There is no shortage of young people today who, while being of average height, wish to get taller in order to have a more attractive and self-assured physique. Some people have turned to the leg lengthening service, which has been proven to be a safe and effective procedure, due to the nature of their jobs, their plans for the future, or the fact that they are foreign students or overseas Vietnamese who want to blend in with the host country.

40-year-old actor gets his legs lengthened so he can land more new roles

NTH is a 40-year-old actor who underwent surgery to stretch his legs by 7 cm. The procedure was performed in Vietnam by Assoc. Prof. Dr. Le Van Doan, Director of the Institute of Traumatology and Orthopedics – 108 Military Central Hospital.

Sharing about his leg lengthening journey, actor NTH said: “I actually wanted to undergo leg lengthening when I was 20, but my financial situation at that time did not allow it and I was building my career. Also, back then, the intramedullary nailing technology did not exist and the time spent in an external fixator was still very long.

However, for an actor with a good-looking face, outstanding acting skills, and great feedback from directors in auditions, having short stature was very challenging. I hardly got the chance to play couples with actresses, and I was extremely unfit to “match” with fellow actresses at their ideal height. This prompted me to have leg lengthening surgery before I was too old. My work reaches maturity when I am 40 years old. At 40, I still have many years ahead to wear better clothes, to love life, to have more favorable situations, and to fulfill the wishes of my youth.”

According to Mr. N.T.H, before his surgery, he also went through a period of worry and anxiety because he was old and did not have the same advantages as young people. But after learning more about the treatment regimen, surgical methods, and previous leg lengthening cases as well as getting consulted by the medical team, he felt that every stage was safe and uneventful. Therefore, he decided to spend 2 months for the surgery and another 2 months resting and actively exercising to achieve the desired height.

N.T.H’s career will undoubtedly have many new turning points, many new spectacular roles on the screen, with his height changing from 164 cm to over 171 cm. “There’s nothing greater than letting yourself achieve your long-time wish to become a taller, more confident, and better dresser…” – Mr. N.T.H emphasized.

Photo of N.T.H before undergoing his leg lengthening surgery

9x girl hides her family from her leg lengthening surgery to become more attractive

N.D.L, born in 1990, was only 158 cm tall, but after seeing her close friends, who have model heights, the girl decided to hide her family in order to extend her legs by 5 cm.

Sharing about the decision to lengthen her legs when her height is not too low, N.D.L said that two of her close friends had already had their legs stretched, so the young girl from Hanoi already had a lot of experience, from choosing a prestigious institution at Dr. Doan’s to taking care of herself after surgery and planning exercise time and physical therapy to achieve the highest height. Her friends’ current appearance was the motivation for N.D.L to decide to stretch her legs to be taller and more beautiful.  “Although I am not too short, when I walked with friends who are nearly 170 cm tall, I felt inferior. Above all, I also wanted to have the height of a model, so I didn’t hesitate to get my legs stretched. Now the surgery is very simple as well.”

N.D.L also hid her decision to get surgery from her family. She decided to undergo the surgery herself, because L understood that after only 4-5 months, all her activities would return to normal. The surgery was quite simple. All services at Dr. Doan’s were excellent and very safe. Therefore, L feigned a business trip so that her parents wouldn’t have to worry. After finishing the long trip, her parents saw their daughter as a beautiful and confident woman! And now, when she goes out, many people look up and admire her height. L also enjoys a very confident and proud feeling when striding.

Photo of N.D.L before undergoing her leg lengthening surgery

Young man desires to be taller to realize his dream of studying abroad

Despite possessing a desirable height of 172 cm, the young man from Hanoi N.V.D still went to Dr. Doan’s to extend his legs by 6 cm, to achieve a height of 178 cm.

With the dream of studying in Spain and the desire to walk with his Western friends with pride, N.V.D did not hesitate to spend 2 months to get his legs lengthened by 6 cm.

Thanks to the good mental preparation and health background, the support of the family, excellent service and skills, and Dr. Doan’s great reputation, D was able to achieve his dream without much difficulty.

Photo of N.V.D before undergoing his leg lengthening surgery

The surgery went smoothly, and the recovery time was fast. D quickly returns to his normal life. After only 2 months of surgery, D is learning to walk on his new legs with a height that many people now have to “look up”.

International male student in the UK: To be beautiful requires determination and courage

In order to gain more confidence and easily integrate into the life in the UK, 25-year-old international student L.A.M spent his summer vacation in Vietnam undergoing leg lengthening surgery.

