Journal of Limb Lengthening & Reconstruction

: 2022  |  Volume : 8  |  Issue : 1  |  Page : 63--66

Can a checklist protocol improve limb lengthening?

Monica Paschoal Nogueira, João Pedro Osseti Felicio Silva, Ana Maria Ferreira Paccola, Sandra Meire Prado 
 Department of Orthopaedics, Pediatric Orthopaedic and Reconstruction Unit, State Hospital of São Paulo, São Paulo, Brazil

Correspondence Address:
Monica Paschoal Nogueira
Assistant Professor, Department of Orthopaedics, Pediatric Orthopaedic and Reconstruction Unit, State Hospital of São Paulo, São Paulo


Background: In recent years, hexapodal external fixators and telescopic nails have improved the accuracy of limb lengthening and correction of deformities. However, careful follow-up in the postoperative period is extremely important; complications are still frequent and directly interfere with patient's outcome. Aims and Objectives: We have developed a follow-up limb lengthening reconstruction checklist. Materials and Methods: Like a flight checklist, professionals systematically record relevant data in every postoperative visit, to improve clinical management during distraction and consolidating phases. Results: LLR-Checklist was used in 53 consecutive patients, from 2006 to 2020. Average age was 11 (2-45) years. A pattern was found in the 18 patients with fibular hemimelia in relation to the use of antibiotics. Superficial infection was common. 21% of patients had delayed ossification in the regenerate. 25% of patients had nerve injuries; 9,4% of them had nerve decompression, all had total recovery. Contractures and pain improved with physical therapy. Conclusion: This checklist can improve quality in the treatment and is a valuable teaching tool for young practitioners.

How to cite this article:
Nogueira MP, Silva JP, Paccola AM, Prado SM. Can a checklist protocol improve limb lengthening?.J Limb Lengthen Reconstr 2022;8:63-66

How to cite this URL:
Nogueira MP, Silva JP, Paccola AM, Prado SM. Can a checklist protocol improve limb lengthening?. J Limb Lengthen Reconstr [serial online] 2022 [cited 2022 Oct 6 ];8:63-66
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Full Text


Limb lengthening devices have evolved in the past 100 years. In recent years, computer-assisted correction with hexapodal frames improved the accuracy of limb lengthening and deformity correction. To shorten the external fixation period, other methods were developed, such as lengthening over nail and lengthening followed by nailing or plating. In the past two decades, internal telescopic lengthening nails have become popular and eliminated the need of an external fixator as motor.[1] However, difficulties with quality of regenerate, nerve problems, pain, and contractures are still a challenge in those patients.[2] In this context, limb lengthening continues to be a real challenge to both patient and orthopedic surgeon.

Surgery is only the first part of the lengthening/ deformity correction process; there is a long and detailed postoperative protocol to avoid problems, obstacles and complications.[3] Most of the “action” occur in the following weeks and months after surgery, usually in clinical visits every 2 weeks or, sometimes, every week. In this context, it is necessary to observe several aspects of the patient to obtain satisfactory results.

Difficulties during limb lengthening with or without external fixators can include muscle contractures, joint dislocation, axial deviation, neurologic injury, vascular injury, premature consolidation, delayed consolidation, nonunion, pin site problems, and hardware failure. Late complications as loss of length, loss of alignment, fracture, and joint stiffness may also compromise function. Pain and difficulty in sleeping are other problems that arise during limb lengthening, especially in children and in more extensive lengthenings.[4] Fever and constipation, especially in children, can be diagnosed during distraction phase.[5]

Early diagnosis of an infection, axial deviation, nerve lesion, or problems in bone formation require an immediate action: antibiotic or pain control management, change of the lengthening construct, nerve decompression, decrease in the lengthening rate. These actions allow for the correct assessment of the problem and improve limb-lengthening process.

Like an airplane flight checklist, we propose a document to be filled in every postoperative visit aiming to look for every important aspect of the limb lengthening reconstruction (LLR) process, the “LLR-Checklist.”

 Materials and Methods

In the first visit of the postoperative period, the LLR-Checklist must be completed with general information of the patient: identification, parent's name, contact and the patient's operative data, such as diagnosis, type of surgery and on which side of the body was performed. The objective of the limb lengthening/reconstruction procedure is also recorded in the header of the checklist.

Every visit is recorded in a line marked with the number of visit and number of days postoperatory. Each column is related to different items divided into 5 groups of information.

The first is related to patient's complaints; they should be recorded as reported by the patient.

