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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 28-32

Psychological and orthopedic outcomes after stature lengthening surgery using intramedullary nails

1 Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD, USA
2 College of Medicine, SUNYDownstate Health Sciences University, Brooklyn, New York, NY, USA
3 Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
4 Department of Psychiatry, NYU Langone Medical Center, New York, NY, USA

Date of Submission11-Feb-2020
Date of Decision26-Mar-2020
Date of Acceptance03-Apr-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. S Robert Rozbruch
Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jllr.jllr_4_20

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Introduction: Patients undergo stature-lengthening surgery (SLS) with the hope of improving their psychological health. The presumption is that increased height will improve body-image and self-esteem. The use of motorized internal lengthening nail and lengthening and then nailing techniques has eliminated or minimized time in external fixation increasing interest in the procedure. Material and Methods: Fifteen patients (32 bone segments) who underwent SLS were included in the study. All patients were bilateral, and one patient underwent four-segment treatments in two stages. Psychological assessment was performed with the body image quality of life inventory (BIQLI), the situational inventory of body-image dysphoria (SIBID), and the multidimensional body-self relations questionnaire before surgery and at latest follow-up. Orthopedic data included length obtained, bone healing index (BHI), adjacent joint range of motion, and Association for the Study and Application of Methods of Ilizarov (ASAMI). bone and functional scores. Results: The mean magnitude of lengthening was 64 ± 9.3 mm (48–77) (P < 0.001), resulting in an average increase from 161 cm to 167.4 cm. Mean BHI was 0.86 month/cm. ASAMI bone and functional results were all excellent after average follow-up of 37 months, with no loss of adjacent joint range of motion. BIQLI score significantly increased from 0.62 ± 1.26 (range −1.6–1.9) to 1.67 ± 0.85 (range −0.16–2.6) (P = 0.02). SIBID score significantly improved from 1.3 ± 0.81 (range 0.4–2.5) to 1.02 ± 0.68 (range 0.42–2.1) (P = 0.03). Discussion: Patients' significant increase in BIQLI score postoperatively, when compared to their scores preoperatively, demonstrate higher satisfaction in their body-image following SLS. Significant improvement in patients' SIBID score demonstrate a decrease in the impact of stature dysphoria in patients' everyday life following SLS. Conclusion: SLS is a safe and effective treatment to increase height. In patients, psychological health, including body-image and self-esteem, is improved.

Keywords: Bone healing index, femur, limb lengthening, Precice, self-esteem, stature lengthening, tibia

How to cite this article:
Assayag M, Buksbaum JR, Khabyeh-Hasbani N, Westrich EK, Fragomen AT, Rozbruch S R. Psychological and orthopedic outcomes after stature lengthening surgery using intramedullary nails. J Limb Lengthen Reconstr 2020;6:28-32

How to cite this URL:
Assayag M, Buksbaum JR, Khabyeh-Hasbani N, Westrich EK, Fragomen AT, Rozbruch S R. Psychological and orthopedic outcomes after stature lengthening surgery using intramedullary nails. J Limb Lengthen Reconstr [serial online] 2020 [cited 2023 Feb 9];6:28-32. Available from: https://www.jlimblengthrecon.org/text.asp?2020/6/1/28/288567

  Introduction Top

Novel surgical techniques in the field of limb lengthening in recent years have increased patients' interest in stature-lengthening surgery (SLS). Lengthening and then nailing (LATN) was introduced to lengthen bone segments while minimizing the time patients spend in external fixators.[1] In this procedure, an external fixation is used for lengthening during the distraction phase and once lengthening has been achieved, the frame is removed, the canal is reamed, and a locked intramedullary nail is inserted across the regenerate bone to support the bone during the consolidation phase.[1]

The gradual shift from external fixation devices to integrated fixation and now to motorized internal lengthening nails (MILN) for limb lengthening has made SLS more accessible to patients.[2] Prospective patients express psychological issues such as difficulty in interpersonal or professional relationships as motivational factors to undergo the procedure.[3] However, in their quest for improved self-esteem,[4] these patients are willing to accept reasonable risk[5] to undergo surgery to increase their stature.