With a height of only 1m62, the young man planned to get his legs lengthened by 8cm, so that after surgery he would reach an average height of 1m70.

“Actually, when you understand the principle of leg lengthening surgery, you will find it is quite simple but effective. After surgery, it is similar to what happens to a broken bone because the bone will heal right away,” L.A.M shared.

Photo of L.A.M before undergoing his leg lengthening surgery

If you desire to be taller, have stable financial resources and are mentally prepared, especially for the recovery and exercise times, then do not hesitate to book an appointment for leg lengthening surgery. It’s all about making yourself more confident and beautiful.

More and more young individuals are deciding to have leg lengthening surgery to increase their height, beauty, and confidence so they can stand shoulder to shoulder with their international friends. Do not hesitate or pass up the chance to stretch your legs if you are also trying to gain height. We might need to spend money and time, but in exchange we get a fresh start, a new height, a new look, greater confidence, and the ability to enjoy life more. It is definitely worth it.

Recently, 2 cases of severely deformed bow legs were successfully operated on by Assoc. Prof., Ph.D. Le Van Doan, Director of the Institute of Traumatology and Orthopedics, 108 Military Central Hospital. Read Dr. Doan’s commentary on these two cases.

Bow leg correction – Giving new hope to young girl

N.T.H., a 20-year-old from Hanoi, is one of the peculiar patients that Dr. Doan will always remember. Initially, H’s legs were only slightly bent, but after the family took her to get surgery to straighten the legs, the complications became more severe. Every hospital shrugged its shoulders when she requested a second surgery after the first one because it was too difficult and there was a risk of complications. This made H and her family more depressed. However, the burden and pressure were only lifted off of H’s family and friends when Assoc. Prof., Ph.D. Le Van Doan nodded in agreement to perform the surgery. Sharing about this special “patient,” Dr. Doan said that it was not a very complicated case. H admitted that she lacked confidence because of her bow legs when visiting Dr. Doan. Her family has taken her to numerous hospitals and doctors’ offices for treatment, but each one has “shaken their head.” Indeed, only those with bow legs could comprehend their affliction and tenacity.

H’s surgery was successful, and she was able to walk normally after a few months. Although H’s legs still have scars, she can get plastic surgery in the future to have the scars removed as her legs become straighter. Few people can tell she once had bow legs, even when she wears long pants.

The young girl and her family have gone through many difficulties, seeking treatment everywhere, and having sad and desperate days. Now, H wept tears of joy while gazing at her feet in front of the mirror, knowing that she has escaped from the life of bow legs and concerns about disability.

Another example would be 12-year-old N.L.A., who also had severe bow legs. At school, she would get teased by her classmates, making her feel very inferior. A’s family did some research and took her to a hospital in Hanoi. But after the procedure, things got even worse. After a while, there were still surgical scars on the legs, along with deformities. Her family was very concerned. Every hospital they tried to take her to for medical attention shook their heads and refused to accept the surgery because it was too complicated to handle.

What lies ahead for the 12-year-old girl? Her parents looked up every bit of information online while worrying about the disabled child and just so happened to be aware of Dr. Doan and numerous instances of successful surgery. The family made an appointment right away and took L.A to the doctor.

Fortunately, Dr. Doan was able to straighten L.A.’s legs, and as a result of that surgery, L.A. is now happier, more vibrant, and more self-assured when standing in front of everyone.

Trusting the right institution

Nearly every week, patients contact Assoc. Prof. Doan with inquiries about bow legs, X-shaped legs, K-shaped legs, and so on. All of them want to have straightening surgery. According to Assoc. Prof. Doan, leg straightening is performed best at certain ages. It is best to have the surgery when you are 18 years old, but for young children, their legs can be treated with orthotics, casts, or orthopedic braces, which guarantee improvement.

Patients should carefully consider and select a reputable institution and an experienced surgeon to perform the surgery in order to avoid any potential unfavorable complications.

Contact Dr. Doan immediately for advice.

Bow leg is a condition where the knee is pointed out and the leg is bent, causing the ankles to be close together and the knees to be far apart when standing straight. Bow legs often come from causes such as genetics, malnutrition, being overweight, or some diseases of the joints.

Parents with bow legs have a higher chance of passing this deformity to their babies. Bow legs can also develop in children who have chronic calcium and vitamin D deficiencies. Babies with excess weight who learn to walk too soon are also more likely to develop bow legs. Bow legs can also be caused by rickets, osteogenesis imperfecta, fractures that are displaced near the knee joint, injuries that cause cartilage damage, and other conditions.

