ) pozitifidir. Yırtık olan bölgede tendonda elle hissedilebilir çukurlaşma vardır ve ultrasonografi tetkikinde yırtığın tespit edilmesi ile tanı netleşir.

Tedavisine bakarsak; konservatif (cerrahi dışı) ve cerrahi yöntemler vardır. Kısmi yırtıklarda cerrahi dışı tedavi yöntemleri tercih edilebilir. Hasta taraf bacak hekimin tercihine göre diz altı ya da dizin üzeri seviyesinden ayak bileği ekin pozisyonunda ( ayak bileği aşağıya doğru itilmiş pozisyonda) alçıya alınır. Daha sonra özel tip aşil botları, aşil atelleri ve kısa yürüme cihazları ile tedavi 3-6 aya kadar uzatılabilir.

Tam yırtıklarda farklı görüşler olsa da; genelde tercih edilen yöntem acil cerrahidir. Kısmi açık ( yırtık üzerinden 3-4 cm) yada açık yöntemler ile tendon cerrahi olarak tamir edilir ve tedaviye yukarıdaki gibi alçı, ardından özel tip aşil botları, aşil atelleri ve kısa yürüme cihazları ile tedavi 3-6 aya kadar devam edilir.

KAYNAKLAR

1. Kellam, JF., Hunter, MB., Mc Elwain, JP., Review of the operative treatment of Achilles tendon rupture. Clin Orthop. 1985;201:80-83.

2. Assal, M., Jung, M., Stern, R., Limited Open Repair of Achilles Tendon Ruptures. Journal of Bone and Joint Surg. 2002;84-A:161-170.

3. Ma G.W.C, Griffith, TG., Percutaneous repair of acute closed ruptured Achilles Tendon. Clin Orthop. 1977;128:247-255.

4. Klein, W., Lang, D.M., Saleh, M., The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendo achillis. Chir. Org. mov. 1991; 76:223-228.

5. Sutherland, A., Maffulli, N., A modified technique of percutaneous repair of ruptured Achilles tendon. Oper. Orthop. Traumat. 1999,7:288-295.

6. Kakiuchi, M., A combined open and percutaneous technique for repair of tendo Achilles. J Bone and Joint Surg. (Br) 1995;77-B;60-63.

Kırık iyileşmesini birçok faktörün bozduğu bilinmektedir. Kırık iyileşmesini geciktiren faktörleri mekanik ve biyolojik olmak üzere iki grupta toparlamak mümkündür. Erken hareket ve yük ile normal fonksiyonel dönüşü sağlayan sıkı bir kırık tespiti mekanik ve tamir için gerekli olan biyolojik desteği oluşturan etkenlerdir. Tüm bu lokal faktörlerin yanı sıra kaynama yokluklarında sistemik faktörleri de ihmal etmemek gereklidir. Cinsiyet, yaş, birden fazla kırık varlığı, sigara kullanımı ve hormonal durumun kırık iyileşmesini etkileyeceği düşünülmektedir. Geniş yumuşak doku travması ile birlikte olan açık kırık, yüksek enerjili travma, enfeksiyon, kan desteğinin bozulması, radyasyon, kırık uçları arasındaki düzenin kaybı, kırık uçlarında hareketlilik ve kemik doku kaybı da kaynama yoklukları için hazırlayıcı faktörlerdendir.

Kaynama yokluklarının tedavisinde çok çeşitli yöntemler kullanılmaktadır. Tek bir tedavi yöntemi yoktur. Tüm bu yöntemler problemli ve daima komplikasyonlara açıktır. Gereğinde birden fazla tedavi yöntemi kombine edilebilir.

Eksternal fiksatör (dışarıdan tespit)  uygulamaları kaynama yokluklarının tedavisinde, çok yönlü yaklaşım olarak son 50 yıldır yoğun olarak kullanılmaktadır. Kırık parçalarının, dışarıdan cerrahi sonrasında dahi düzeltilebilmesi, gerektiğinde kırık parçalarının pozisyonlarının değiştirilmesi, bacak uzunluğunun ayarlanması yöntemin en büyük üstünlüklerindendir.

Ilizarov ve arkadaşları, 1950’den beri, kendi uyguladıkları yöntem ve halkasal cihaz ile, aynı anda hastanın günlük aktivitelerini kısıtlamadan, eklem fonksiyonlarını koruyarak kaynamayı başarmış, eğriliği düzeltmiş, uzunluğu yeniden sağlamıştır.  Yine bu yöntemle kemik yoklukları giderilmiş ve enfeksiyon ortadan kaldırılmıştır. Bu sistem ülkemizde de 1980 lerden itibaren başarı ile uygulanmakta ve özellikle ateşli silah yaralanmaları, trafik kazaları gibi yüksek enerjili travmalar sonucu oluşan kemik kayıpları, eğrilikler, kısalıklar mükemmel ya da mükemmele yakın neticelerle tedavi edilmektedir.

Hastaların umut kaynağı olan bu yöntemde son nokta olan ADAM FRAME sistemi Türk mühendis ve hekimlerinin yoğun uğraşıları sonucu hasta ve hekimlerin hizmetine sunulmuştur. Bilgisayar destekli iki ayrı yazılımdan oluşan ve birbiriyle kombine çalışan (I-Tech Bone Correction ve Jonah Bone Navigation Software)  ve hastaların hekim tarafından sık kontrolünü ortadan kaldıran, tedavi aşamalarının tedavi öncesinde görülebilmesini sağlayan uygulanması kolay  bu yeni sistemin geliştirilmesinde esin kaynağı yine ünlü bir Türk olan Mimar Sinan’ın ustalık dönemi eseri olan Selimiye Camisinin kubbesini sekizgen zemin üzerine oturtması ve yine Mimar Sinan’ın Kanuni Sultan Süleyman Türbesinde kullandığı bu 8’gen yapının kare zemin içerisine yerleştirilmesi olmuştur.

Adam Frame`i kolay ve faydalı kılan en önemli özelliklerin başında dünyada ilk kez bir eksternal fiksatorde Navigasyon yazılımın kullanılmış olmasıdır. Bu özellik kullanıcıya kolaylık sağlamakta ve zaman kazandırmaktadır. Aynı zamanda uygulama surecindeki oluşabilecek hataları azaltmakta, dolayısıyla sonucun başarısına yüksek oranda katkı sağlamaktadır.

Ülkemizde GATA, Ortopedia Hastanesi(Adana), İnönü Üniversitesi, Cumhuriyet Üniversitesi, Pamukkale Üniversitesi gibi merkezler başta olmak üzere kullanılmakta olan bu sistem kaynama yokluklarının yanı sıra Polio Sekeli, Raşitizm, Cücelikler ve tek taraflı kısalıklarda da başarıyla kullanılmaktadır. Adam Frame’ in eğitimi yine Türk Ortopedistleri tarafından yurt içi ve yurt dışından gelen misafir ortopedistlere de yoğun olarak verilmektedir.