Stature dysphoria is a condition in which preoccupation with one's height is perceived as having a negative influence in interpersonal interactions, professional achievement, and social satisfaction.[6] Investigators observed as a result of preoperative psychological evaluation that patients who were declined as candidates for SLS had a greater sense of future despair, were more likely to express symptoms of depression and anxiety and were less likely to report supportive family interactions than accepted patients.[6] Few studies have been published about the psychological effects of cosmetic surgery,[7] body dissatisfaction,[8] and psychological effects of SLS.[3],[9]

To address patients' psychological impact on their body-image after SLS, the use of three objective, validated and reliable questionnaires targeting the body-image sphere of the patient's psyche, were collected. The situational inventory of body-image dysphoria (SIBID) is a 48-question assessment of the frequency of negative body image-related thoughts during social and nonsocial situations related to the activities of daily living.[10] Scores potentially range from 0 to 4, with higher values indicating more frequent cross-situational body-image dysphoria. According to the 2000 SIBID Manual, on the SIBID questionnaire, mean normal scores for 386 men and 1207 women were 1.20 (standard deviation [SD] = 0.64) and 1.72 (SD = 0.79), respectively.[11] The SIBID has excellent internal consistency for both sexes with a Cronbach's alpha of 0.96 for both sexes.[11]

The body image quality of life inventory (BIQLI) is another validated outcome measure of body-image intervention.[12],[13] In a study that empirically evaluates the BIQLI questionnaire with 116 college women with a mean age of 21.3 years (SD = 5.1), the 19-item assessment was found to be internally consistent and stable over a 2–3-week period.[12] Participants rated the impact of their own body image on each of the 19 areas, using a 7-point bipolar scale from −3 to +3, thereby permitting reports of negative, positive, or no impact.[12] A higher score on the BIQLI questionnaire represents a more positive impact of body image in various life domains among others, the sense of self, social functioning, sexuality, emotional well-being, eating, and exercise. The study demonstrated that a more favorable body-image quality of life was significantly associated with higher body satisfaction (r = 0.66, P < 0.001).[12]

The multidimensional body-self relations questionnaire (MBSRQ) is a 69-item self-report inventory intended for the use of adults and adolescents (15 years or older) for the assessment of self-attitudinal aspects of the body-image construct.[14] One of the MBSRQ subscales, MBSRQ-appearance scales, evaluates the cognitive and affective components of appearance and body-image, and internal compensatory mechanisms.[14]

In this study, we evaluated both orthopedic outcomes and the psychological impact of patients' self-esteem and body image after SLS. Musculoskeletal data on bone healing and function were deemed essential to evaluate if, after surgery, there was compromise that would in fact contribute to the patient's psychological state.

  Material and Methods Top

After gaining approval from the institutional review board, we performed a retrospective analysis of prospectively acquired clinical data. Patients who underwent SLS between 2009 and 2015 at our institution were screened for inclusion criteria. To be included in the study, approval by the patient or their legal guardian was required.

Thirty-one consecutive patients underwent SLS at our institution between 2009 and 2015. Due to the inclusion criteria, only 15 of those patients were included in the study. All patients underwent mandatory psychological evaluation and clearance. Since completion of preoperative psychological questionnaires was mandatory before surgery, calculations of preoperative psychological scores for all 15 patients were obtained. However, only nine of those 15 patients responded to complete postoperative psychological assessments. Therefore, all fifteen patients were included to measure the orthopedic outcomes of SLS, while nine out of the 15 patients, who had completed both preoperative and postoperative psychological questionnaires, were included to evaluate the psychological impact of SLS.

In 15 study patients, a total of 32 bone segments were analyzed in this paper. One patient underwent bilateral lengthening of both the femur and tibia to increase short stature, while twelve patients underwent bilateral femoral lengthening and two patients underwent bilateral tibial lengthening to increase short stature. In total, 26 femurs and six tibiae were lengthened. With the evolution in surgical techniques during the study period, the preferred SLS technique changed. Two out of the 32 segments were lengthened using the LATN[1] technique with a hexapod frame for lengthening and a titanium trauma nail for consolidation. Thirty of these segments were lengthened using the Precice (Nuvasive, San Diego, CA, USA) MILN.

The psychological testing was performed using results from the BIQLI,[12] the SIBID,[10] and the MSBRQ[15] scores. All 15 patients completed the preoperative psychological questionnaires. The postoperative questionnaires were sent by mail to patients with the directive to mail it back on completion, filled during follow-up clinic visits or performed over the phone by an author.

Thirteen males and two females with a mean age of 32.5 years old (range 17.6–53.0 years) were included in the orthopedic analysis. Complete pre- and post-operative psychological scores were available for nine out of the 15 cases. Despite numerous reminders, the remaining six patients did not complete the postoperative scores.