With more than 30 years of experience in the field of surgery and orthopedics, Assoc. Prof., Dr. Le Van Doan has pointed out a number of solutions that can assist people with bow legs to improve this deformity.

Dietary Modifications

One of the causes of bow legs is nutritional deficiencies. Therefore, adjusting the diet and supplementing with suitable substances is a positive solution to solve the issue.

In the daily diet, nutritionists recommend that people with bow legs should increase protein, vitamins, and minerals, especially calcium, vitamin D3, MK7, etc. These substances support the treatment and prevention of rickets and malnutrition while assisting the body’s improved calcium absorption, enhancing bone strength and flexibility.

The following foods should be on the menu because they are high in nutrients and good for bones: shrimp, crab, eggs, milk, fish, etc.

Image of bow legs

Exercising

To improve their bow legs, children need to be encouraged to be active and play sports regularly. Some simple exercises, easy to do at home, such as tiptoe exercises, squats, glute stretching exercises, and using massage rollers, etc, are also recommended.

Regularly performing these exercises will strengthen the legs, ease knee pain, tone the muscles, adjust the knee inward, improve ligament and tendon structure elasticity, etc.

Physical Therapy

Children with bow legs should be taken to medical facilities with specialized physical therapists to get their legs corrected. Depending on the degree of curvature, the doctor will prescribe a physical therapy regimen that includes exercises ranging from simple to complex movements to start the correction.

Exercises will be performed under the guidance and prescription of qualified doctors and rehabilitation technicians. Some basic physical therapy exercises that can be referred to are using leg belts or leg press.

Orthopedic surgery for bow legs

Orthopedic surgery is a successful treatment option when the aforementioned measures fail to improve the condition and the bones and joints have stabilized by the time the patient is 19 to 20 years old. The leg shaft will be surgically adjusted to be straight, attractive, and to enhance the figure. Additionally, this solution aids in weight adjustment to properly focus on the joints, preventing later-onset osteoarthritis of the knee and ankle.

According to Dr. Doan, a bow leg operation typically lasts two hours. A bone is usually cut below the knee, where it is most curved, and then straightened by the surgeon. Depending on the degree of the deformity, the legs will be 1-2 cm longer. Bone from either the donor or the patient will be used to fill the gap. The bone is firmly fixed by the locking screw brace.

After five days of surgery, the patient will be able to stand up and practice walking. After 3-4 weeks, the patient can begin to walk slowly. After 2-3 months, the patient can be active and exercise like a normal person.

Assoc. Prof., Dr. Le Van Doan has successfully performed hundreds of surgeries to correct deformities of the legs and arms, including many cases of severe bow legs. This is a type of surgery that is not too difficult but requires a specialist in orthopedics to avoid complications.

At the same time, this type of surgery needs to be performed at a hospital with modern medical equipment, with a team of highly skilled doctors and technicians, and with dedicated care to guarantee safety and good results.

Turning low self-esteem into motivation to escape the life affected by bow legs

According to Assoc. Prof., Ph.D. Le Van Doan, who has more than 30 years of experience in the field of orthopedic surgery, the number of patients seeking correction of bow legs into straight legs has increased in recent years. “Every patient who comes to me for advice has their own set of feelings and goals. They feel inferior and have a lot of self-doubt about their body shape and physique.” – Assoc. Prof., Ph.D.Dr Le Van Doan said.

H.V graduated from university with a first-class degree, has a bright face, and an ideal height of more than 1.6 meters, but she still feels scared and lacks confidence because of her bow legs. “Despite having long legs and white skin, I’ve only ever dared to look at short skirts. I tried on my favorite beautiful dress several times, but I was never confident enough to wear it out on the street because I was always afraid of people looking at my bow legs.” – Ms. H.V., 24 years old, shared.

Ms. H.V. was overjoyed after doing her research online that there is Dr. Doan, who has experience performing corrective surgery for numerous cases of severe bow legs. She immediately scheduled a consultation and eagerly anticipated the appointment to fulfill her dream. “Before performing any orthopedic surgery, I personally examine each patient, take the time to learn about their goals, and use tomography to measure the lower limb axis and provide personalized recommendations. Customers in particular cases were aware of the surgical procedure and the recovery from surgery process.” – Assoc. Prof. Doan shared.

H.V. sought advice and discovered that the surgery, hospital stay, and rehabilitation process were not as difficult and drawn-out as she had originally believed. With the support of her family, she scheduled the surgery right away. Ms. H.V. was unable to contain her happiness as she gazed at her long, straight legs in the mirror before sobbing uncontrollably.