The second group is patient general health. Includes: Sleep (classified from 0 to 2, from always regular to never regular, respectively); appetite (rated from 0 to 2, from always to never); psychological status, in which anxiety, anguish, irritability, apprehension, anguish, isolation will be observed (rated 0 to 2, from good to bad, respectively);[6] pain (classified according to the VAS – visual analogue scale); nutritional status (classified as good or bad); neurological status; whether or not antibiotics are used and whether infection is present or not.

Third group is radiographic analysis, including: alignment (degrees); quality of regenerate (classify as good, average or bad); lengthening amount (cm), and the lengthening rate (mm/day).

The forth group is physical therapy, with joint range of motion (ROM - degrees); muscle strength: No muscle movement (0), Muscle movement without joint motion (1); moves without gravity eliminated (2); moves against gravity, but not resistance (3); moves against gravity and light resistance (4); normal strength (5));[7] Presence of contractures, and protocol of PT days/week, hours/day are also recorded [Figure 1].{Figure 1}

Finally, medical professional recommendations for the patient are described.


The LLR-Checklist was applied in 53 consecutive patients from 2006 to 2020. 58% were male and 42% female, with 11 different surgical procedures. Patients had different diagnosis: 18 fibular hemimelia; 1 posteromedial bow; 3 congenital femoral deficiency; 1 congenital pseudoarthrosis of tibia; 16 achondroplasia; 4 rickets; 4 discrepancy and deformity due to physeal injuries; 1 fibrous dysplasia; 3 multiple osteochondromatosis; 1 idiopathic discrepancy; 1 discrepancy due aneurismatic bone cyst.

Average age was 11 years of age (2–45); there were 27 procedures in children, with average age 6 (2–10); 16 procedures in teenagers, with average age 14 (11–17), and 10 procedures in adults, average age 24 (18–45).

A pattern was found in the 18 patients with fibular hemimelia in relation to the use of antibiotics. Antibiotics were used about 3 times per patient, around once or twice in the postoperative week and another two times in the bone consolidation phase, related to more movement and was responsible for irritability and weight loss. There was an average external fixation time of 7 months in these patients. There was worsening in sleep and appetite due to pain, especially at the end of the stretching phase, as well as when the patient had inadequate or insufficient physiotherapy.

There was no infection in only one of the patients (2%), and all the others used oral antibiotics and responded well to this treatment. This was a 6 cm humerus lengthening, with a new laser protocol. One patient had an osteomyelitis, deep infection after an acute correction and intramedullary fixation, after 10 months of external fixation. It was treated by surgical debridement and intravenous antibiotics.

Furthermore, 11 of our patients had problems with the quality of bone regenerate, and two of these cases also had problems with alignment. However, all of them were corrected with the right follow-up of physiotherapy and postoperative consultations. One patient had a very hypoplastic regenerate with a cyst in the center, but it healed within 9 months. It was diagnosed after 3 weeks of lengthening (mother had speeded the correction). In two patients, open bone graft procedure was required.

Nerve injuries occurred in 13 of the 53 procedures; 2 improved after reducing the rate of lengthening (one humerus lengthening) and 1 possibly too fast correction of a tibial deformity with an external rotation component. In 5 procedures, it was necessary to decompress the nerve after motor function loss: in two humeral lengthenings (radial nerve in achondroplasia patients), one femoral lengthening (peroneal nerve decompression after 5 cm of lengthening, of a total of 10 cm), one tibial lengthening (peroneal nerve decompression just after osteotomy, on the first postoperative day), and 1 rotation correction of a tibial deformity in rickets, (peroneal nerve decompression) after 30 degrees of a total of 40° rotation correction. These patients were operated in the following day of diagnosis of nerve function loss, with motor deficit, and recovered completely within 2 months, and attention directed to this motor deficit recovery was highlighted in physical therapy. All those 5 patients developed nerve deficits after 2 cm lengthening. Fractures were diagnosed in 8 patients (15%), all after lengthening and removal of the external fixator.

Contractures were common with high-speed lengthening, and discontinuation or insufficient physical therapy. They were more frequent at the end of lengthening phase and related to depressive behavior in 3. Because of this, it was difficult to correct it with intensive rehabilitation. This also influenced the nutritional status and could have interfered with bone healing.

Pain was present with infection and contractures. Pain was also present with dehiscence of open acute extensive dissection of reconstruction areas. This granulation tissue required debridement and special care to heal. Laser therapy was applied in the last three patients with reduction of pain and better healing of soft tissues.


