Dror Paley, MD, FRCSC
|ORTHOPEDIC EDUCATIONAL SITE BY THE MOST
EXPERIENCED LIMB LENGTHENING SURGEON IN THE
Cosmetic Stature Lengthening:
A New Breakthrough
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Click here to read Cosmetic Stature Lengthening Frequently Asked Questions (FAQ’s)
Dr. Dror Paley,
Director Paley Advanced Limb Lengthening Institute,
West Palm Beach, Florida.
For further inquiries contact our patient coordinator:
Caroline Eaton firstname.lastname@example.org (561-307-8703)
For administrative or financial inquiries please contact the Institute Administrator:
Craig Nesta email@example.com (561-844-5255)
In August 2011, a new implantable lengthening device, the PRECICE, was approved by the FDA. It was
developed by Ellipse Technologies, out of California in conjunction with a team of orthopedic surgeon
consultants, myself included. The Precice has an internal lengthening mechanism that consists of a magnet
connected to three sets of planetary gears (1/64 reduction), connected to a threaded rod. The threaded rod
drives a telescopic tube which can expand. Using an external rotating magnet (ERC device) applied close to the
skin at the level of the magnet inside the rod the internal magnet can be rotated. Rotating one way causes
lengthening which rotating the magnet the opposite way causes shortening. It takes hundreds of revolutions
of the external magnet to effect a 1 mm change in length of the nail. It takes 7 minutes to achieve 1mm.Unlike
previous devices the Precice has excellent rate control in both directions. The nail is designed to be able to
lengthen against a force of 80kg (176 lbs). The forces that need to be resisted inside the limb have been
reported to be up to 50 kg (110 lbs). Therefore this nail is more than strong enough to lengthen even the
largest bone (femur).
Although each Precice is for one time use, the ERC device can be used for many patients. At present the FDA approved the use
of the ERC device for the physicians office. This means that the patient must come in to the office daily to have the lengthening
performed, including on weekends and holidays. The Precice can lengthen up to 6.5cms, although this amount may increase in
future models. At the Paley Institute our specially trained orthopedic technologists Mark and Tony perform the lengthening for
each patient daily. If there is any problem they alert the clinical team, and the patient is seen by a physician assistant or doctor
the same day. Since patients undergo daily physical therapy (PT) sessions at the Paley Institute, we coordinate the lengthening
sessions with the physical therapy schedule. Patients have an x-ray every other week to monitor the lengthening. The x-rays
are measured to confirm that the amount of lengthening that the ERC did has in fact been achieved. After the x-ray they are
seen by one of our doctors or PA’s.
The Precice heralds in a new era for limb lengthening but especially for cosmetic limb lengthening. We now finally have a device
that can be implanted with minimal incision surgery and which can perform lengthening by a remotely controlled mechanism
without rate control problems. The safety factor with this device is excellent since it can be lengthened at any rate and can even
be reversed to shorten the limb.
Despite the ease of insertion and use, the limb lengthening process remains the same and the risks associated with limb
lengthening remain unchanged. For these reasons it is still essential that a surgeon experienced in limb lengthening and in the
treatment of lengthening complications be he one performing the procedure and following the patient. (see complications section
Recovery from Implantable Limb Lengthening
The typical recovery from bilateral femoral or tibial lengthening is as follows:
1) surgery and hospitalization: 3-4 days
2) distraction phase (weight bearing (WB) for transfers only; daily PT). Femur:one day for each mm of lengthening (65 mm
= 65 days); Tibia ¾ mm per day (65mm=87 days)
3) consolidation phase until full WB permitted = 4-6 weeks in most but can be longer. The end of this phase is when the
bone on the x-ray appears to bridge the lengthening gap at least on one side. WB is progressed from transfers only to full WB.
4) Rehabilitation phase: full WB without crutches. Regaining of muscle strength and joint range of motion to normal.
Usually 1-3 months.
5) Return to sports usually by 4-6 months after surgery.