Or, in the case of Ms. N.T. K, she poured her heart out when she saw Dr. Doan. “Having bow legs is still a defect, even if a woman is smart, has an oval face, and is young. I am extremely self-deprecating because of my legs, especially when the nature of my job requires me to meet customers frequently.”

Ms. N.T.K had her legs directly operated on by Doan doctors to straighten them at the end of 2021. “I consider myself lucky and appreciative that the doctors were able to help me have straight legs, something I previously believed could only be accomplished in countries with highly developed medical systems, such as the UK and the US. I am now significantly more confident in life and work after only 4 weeks of surgery and recovery. – Ms. N.T.K revealed.

According to Associate Professor Doan, men are just as likely as women to be interested in leg lengthening surgery or correcting bow legs. “I once gave two French brothers both leg lengthening and leg correction procedures. Having crossed great distances to Vietnam, they showed confidence and determination to have longer legs despite having bent legs and shorter legs than the natives. The French brothers have been able to proudly display their tall figure with straight, long legs that have grown from 1m63 to 1m70 up until this point.”

What level of correction will be used, and when will surgery be necessary?

The majority of people with normal legs are slightly bent, according to Associate Professor Doan, but not everyone has surgery as a result. The doctor decides whether or not to perform the surgery based on the severity, and the outcomes vary depending on each case. The severity is also generally reduced from its initial level to between 90 and 95 percent. Therefore, please feel confident in Dr. Doan for the most detailed advice on indications and procedures for surgery and rehabilitation.

Additionally, Assoc. Prof. Doan claims that surgery to correct the bow leg heals more quickly than leg lengthening. Typically, a patient who has undergone surgery to correct bow legs only requires three to four weeks of rest before being able to walk normally. The patients are once again free to participate in sports after six months.

With only two hours of surgery, having straight legs and being the right height is a significant change that will bring joy, happiness, and a lifetime of confidence.

Link to article on Afamily: https://afamily.vn/phau-thuat-keo-dai-chan-giac-mo-tang-chieu-cao-khong-con-qua-kho-khan-20211228210613908.chn

As society develops, people start to pay more and more attention to each other’s height. Not everyone is born with a desired height. Thus, the need for leg lengthening surgery to improve height is increasing.

So what actually is leg lengthening? What are our safe stretched lengths? How long does it take to return to daily life, will there be any sequelae, etc. These are questions that most people with a “modest” height are interested in.

How does leg lengthening work?

Leg traction surgery is a surgical method to increase the length of the legs by 1mm every day, based on the body’s ability to regenerate new bone on its own, and the recovery of soft tissues, blood vessels and surrounding nerves.

In the past, leg lengthening surgery was only performed for people with limb length discrepancy. However, nowadays, more and more people are choosing this surgery to improve their height to become more confident in life.

So how many centimeters can your legs get stretched by? Assoc. Prof., Dr. Le Van Doan said, depending on the specific condition of each individual, the doctor will examine and advise where the procedure should be performed and how long the legs should be stretched to ensure the best aesthetic result and recovery. Achieving the desired length depends on your age, health status and surgical condition. Your current height, gender and surgical site will determine your stretched length, which can range from 10-12cm.

A method that guarantees safety and fast recovery

More than 10 years ago, just using only the external fixators to stretch will result in the patient having to wear them from 9 to 12 months (average stretching rate of 45 days for each centimeter). Currently, the combination of intramedullary nailing and external fixation is one of the most advanced surgical methods, allowing the lengthening process to still achieve maximum efficiency, while the time having to the fixators is shortened to only ¼ of the original duration (average rate of 10 days for each centimeter). Because in addition to cutting the bone and installing the fixators for daily stretching, the doctors also put into the marrow canal a nail with a screw at the top of the bone. This new method has been applied to hundreds of cases, without any distortion or complication. After recovery, patients can move their legs freely, and even play sports safely.

Patients who underwent leg lengthening usually suffer pain in the first 2 days. After 2 months, they can climb stairs and 20 months later, almost all basic activities are back to normal. The patients can play tennis and many other different sports.

With a shortened duration, scars get smaller (1-2cm) and their number is less. This advanced method is currently being applied in many cosmetic leg lengthening surgery centers around the world and in Vietnam.

Change your life with the decision that “let you be your most confident self”

Not only does leg lengthening make you look more radiant, but it also makes you more confident and strong in life. So don’t be afraid of changes, because the decisions you make now will change your future.