The mean preoperative height was 161.0 cm (range 140.2–168.9 cm) for all 15 patients. In addition, the average follow-up period for all fifteen patients was 36.8 months (range 14.9–95.5 months). These demographics, such as the sex ratio, age of participants, preoperative height, and average follow-up time, are summarized in [Table 1]. Orthopedic outcome measurements such as pre- and post-operative patient height, segment length, adjacent joint range of motion, total lengthening performed, bone healing index (BHI), complications, need for additional surgeries and the Association for the Study and Application of Methods of Ilizarov (ASAMI). bone and function scores[16] were determined. A quantitative descriptive analysis was performed on the orthopedic dataset. Two-tailed Student's t-tests scores were performed, and a P < 0.05 was considered statistically significant.
Table 1: Study demographics

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Surgical technique

Thirty of the 32 bone segments analyzed in this study had undergone lengthening using a Precice MILN. In these cases, a single-stage bilateral osteotomy and fixation was performed. Percutaneous low-velocity osteotomy using a multiple drill hole technique and osteotome was done through a percutaneous approach with bone using a hemostatic clamp. Two 3.2 mm Steinman pins were used to account for rotational landmarks. Antegrade femur insertion of the Precice nail was the preferred method as to avoid violation of the knee joint. Trochanteric entry for MILN was performed for individuals under 18 years of age, while piriformis entry for MILN was performed for adults. Lengthening was initiated on postoperative day four at a rate of 0.33 mm, four times a day, for 4 days, and then at the same rate for three times a day, until the lengthening goal was achieved. Rate and lengthening goal were modified based on clinical and radiological progress. Surgical protocols for segments lengthening using LATN technique was according to the protocol described in Rozbruch et al. 2008.[1]

An aggressive physical therapy program to preserve adjacent joint range of motion with partial weight-bearing, depending on the particulars of the technique of the surgery to improve stature, was recommended. For cases of the tibia with an external fixation, weight-bearing was allowed as tolerated. However, for cases of using the MILN, weight-bearing was limited based on the biomechanical recommendation of the manufacturer. Full weight-bearing was allowed with radiologic evidence of two healed cortices. Complete healing was considered with radiologic evidence of three healed cortices.

  Results Top

The average BHI for all 15 cases was 0.86 ± 0.26 months/cm (range 0.46–1.38 cm). With an initial average segment length of 412 ± 45.1 mm (range 322–462 cm) and an average lengthening magnitude of 64 ± 9.3 mm (range 48–77 cm) (P < 0.001), a lengthening percentage of 15.7% ± 2.4% (range 10.8–18.1 cm) was obtained. Compared to the mean preoperative height of 161.0 cm (range 140.2–168.9 cm], the mean posttreatment height of all 15 cases was 167.4 ± 6.6 cm (range 149.7–175.4 cm) (P < 0.001) [Table 2].
Table 2: Orthopedic data

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Sixty percent of the patients completed both preoperative and postoperative psychological scores. Mean preoperative BIQLI score was 0.62 ± 1.26 (range −1.6–1.9) and mean postoperative BIQLI score was 1.67 ± 0.85 (range −0.16–2.6) for a statistically significant increase of 1.05 ± 1.09 (range 0.1–3.6) (P = 0.02) [Table 3]. In addition, mean preoperative SIBID score was 1.3 ± 0.81 (range 0.4–2.5) and mean postoperative SIBID score was 1.02 ± 0.68 (range 0.42–2.1) for a statistically significant improvement of 0.28 ± 0.23 (−0.67–0.02) (P = 0.03) [Table 3]. There were no significant changes in any of the 10 MBSRQ subscales.
Table 3: Psychological results summary

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Over the course of the study, complications were recorded. One varus and procurvatum deformity of the femur was created during lengthening and required surgical correction by distal femoral osteotomy and retrograde nailing fixation. One case of premature consolidation occurred which prompted for termination of treatment before the goal was achieved. In addition, two ankle equinus contractures occurred during tibial lengthening and required gastrocnemius-soleus resection and physical therapy. Six segments with delayed consolidation required bone marrow aspirate concentrate injection through the regenerate site. During the management of complications, patients were counseled by their surgical team. In this carefully selected group of motivated patients, these temporary setbacks did not appear to have long-term orthopedic or psychological consequences.