Every lengthening procedure must have an intensive physical therapy protocol that can vary from 2 h per day to 2 or 3 times a week. Lengthening may create sympathetic reflex dystrophy every time motors are activated. Lymphatic and venous congestion and stretching pain reminds of a true fibromyalgia syndrome. Motion and soft tissue mobilization aim to avoid persistence of acute symptoms and allow for an efficient lengthening process.

Children were well managed with a physical therapy protocol with mobilization of fascial tissues. It decreases postoperative edema and reduces venous and lymphatic congestion. Patients improve sleep and appetite, sometimes also improve a low fever and constipation. After the initial two or three weeks, children get used to the external fixation routine and are well adapted. This was observed in younger children, especially the ones with fibular hemimelia and achondroplasia.

Adult patients adjust well in the beginning and become tired and demotivated as limitations and chronic pain appear.

Incidence of pin infection was 98%, and may reach 100% of treated patients.[4] There are many variables which affect the frequency of this complication, such as time of external fixation, material of the wires or half pins, surgical procedure and wound care.[8] Gordon et al. suggested that showering after postoperative day 5 is not only acceptable, but could be used successfully as the only means of pin site care.[9] In achondroplasia patients, pin track infections were diagnosed most in the consolidation phase, due to more movement of the soft tissues around the pins. Also because of loosening of pins in the first cortex with prolonged external fixation.

Treatment usually starts with oral antibiotics, increasing the frequency of pin site cleaning in mild cases and ending up with removal of the pin in severe cases. In our patients we use cephalexin, 500 mg/5 mL orally, satisfactorily. Poor regenerate is a serious problem during limb lengthening and results from many systemic or local causes. It is important to modify rate and frequency of distraction according to regeneration. Once delayed regeneration has been diagnosed, alternate cycles of compression distraction can solve the problem. Axial malalignment can develop with distraction as there is variable resistance of the different muscles surrounding the limb. Joint subluxation or dislocation is a serious complication with unstable joints common in congenital shortening. Eleven of our patients had problems with the quality of bone regenerate, and two of these cases also had problems with alignment. However, all of them corrected with the correct follow-up of physiotherapy and postoperative consultations. Management of joint abnormality or instability has to precede lower limb lengthening, and sometimes extending the frame cross the joint may protect it against the development of this complication.[2],[3]

Nerve injury is one of the most feared complications in limb lengthening. It can cause impairment of the limb function, compromising the results of limb lengthening or deformity correction. Reported incidence varies from 3% to 30%. Early diagnosis and treatment are very important to avoid permanent impairment. In our patients, nerve injuries occurred in 13 of the 53 procedures (24.5%). In 5 procedures, it was necessary to decompress the nerve after motor function loss. There is no direct correlation between the amount of lengthening and nerve injury, as well as no specific threshold in the number of centimeters for nerve injuries to occur.[2],[10]

Recently, hexapodal computer assisted circular frames such as the Taylor Spatial Frame have gained popularity. The next step in evolution was the application of self-distraction motorized nails (a magnetically driven, titanium intramedullary nail) to avoid complications of external fixation and gain rapid rehabilitation. However, Ilizarov's principles are still the cornerstones of all bone lengthening procedures.[3],[11],[12]

In aviation, safety and precision are paramount in accurate measures to avoid mistakes in high risks procedures. Those professionals have come to rely heavily on simple tools to aid in reducing human error.[13] The checklist is a key instrument in reducing the risk of costly mistakes and improving overall outcomes. This process led us to propose some general aspects to be observed with each visit, as a checklist, which have been used in many different situations for patient safety.[14]

Therefore, following the LLR-Checklist during subsequent visits to surgery will enable to track: How many antibiotic cycles are used and when they are needed; adjust the best lengthening rate for each specific procedure; when contractures or nerve lesions occur and how we can interfere with this process; value the best lengthening rate for each specific procedure; strategies to improve pain, nutrition, sleep and humor of the patient, as well as any other standardized data to improve our performance in monitoring segment stretching.

Moreover, this checklist protocol can be a powerful tool for teaching new generations of professionals with interest in limb lengthening and reconstruction.

In this context, as in aviation, in medicine, safety and precision are fundamental in precise measures to avoid errors in high-risk procedures.


The LLR-Checklist is a precise, easy-to-use and fundamental tool to reduce the risk of costly errors by professionals and, thus, improve the patient's overall results at each postoperative visit and, consequently, in their quality of life in the future.


We would like to thank Aurora Segre for testing the patient general health part of the check list on our patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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