This is a 24-year-old short girl from Saigon. She has a pretty face but her height was only 1.48m. After more than 2 months of surgery, every time she stood in front of the mirror, she burst into tears of joy when she found out that her legs were longer and her body was much taller than before. From then on, Q could confidently walk on the street in her most beautiful dresses.

In addition, people who work in specific fields such as models, actors, international students, etc. because of the nature of their work, have also undergone leg lengthening surgery to gain confidence and have more new opportunities

Many other patients who are overseas Vietnamese and foreigners who are currently living and working abroad, also took advantage of the arrangement to fulfill their dream of leg lengthening, with the desire to have better opportunities in the host country. Such is the case of Preeda, a 23-year-old young man from Thailand, a country famous for many cosmetic services, who also trusted Dr. Doan to conduct leg lengthening surgery on his legs. This affirms that the service quality as well as the expertise and skills of doctors in Vietnam are not inferior to other countries in the world.

Having an ideal height has been the dream of many people. Now, that dream is completely “within reach”. According to experts, improving height is a very significant change in appearance and if that helps you to become confident in life, then this method is the best way to achieve your desired height.

Learn more about leg lengthening:

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Author links open overlay panel: DoanVan Le LuongVan Nguyen
Read original article: https://doi.org/10.1016/j.ijscr.2021.106577

Highlights

• Tibial pseudoarthrosis with large leg-length discrepancy and extensive scarring was a great challenge.
• The treatment for these lesions was not defined.
• Ipsilateral fibula lengthening then centralization for the treatment of tibial pseudoarthrosis was a safe, rapid, and inexpensive procedure.
• Our procedure was not difficult, and microvascular skills and special devices were not required.
Abstract

1. Introduction and importance

Tibial dysplastic pseudoarthrosis associated with large leg-length discrepancy and extensive scarring was a great challenge for orthopedic surgeons. The treatment for these lesions was not defined.

2. Case presentation

We report a 24-year-old case of dysplastic pseudoarthrosis at the middle third of the right tibia with a 10 cm leg-length discrepancy and a 250 medial deviation and 200 internal torsion due to osteomyelitis 14 years previously. She was treated by fibula lengthening then centralization for the treatment of tibial pseudoarthrosis. Eight months after the operation, the patient reported no pain and became capable of walking without an orthosis. X-rays showed full bone union at the proximal tibiofibular synostosis and the lengthening site of the right fibula. The distal tibiofibular synostosis was healing. The range of movement of the knee and ankle was restored.

3. Clinical discussion

This technique was different from the Huntington procedure. A good union between the transposed fibula and the remaining part of the fibula brought a better strength of the reconstructed tibia. The tibial pseudoarthrosis, leg-length discrepancy, and malalignment had been solved by our techniques. The procedure was easy, rapid, and inexpensive without requiring microsurgery skills and special devices.

4. Conclusion

Leg lengthening then centralization of ipsilateral fibular graft is an excellent option for reconstruction of a tibial pseudarthrosis with a large leg-length discrepancy. It is a safe, rapid, and inexpensive procedure. The procedure was not difficult, and microvascular skills and special devices were not required.

Level of evidence

A case report.

Keywords
Tibial defect
Tibial pseudoarthrosis
Leg-lengthening
Leg-length discrepancy

1. Introduction and importance

Tibial dysplastic pseudoarthrosis with large leg-length discrepancy was a great challenge for orthopedic surgeons, especially when associated with extensive skin and soft tissue damage. The deformities of the tibia with shortened, deviation, dysplastic non-union must be solved as much as possible. The treatment for these lesions was not defined. Reconstruction of this injury could be done by various methods including segmental allograft, vascularized and non-vascularized autograft, induced membrane technique, bone transport, and Huntington procedure. Implantation of segmental allograft and non-vascularized autograft in the tibial dysplastic pseudoarthrosis with surrounding extensive scarring post-osteomyelitis may be at a high risk of failure, like infection, rejection, fractures, and nonunion. The free vascularized bone transfer had been suggested as the leading option for tibial defects of 5 to 12 cm. Although vascularized fibular autografts have distinct benefits and allow simultaneous soft tissue coverage, problems were relatively common. These included infection and stress fracture and could occur at both donor and recipient sites, the hypertrophy of the graft was unreliable. The technique also was an extensive and time-consuming procedure, which requires harvesting a contralateral fibula and microsurgery skills [1], [2]. Huntington procedure has been used for managing complex tibial nonunion with intensive tissue damage [3], [4]. It provided a large graft of the ipsilateral fibula raised on a pedicle of the peroneal artery, aligned and fixed to the tibia; avoiding exposure of the site that is vulnerable to infection and facilitated wound healing without prolonged hospitalization. The Masquelet technique was relatively ineffective in achieving union in the reconstruction of great tibial defects and was associated with a high rate of infection [5], [6]. However, the leg-length discrepancy and an acceptable limb alignment had not been solved by the abovementioned techniques [4], [7]. Leg lengthening had been done following tibial reconstruction. Bone transport also was used for massive tibial bone loss, but if the amount of bone loss was great, the time to achieve the desired length of regenerate could be extremely long with many complications. Bone transport required a one-month consolidation period for 1 cm of regenerated bone and distal consolidation between the distal and transported fragments required 6 months [8]. In patients with massive tibial bone loss, the Ilizarov technique for distraction-compression osteogenesis could be associated used with the Huntington procedure [3]. However, this method was technically demanding and had theoretical risks of complications that may occur even when performed by experienced orthopedic surgeons. Complications included pin site infection (up to 80%), loss of alignment, failure of bone consolidation, nonunion at the docking site (up to 44%) refractures, and scarring [5].