At the end of all treatments, there was no loss of range of motion of the hip, knee, or ankle in any patient. All 15 patients had excellent ASAMI bone and functional scores. No patient had leg length discrepancy or deformity after surgery. Final endpoints for patients are reflected in their psychological scores.

  Discussion Top

Although many studies have been published on the technical feasibility of SLS, very few authors have tried to objectively evaluate the psychological impact of the procedure on individuals. One study published their experience with SLS in a series of 54 patients lengthened with circular external fixation.[17] With a mean lengthening of 7 cm, they reported a low complication rate with good to excellent ASAMI scores. They also reported a subjective patient-reported improvement of psychological disturbances related to short stature.[17] In another study, a series of 28 patients who underwent SLS by LATN technique, the authors reported an evident increase in self-esteem at 1 year, followed by a drastic decrease near preoperative levels at 7 years as measured by the Rosenberg Self-Esteem scale.[4] Although there is a clear correlation between both concepts, body-image dissatisfaction is not the only causal agent for low self-esteem.

The main strength of this study lies in the use of validated questionnaires targeting specifically the body-image sphere of the patient's psyche. SIBID is a 48-question assessment of the frequency of negative body image-related thoughts during social and nonsocial situations related to the activities of daily living.[10] It has been repeatedly validated as a stable, internally consistent measure of responsiveness to body image therapy. A lower score translates to a lower preoccupation with one's body image. Our cohort of patients, who answered the SIBID questionnaire pre- and post-operatively, demonstrated a consistent decrease of the impact of stature dysphoria in their everyday life following SLS.

The BIQLI is another validated outcome measure of body-image intervention.[12],[13] A higher score represents a more positive impact of body image in various life domains among others the sense of self, social functioning, sexuality, emotional well-being, eating, and exercise. Consistently, our patients' increase in BIQLI score postoperatively, when compared to their scores preoperatively, demonstrate higher satisfaction in their body-image following SLS.

The MBSRQ is a self-report measure that assesses feelings about one's body, with regard to physical fitness, overall health, health consciousness, stamina, weight, reactivity to and interpretation of physical sensations. The MBSRQ contains ten different subscales which include appearance evaluation, appearance orientation, fitness evaluation, fitness orientation, health evaluation, health orientation, illness orientation, body areas satisfaction scale, overweight preoccupation, and self-classified weight. On average, our patients demonstrated no significant change in any of the ten MBSRQ subscales.

When comparing all three psychological assessments, the SIBID addresses body image across different contexts and situations, the BIQLI measures the overall impact of body image, both negatively and positively, on one's quality of life, and the MSBRQ measures the sense of one's body integrity. Since the SIBID directly assesses body image across situations, the intensity of body dysphoria can depend on various circumstances, for example, one would feel more self-conscious at a party and less so while at home. Many of these patients included in the study meet criteria for social and/or interpersonal anxiety, which they attribute to stature. The SIBID measures perceived social scrutiny, comparison to others, how one feels in clothing, and looking in the mirror, which are all experiences we would expect to improve after surgery, as we have seen with our data. Similarly, the BIQLI measures how body image impacts a range of domains, from emotional well-being to sexuality/intimacy and social functioning. The BIQLI measures all aspects of self-image that we would expect to be positively impacted by surgery and, as such, is supported by our data. The SIBID and BIQLI assess thoughts and feelings about the body itself, across different social, emotional, psychological, and cognitive domains. We would expect patients to feel better about their bodies postoperatively, which would be reflected in responses to these two measures. The MBSRQ, on the other hand, captures the way SLS patients compensate for their feelings about stature by focusing on other ways to control their bodies. This may explain why this score did not change significantly.

Many of our patients who express a desire for SLS are screened for any other kind of fixation or focus on other perceived physical deficits. The patients who go on to have surgery generally describe height as the physical aspect of their bodies that cause significant distress. We have also found that patients who feel self-conscious about their stature have tended to compensate for their perceived deficit by trying to control what they can about their bodies, such as their diet, weight, exercise and overall physical health. We think an unintended byproduct of the MSBRQ is that it captures this compensatory mechanism. SLS patients may be more likely to feel good about their efforts to control what they can by exercising, staying fit, and focusing on their health in a positive and productive way. This tendency probably would not change.

The discrepancy between preoperative and postoperative response to the questionnaires can be explained by the fact that the evaluation was mandatory to be accepted to undergo the sought-after surgical procedure. The three assessments combined represented a total of 136 statements to answer, an amount that can be dissuasive for the patient. Utilization of the short form versions and systematization of questionnaire completion during long-term follow-up visits may be implemented to increase compliance.

