The Pursuit of Height

Tall, dark and handsome…a leggy blonde…supermodel stature…there's no denying that physical attractiveness is linked in today's culture in many ways to a person's height. If being tall wasn't desirable, why would women perch themselves on high heels to gain an inch or two? Up until several decades ago though, the only way to grow taller was through artificial means like heels. But that all changed with the advent of the limb lengthening procedure that was discovered almost by accident. The procedure has helped thousands of individuals with severe leg and arm deformities. However there is also the cosmetic application. And some argue that this not only shows the extreme lengths some will go to for the pursuit of perfection but also the field of orthopedics moving into a strange new world. However, ask a man who began the procedure at five-foot four-inches how life has changed by growing three inches and the procedure begins to seem a lot less vain.

A Tall History

Limb lengthening is not at all a new procedure and is for that matter relatively low-tech. The procedure was developed about half a century ago in Kurgan, Russia, where Gavriil Ilizarov was trying out methods for healing leg fractures of World War II veterans whose injuries had not healed properly. Dr. Ilizarov knew that compressive forces could stimulate bone healing in a fracture so he invented an external fixation frame that could be mounted around the injured leg to compress the bone. Patients were then instructed to turn the attached rods to keep the compression level up as the bone grew properly together. But an interesting side effect of the project occurred. One patient turned the rods the wrong way. That of course caused distraction of the bone, further separating the fracture. But Ilizarov saw something interesting in the patient's error: new bone was forming in the expanding gap. From that first patient mistake, research began to determine whether limb lengthening was possible and whether it was indeed safe. There had been other methods used in the past from the beginning of the 20th century to create bone distraction, but Ilizarov was the first to identify the factors needed for bone and soft tissue regeneration and used better scientific methods than past doctors.

Over time, Ilizarov and his team performed literally thousands of limb lengthening procedures. The Western world only discovered his work when Italian surgeons took up the procedure in the 1980s. Interest in limb lengthening grew and the device and mechanics improved and by 1988 the first limb lengthening procedure was performed in the U.S.

The Mechanics of Growth

Most limb lengthening techniques aren't done for cosmetic reasons. In fact there is a multiple set of issues the process can resolve, including the replacement of missing bone and the lengthening and/or straightening of deformed bone segments. "Ninety-five percent of what we do is reconstructive for deformity and discrepancy and limb salvage, " says Dr. S. Robert Rozbruch, director of the Institute for Limb Lengthening & Complex Reconstruction at Weill Cornell Medical College's Hospital for Special Surgery in New York City. These could be caused by birth defects, diseases or injuries and doctors can perform the procedure on both children and adults. One of the biggest reasons for limb lengthening is to correct an unequal limb which, if left untreated, can cause complications such as arthritis. Although today there are several slightly different methods, they all follow the principle of distraction osteogenesis.

(X-ray images of limb lengthening devices/Institute for Limb Lengthening & Complex Reconstruction)Distraction osteogenesis is a shining example of the fundamental biologic fact that bone regenerates. Rozbruch explains the procedure used at his institute, "We cut the bone and pull the ends apart very slowly at 1mm per day (one inch per month). Bone has the ability to regenerate. We have innovated new hybrid techniques where we use the external fixation for the lengthening phase and then substitute internal fixation to support the new bone. In this way we can limit the time needed in an external fixator to one month per inch of lengthening." At the Institute, Rozbruch uses a variety of techniques, including monolateral and circular external fixation devices for the correction of angular deformities and limb length discrepancies.

Some of the risks from the procedure include bone infection, injury to nerves and blood vessels, poor bone healing, avascular necrosis of the femoral head, chondrolysis and complications from the hardware used, including infection of the pins or wires that go through the bone. ”Yes of course there are risks, " adds Rozbruch, "but in experienced hands they are minimal like other surgery. We have had excellent physical and emotional outcomes."

The regenerated bone is normal bone and is no weaker or prone to wear than any other bone. The muscles, nerves and blood vessels grow in response to the osteogenesis just as they would during a growth spurt. And although the procedure takes several months to complete, all of which during the patient must wear a cylindrical metal device around a leg, the patient can go about a somewhat normal life and can still retain mobility.

Candidates for New Height

(Before and after photos of double level osteotomy of tibia for lengthening and deformity correction/ Institute for Limb Lengthening & Complex Reconstruction)Aside from the patients with medical conditions that demand a treatment such as this, there is a class of patients who seek limb lengthening for quality of life issues. Those suffering from dwarfism for instance are prime candidates. The Little People Association of America at one time came out against limb lengthening, but today has developed a position summary that presents the risks and guidelines for patients considering the procedure. In the statement however the organization does state, "There are no established medical indications for symmetric extended limb lengthening." The Institute for Limb Lengthening & Complex Reconstruction has been able to give dwarf patients nearly one foot of growth in the legs and five inches in the arms, something that allows these patients to function more independently. Just imagine for the first time being able to reach the gas pedal of your car!

However it is not only people that have a height condition that are seeking the procedure. Men and women who are above five-feet are also looking to limb lengthening to offer a way to be head and shoulders with their peers. Rozbuch explains the guidelines he follows. "We will perform limb lengthening on below normal stature patients and anyone less than five-foot five-inches tall for a man who has psychological dysphoria related to this. We have patients undergo a thorough psych evaluation to determine if they are a suitable candidate." The procedure appears to be particularly popular with men, who see the promise of an extra few inches of leg to be beneficial to all aspects of their life, from sports and social interactions to landing a better job. Rozbruch sees an expanding field in limb lengthening. "As we further improve our techniques, it will become more popular."

The Height of Ethics

There has been no shortage of controversy surrounding the subject, beginning with its introduction into the U.S. Lately the topic has become a popular debate issue on network news, with critics holding it up as a symbol of society's increasing efforts at perfectionism and obsession with attractive appearances. Besides what the need for height says about us as a society, the procedure is also turning a new page for the orthopedics community, who are in the position now of offering a procedure for purely cosmetic purposes. It raises many questions then about the role of the orthopedic surgeon and the relationship between doctor and patient in the decision making process.

Dr. James Capozzi is a member of the American Academy of Orthopedic Surgeons ethics committee and a board certified orthopedic surgeon, specializing in joint replacement surgery. He says this procedure raises interesting questions and should give doctors time to think about their own medical values and how they balance these against those of their patients. "We have to be careful not to impose our values and our priorities, " explains Capozzi. "Our ethical obligation is to convey information about a procedure or a condition to the patient so that they can make an informed decision. The patient makes the decision. The doctor can decide whether they want to perform the procedure, since just because the patient is requesting something doesn't mean you need to go along with it."

He adds that limb lengthening presents debate because the motivations can be objective and interpreted differently by each person. He asks who determines what height constitutes a cosmetic procedure rather than a medical one and how does one person's perception's affect the care of another. He suggests the orthopedic community look to the plastic surgery field for some answers. "They run the gamut in terms of procedures, from medically necessary treatments to purely cosmetic ones. They have done the work to explore this issue and I think we can gain a lot from their experience and examine the spirit of their guidelines to determine the best approach to an open dialogue on the subject within the field of orthopedics. As orthopedists we are essentially about quality of life procedures, so the groundwork has already been laid for this type of procedure."