We report a 24-year-old case of tibial dysplastic pseudoarthrosis with a 10 cm leg-length discrepancy due to osteomyelitis. Our case was treated using an atypical procedure by fibular lengthening then centralization for the treatment of pseudoarthrosis at the middle third of the right tibia.

2. Case presentation

This case follows 2020 SCARE guidelines for reporting of cases in surgery [9]. A 24-year-old woman was transferred from a local hospital to our hospital with a diagnosis as pseudoarthrosis of the right tibia due to osteomyelitis. She reported a history of right tibial hematogenous osteomyelitis when she was five years old. She was treated in a local hospital and was under the intervention of removal of dead bone of the right tibia. Unfortunately, she had a purulent at the right post-operatively. She was transferred to the central hospital and had five other operations of debridement. The wound in the right leg had not been healed well until 10 years later. The right tibia had been non-union with leg length discrepancy. After that, she had not been under any treatment. As she was growing up, the shortening and deformity of her left lower leg became obvious. She could walk without crutches, but with difficulty. The patient was well. During the physical examination, upper limbs and spine were unaffected, as well as the left lower extremity. The right hip and knee were stable and normal in terms of the range of motion. There was a 250 varus and 200 internal torsion deformity of the right leg with a 10–cm-leg-length discrepancy. The anterior soft tissue at the middle third of the right leg was in poor condition with extensive scarring and the right foot was in equinovarus deformity (Fig. 1). The movement range of the right ankle was 0° dorsiflexion and 30° plantarflexion. There was no comprimisation of blood flow, sensation, or motor-nerve function. X-rays showed a dysplastic pseudoarthrosis at the middle third of the right tibia with a 10 cm leg-length discrepancy. There was a 250 medial varus and torsion deformity of the right tibia. The right fibula was hypertrophied and curved at the distal third. The ankle joint was nearly normal except for a thickened lateral malleolus. A radiograph showed the pelvis severely tilted to the right (Fig. 1). The patient had no family history of any relevant genetic information, psychosocial history, or relevant pre-existing illnesses. She did not smoke and drink alcohol.

Fig. 1. X-rays and Clinical condition pre-operative. A, B, Clinical condition pre-operative. C, D, CT Scanner of lower extremity and X rays of right tibia and fibula.

Based on her history, physical exams, and X-rays findings, it was determined that she had dysplastic pseudoarthrosis at the middle third of the right tibia with a 10 cm leg-length discrepancy and a 250 medial deviation, and 200 internal torsion due to osteomyelitis 14 years ago. After discussion of the risks and benefits of surgery, the patient decided to undergo the recommended surgical procedure: 10 cm leg lengthening using external fixater after proximal and distal fibular osteotomies and then fibular centralization for the treatment of pseudoarthrosis at the middle third of tibia. The patient underwent surgery in the supine position with spinal anesthesia. She has received a single dose of prophylactic antibiotics before thigh tourniquet inflation. The operative leg was prepared and draped in a routine surgical sterile fashion above the knee. The Nhan’s external fixater was used for leg lengthening in this case. That had been used widely in Vietnam for the management of open fracture for over 20 years.

Nhan’s external fixator was made in Vietnam. The frame consists of two vertical bars (10 mm diameter) (Fig. 1) with opposing threads (1 mm pitch) to stretch or compress the bone by turning. Each bar was 320–350 mm in length and included six operable flat faces at the center, numbered 1-2-3-4-5-6 in the direction of stretching. By rotating each vertical bar three times daily, with each turn equal to one number in the middle of the bar, the pin clamps at the proximal and distal of the bar would expand approximately 1 mm.