  Conclusion Top

Despite our small sample, the correlation between SLS and psychological score improvement remained consistently strong even though the average patient height after treatment remains below the national average. Long-term reassessment of the same psychometric questionnaire should be performed to ensure the long-lasting benefits of the procedure.

The relatively benign nature of complications encountered in our patient population as well as excellent ASAMI bone and functional scores show that in experienced hands and with appropriate follow-up, SLS is a safe, predictable procedure that can have a beneficial psychological impact on the patient willing to submit to the necessary rigor of the rehabilitation. Patients need to be screened by the surgeon, and we have found additional screening by our clinical psychologist to be important.

Financial support and sponsorship


Conflicts of interest

Dr. Austin T. Fragomen is a consultant for Depuy Synthes, NuVasive, and Smith and Nephew. Dr. S Robert Rozbruch is a consultant for NuVasive, Smith and Nephew, Orthospin, and Stryker. All other contributing authors declare no conflicts of interest.

  References Top

Rozbruch SR, Kleinman D, Fragomen AT, Ilizarov S. Limb lengthening and then insertion of an intramedullary nail: A case-matched comparison. Clin Orthop Relat Res 2008;466:2923-32.  Back to cited text no. 1
Kirane YM, Fragomen AT, Rozbruch SR. Precision of the PRECICE internal bone lengthening nail. Clin Orthop Relat Res 2014;472:3869-78.  Back to cited text no. 2
Paley D, Debiparshad K, Balci H, Windisch W, Lichtblau C. Stature lengthening using the PRECICE intramedullary lengthening nail. Tech Orthop 2015;30:167-82.  Back to cited text no. 3
Emara K, Al Kersh MA, Emara AK. Long term self-esteem assessment after height increase by lengthening and then nailing. Acta Orthop Belg 2017;83:40-4.  Back to cited text no. 4
Paley D. problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res 1990;250:81-104.  Back to cited text no. 5
Paley D, Windisch W. Cosmetic Limb Lengthening for Stature: Ethics, Methods, and Results. Perth, Australia: Australian Orthopaedic Association; 2005.  Back to cited text no. 6
von Soest T, Kvalem IL, Roald HE, Skolleborg KC. The effects of cosmetic surgery on body image, self-esteem, and psychological problems. J Plast Reconstr Aesthet Surg 2009;62:1238-44.  Back to cited text no. 7
Paxton SJ, Sztainer DN, Hannan PJ, Eisenberg ME. Body dissatisfaction prospectively predicts depressive mood and low self-esteem in adolescent girls and boys. J Clin Child Adolesc Psychol 2006;35:539-49.  Back to cited text no. 8
Watts J. China's cosmetic surgery craze. Leg-lengthening operations to fight height prejudice can leave patients crippled. Lancet 2004;363:958.  Back to cited text no. 9
Cash TF. The situational inventory of body-image dysphoria: Contextual assessment of a negative body image. Behav Ther 1994;17:133-4.  Back to cited text no. 10
Cash TF. Manual for the Situational Inventory of Body-Image Dysphoria. Situational Inventory of Body-Image Dysphoria Users' Manual; 2000.  Back to cited text no. 11
Cash TF, Fleming EC. The impact of body image experiences: Development of the body image quality of life inventory. Int J Eat Disord 2002;31:455-60.  Back to cited text no. 12
Cash TF, Jakatdar TA, Williams EF. The body image quality of life inventory: Further validation with college men and women. Body Image 2004;1:279-87.  Back to cited text no. 13
Cash TF. The Multidimensional Body-Self Relations Questionnaire. Multidimensional Body-Self Relations Questionnaire Users' Manual; 2000.  Back to cited text no. 14
Brown TA, Cash TF, Mikulka PJ. Attitudinal body-image assessment: Factor analysis of the Body-Self Relations Questionnaire. J Pers Assess 1990;55:135-44.  Back to cited text no. 15
Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res 1989;241:146-65.  Back to cited text no. 16
Catagni MA, Lovisetti L, Guerreschi F, Combi A, Ottaviani G. Cosmetic bilateral leg lengthening: Experience of 54 cases. J Bone Joint Surg Br 2005;87:1402-5.  Back to cited text no. 17


  [Table 1], [Table 2], [Table 3]

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