Removal of Implant
The implantable lengthening device should be removed. Although it is made of inert metal (titanium), there are also other
materials including rare earth magnets, etc. The moving parts also can lead to wear and even corrosion. For these reasons it is
preferable to remove the device. The device can usually be removed as early as one year after surgery. There is no urgency in
the timing of removal but it should be done. The removal is an outpatient procedure but does add some cost to the total costs
of this surgery. It can be deferred for more than one year.
Historical perspective on implantable limb lengthening devices:
I have been performing Limb Lengthening Surgery since 1986. The two main indications for such surgery are limb length
equalization for limb length discrepancy (LLD) and stature lengthening for short stature. Since 1986 I have performed 15,000
limb lengthening surgeries. This is probably more than any other surgeon worldwide. The majority of these surgeries were for
LLD. Over 1300 were for short stature related to dwarfism and cosmetic reasons.
My history with cosmetic lengthening for stature is as follows:
I started with the Ilizarov method for lengthening of both tibias in 1987 and soon after switched to the lengthening over nail
method I had developed in 1990. Although my results were excellent, the scars, the pain, the suffering, the pin site infections
were not conducive to a cosmetic procedure.
I sought a fully implantable lengthening solution. When the Alibizzia nail, developed by Guichet became available I worked with
the French company that made the nail to develop a tibial lengthening Albizzia for stature lengthening. I started using this in
1996. The severe pain experienced by patients from the 15 rotation of the thigh through the break in the bone, as well as
several implant failures lead me to stop using this non-FDA approved device. In 2001, when the ISKD, developed by Cole was
approved by the FDA and marketed by Orthofix became available, I was the first surgeon after Dr. Cole to implant this device. I
thought that this was going to be the panacea for cosmetic lengthening. I have since performed over 350 ISKD implantable limb
lengthenings, more than anyone in the world. Many of these patients were ISKD’s for cosmetic stature lengthenings. The
surgery was minimally invasive with few scars. The problem was rate control. The ISKD lengthening is dependent on movement.
Therefore it can lengthen too quickly, too slowly or at the desired rate of 1mm per day. Over 50% of cases lengthened too
quickly, 20% too slowly and only 30% at the desired rate. I was a consultant for Orthofix and advised them since 2001 that
they need to redesign the mechanism to achieve rate control. Lack of rate control lead to most of the complications such as
muscle contractures, nerve injury, poor bone formation, etc. Furthermore there were many malfunctions of the mechanism,
which for unexplained reasons would fail to lengthen in the middle of the distraction phase. This lead to increased numbers of
procedures to treat complications. For stature patients this also meant increased costs. I learned to work with the ISKD to
minimize complications and became an expert at the treatment and prevention of these complications. My final results due to my
diligence were excellent in almost every patient. The ISKD was the only FDA approved device and was the best implantable
lengthening device that we had in the USA. The ISKD, the Albizzia and the Fitbone are all what I call first generation lengthening
nails. They all suffer from significant mechanical and other problems.
On December 1, 2011, I implanted the first 3 Precice nails. By October 2012, I have performed over 60 Precice cases (more than
any other surgeon worldwide). These cases include femoral, tibial and humeral lengthening with the Precice. Although it is too
early to tell the long term results, in the short term, I can attest to the almost perfect rate control in my cases. Most have had
little pain during distraction compared to the ISKD and Albizzia. While the procedure for implantation was the same as for ISKD
and Albizzia, with few and very short incisions (minimal scars), the postoperative course thus far has been much more
comfortable for the patients. I think this difference is due to two factors: rate of lengthening control and no rotatory movement
through the osteotomy site. I will continue to post up to date results for this new technology. Here are the links to first
PRECICE lengthenings we performed in the news:
Here are the links to first PRECICE lengthenings we performed in the news:
Click here to read Cosmetic Stature Considerations and the FAQs about Implantable Limb Lengthening
Paley Institute Surgical Limb Reconstruction Fellowship Program
This UNIQUE fellowship is designed for orthopedic surgeons interested in
developing an expertise in pediatric and adult limb reconstruction/deformity
surgery of the lower and upper extremities. For more information Click Here