A 3 cm longitudinal incision was done at the lateral border of the proximal fibula. The fascia was opened then the peroneal nerve was identified and retracted laterally. The fibula neck was exposed and osteotomized using a chisel. A 2 cm longitudinal incision was done at the lateral border of the fibular distal third. The fascia was opened then the fibula was exposed and osteotomized using a chisel about 6 cm proximal to the distal fibula. The internal torsion deformity of the leg was reduced. The Nhan’s uniplanar both-side external fixater was applied at the right tibia with four Steinman pins and one Schanz pin. Two Steinman pins and a Schanz pin were inserted at the proximal third of the tibia, two Steinman pins were inserted at the distal third of the tibia. The incisions were sutured (Fig. 3). Lengthening started at day 5 with a 1/3 mm extension applied four times daily. The patient was discharged 10 days postoperatively. Before discharge, she was instructed regarding properly performing distractions at home. She was permitted partial weight-bearing activities with crutches. Seven weeks post-operatively, the distal fibula was medialized and fixed to the distal tibial segment using a lag screw. A percutaneous Achilles tendon tenotomy was done and the right foot was fixated by an external fixater at the same time to correct equinovarus deformity of the right foot. She was instructed regarding properly performing a gradual reduction of right tibial varus deformity during lengthening at home. Every three weeks follow-ups were conducted. 14 weeks post-operative, the right leg had been lengthened 10 cm. The proximal fibula was medialized and fixed to the proximal tibial segment using lag screws. The external fixater was removed and the patient applied a long-leg orthosis (Fig. 2). 18 weeks post-operative, the proximal and distal tibiofibular synostosis were applied iliac crest bone graft and the patient was permitted partial weight-bearing activities with crutches for 2 months. After that, she could walk without crutches. 8 months after the operation, the patient reported no pain and became capable of walking without an orthosis (Fig. 3). X-rays showed full bone union at the proximal tibiofibular synostosis and the lengthening site of the right fibula (Figs. 3). The distal tibiofibular synostosis was healing, it required bone graft again which she refused. The range of movement of the knee and ankle was restored. She is now checked regularly monthly by the authors. The patient reports being very satisfied with the overall results.

Fig. 2. X-rays and clinical condition during lengthening period. A, B, Clinical condition and X-rays post-operative. C, X-rays 3 weeks post-operative. D, E, Clinical condition and X-rays 7 weeks post-operative. F, G, Clinical condition and X-rays 14 weeks post-operative. H, Clinical condition 18 weeks post-operative.

Fig. 3. Clinical condition and X-rays 8 months post-operative.

3. Discussion

Tibial pseudoarthrosis due to trauma or osteomyelitis was not rare. However, our case caused by osteomyelitis during her childhood was quite distinct from the other tibial pseudoarthrosis. It was a tibial dysplastic pseudoarthrosis at the middle third with a 250 medial deviation and 200 internal torsion of the tibia, 10 cm leg-length discrepancy, the hypertrophied curved intact fibula, and intensive scarring at the anterior tibial pseudoarthrosis. The fibula was curved and torsional at the distal third. This lesion was a great challenge for orthopedic surgeons and reconstructive surgeons. The deformities of the tibia with bone defects, dysplastic non-union, deviation, torsion, and leg length discrepancy must be solved as much as possible. It was a considerable surgical challenge, especially when associated with extensive scarring at the anterior aspect at the middle third of the leg. Management of these injuries depended on surgeon experience and training. Reconstruction of this injury could be done by various methods including large segmental allograft, vascularized and non-vascularized autograft, induced membrane technique, bone transport, and Huntington procedure.

Implantation of large amounts of allograft, induced membrane technique or non-vascularized autogenous fibular graft for reconstruction of large tibial defects had been associated with greater risk of infection, graft rejection, fracture, nonunion, and fear of disease transmission, especially when associated with extensive scarring, and the fibular graft may not undergo hypertrophy [5], [6], [10]. It also did not solve the leg-length discrepancy.

The most common methods of treating a segmental bone defect are either with the use of a vascularised fibular autograft or by bone transport using the Ilizarov technique [1]. Bone transport required a lengthy procedure which limited its use in the reconstruction of tibial defects with a big gap. If the amount of bone loss was great, the time to achieve the desired length of regenerate could be extremely long with frequent follow-ups to identify and manage various obstacles and complications such as high rate of infection, equinovarus, deviation deformity, osteomyelitis, refractures, nonunion, pain and discomfortable condition due to a long time of wearing external fixater [1], [2], [11], [12], [13].

