The Latest Developments in Limb Lengthening and Reconstruction Research

The Latest Developments in Limb Lengthening and Reconstruction Research 1024 683 Katie Brind'Amour, PhD, MS, CHES
Dr. Iobst with patient

Orthopedic experts publish an invited review of the past year’s most significant papers in the field of limb deformity correction and lengthening.

To aid clinicians and surgeons who don’t have time for an annual deep-dive into the literature of their subspecialty, The Journal of Bone & Joint Surgery publishes yearly reviews courtesy of invited guest editors. This year’s summary, written by two orthopedic surgeons from Nationwide Children’s Hospital, revealed significant advances in final limb length estimation tools as well as some of the first long-term outcomes data for children who have received internal lengthening nails.

“For me, the most interesting part of this project was reading the research on lower limb assessment, which is a field that has been evolving very quickly over the last few years,” says Anirejuoritse Bafor, MBBS, FMCS, FACS, visiting international scholar and research scientist at Nationwide Children’s and lead author on the review. “Assessment of the lower limb’s growth potential involves a whole spectrum of measurements and complex calculations, and most of the recent research is geared toward simplifying this process to make assessment a more predictable, precise science.”

For example, a combination of three measurement systems offers a comprehensive assessment of bone maturity, enabling effective crucial peak height velocity assessment and coverage of the full pubertal growth period.

For Christopher Iobst, MD, orthopedic surgeon at Nationwide Children’s, renowned limb lengthening specialist and senior author on the review, the most intriguing findings were in the section on limb lengthening, which is his personal specialty. Multiple other topics in limb lengthening and deformity research were also included, organized by theme.

“Research is starting to outline the expected outcomes and risk factors for some of these surgeries,” Dr. Iobst says. “The internal lengthening nails we use have only been on the market for the past 10 years, and they’re the most common nail. Now that we have about a decade of data, we can start to provide more accurate estimations of complication rates. I’ve already incorporated that information into my discussions with patients.”

Summarizing the year’s advances in the field poignantly highlighted the importance of 2021 for the orthopedic community, as it would have been the 100th birthday of Professor G. A. Ilizarov, a Russian physician and the founding father of external fixator limb lengthening and reconstruction methods.

“It’s an honor to be chosen to participate in this project,” says Dr. Iobst, who will remain as the review’s guest editor through 2024. “It has been incredibly gratifying and instructive to take the time to sit down and read all of the articles, and to summarize them in a format that is easy to digest for other limb lengthening and reconstruction surgeons.”

Recent research of Dr. Iobst, Dr. Bafor and their collaborators at Nationwide Children’s was included in the review, including their work supporting retrograde placement of an extramedullary magnetic lengthening nail for femur lengthening in skeletally immature patients. They anticipate their in-progress research may appear in next year’s edition, describing genetic implications for healing and bone regeneration, as well as the application to limb lengthening of their reverse dynamization technique to accelerate the healing of fractures. Dr. Iobst has also simplified a technique for deformity correction in the femur, and the pair is working to understand the biology of limb lengthening in a more basic sense.

Other highlights in the review included:

  • Lower-Limb Assessment
    • Improved estimation techniques for femoral length at maturity
    • Reduction in the number of radiographs needed to determine skeletal maturity
    • Parameters for measuring and investigating persistent bowing in toddlerhood
  • Limb Deficiencies
    • Greater clarity on best procedures for amputation selection and timing
    • Location and size of long-bone defects as key factors in classification and treatment
  • Upper-Extremity Deformity
    • Osteodistraction as the best approach in children under 10 years of age
    • Achondroplasia patients gain length with complication rates similar to those for lower-limb lengthening
  • Lower-Extremity Deformity
    • New method to shorten the patella tendon without any resection
    • Evaluate for Legg-Calve-Perthes disease when children with Blount disease develop a new limp or worsening symptoms
    • 3D-reconstructed CT and MRI more accurate than standard axial CT/MRI for overall femoral torsion in pediatric patients
    • Patient-reported outcomes tools not consistently applied; important to adopt or validate a standard instrument for psychosocial outcomes of adolescents undergoing limb lengthening and reconstruction
    • Vitamin D deficiency common among reconstruction patients, making perioperative screening and supplementation appropriate
  • Foot and Ankle Deformity
    • Ponseti method still best for idiopathic clubfoot management, but relapse is common
    • Universal Neonatal Foot Orthotic equally effective as serial casting for babies with metatarsus adductus, but may be preferable due to increased convenience
  • Limb Lengthening
    • Traditional teaching algorithm for limb-length discrepancies challenged by multiple researchers in light of advances in internal lengthening nails
    • Internal lengthening devices perform better than external devices, offering better healing and lower or similar complication rates
    • Earlier intervention potentially better for large deformities or projected length discrepancies
    • New classification system for osteolysis and periosteal reaction causing pain after STRYDE magnetic lengthening nail use, which arises from corrosion of the telescoping nail

Bone transport, guided growth, basic science and biomechanical advancements, as well as practical surgery tips, were also reported in the review. The full-text article can be accessed for free at The Journal of Bone & Joint Surgery.



Bafor A, Iobst CA. What’s new in limb lengthening and deformity correction. The Journal of Bone and Joint Surgery. 17 Aug 2022;104(16):1419-1425.


Image credit: Nationwide Children’s

About the author

Katherine (Katie) Brind’Amour is a freelance medical and health science writer based in Pennsylvania. She has written about nearly every therapeutic area for patients, doctors and the general public. Dr. Brind’Amour specializes in health literacy and patient education. She completed her BS and MS degrees in Biology at Arizona State University and her PhD in Health Services Management and Policy at The Ohio State University. She is a Certified Health Education Specialist and is interested in health promotion via health programs and the communication of medical information.