The free vascularized bone transfer had been suggested as the leading option for tibial defects of 5 to 12 cm. However, it was an extensive and time-consuming procedure, which required harvesting a contralateral fibula and microsurgery skills. There were many other complications such as flap necrosis, deep infection, but hypertrophy of the graft was unreliable and late fracture, peroneal nerve injury [1], [2]. It also did not solve the leg-length discrepancy.

The Huntington procedure was popularized by Huntington to manage tibial defects with intensive soft tissue injury [3], [4]. It provided a large graft of the ipsilateral fibula raised on a pedicle of the peroneal artery, aligned and fixed to the tibia. The transposed fibula had muscles attached to it, along with its nutrient artery supply, this helped in the good union of the fibula that would substitute the tibia for normal activities. The Huntington procedure avoided exposure of the site that was vulnerable to infection. Both these factors helped reduce the post-operative infection. The procedure was easy to perform without requiring special equipment. However, leg-length discrepancy and malalignment were seen in all patients, and hypertrophy of the fibular graft was unreliable and late fracture [4], [7]. Catagni [3] reported two cases of tibial defects with the leg-length discrepancy in which ipsilateral fibular was gradually medial transferred using the Ilizarov apparatus combined with distal and/or proximal tibial lengthening using any residual tibial bone in the same limb. However, this method was technically demanding and had theoretical risks of complications such as neurovascular injury, infection, muscular damage, articular injury, deep venous thrombosis, refractures, deformities, and scarring.

In our cases, she had a dysplastic pseudoarthrosis at the middle third of the right tibia with a 10 cm leg-length discrepancy, a 250 medial deviation and 200 internal torsion, and extensive scarring so we combined the leg-lengthening according to Ilizarov technique and Huntington procedure for her treatment. The right leg was lengthened using an external fixater to solve leg-length discrepancy after the ipsilateral hypertrophic fibula was osteotomized at the proximal and distal third, then medialized the fibula and fixed the ipsilateral fibula to the tibia using leg screws and applied iliac bone graft. The tibial varus deformity was gradually reduced using an external fixater during lengthening. It was easy for the patient to adjust the Nhan’s external fixater at home. This frame was made in Vietnam, it was cheap and available. Our patient had been applied an iliac bone graft at the proximal and distal tibial-fibular synostosis because of the dysplastic pseudoarthrosis at the middle third of the right tibia.

We had done fibular osteotomy with the maintenance of the periosteum above and below the osteotomy. The right leg was lengthened using the external fixater. This resulted in a good union between the hypertrophy transposed fibula and the remaining part of the fibula in our case, which brought a better strength of the reconstructed tibia. This technique was different from the Huntington procedure. Our technique was an easy, rapid, inexpensive procedure without requiring microsurgery skills and a special device, with a shorter time of wearing external fixater than bone transport. The patient had to wear the frame for 14 weeks then wear the orthosis until six months post-operative. This technique had great advantages of preserving the patient’s limb, with the better psychological aspect.

Some authors encountered iatrogenic common peroneal nerve injury while osteotomy and attempting to medialize the fibula into tibia in patients with extensive soft tissue fibrosis [4], [14]. In our case, the fibula had been osteotomized and lengthened before being medialized to the tibia. So, we did not encounter any difficulty during the medializing fibula and fixation fibula to the tibia. The common peroneal nerve was identified during fibular osteotomy. We did not encounter nerve injury complications in our case.

4. Conclusion

Leg lengthening then centralization of ipsilateral fibular graft is an excellent option for reconstruction of a tibial pseudarthrosis with a large leg-length discrepancy. It is a safe, rapid, inexpensive procedure. Our procedure was not difficult, microvascular skills and special devices were not required.

Funding

No financial support was received for the completion of this study.

Ethical approval

All procedures were approved by the 108 Central Military Hospital’s Institutional Review Board, Hanoi, Viet Nam.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Authors’ contributions

Dr. Doan Van Le: Conceptualization, Surgery, Writing – Review & Editing, Supervision.

Dr. Luong Van Nguyen: Conceptualization, Surgery, Writing – Review & Editing, Supervision.

Registration of research studies

Not applicable.

Guarantor

Dr. Luong Van Nguyen.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors would like to acknowledge with gratitude the precious help of colleagues and the health staff of the Institute of Trauma and Orthopaedics at the 108 Central Military Hospital for the time required to prepare and implement this study.

Availability of data and materials

The data used to support the findings of this study are available from the corresponding author upon request.