Distraction Phase

After the lengthening surgery, you will begin the distraction phase (lengthening phase). During the distraction phase, the PRECICE nail will lengthen the bone one millimeter per day (femurs) and a quarter millimter per day (tibias). These are performed by the ERC device and you will be instructed in its use by an Orthopedic Technologist after discharge. The turns are divided into four equal quarter millimeter turns per day. Physical therapy is required daily during the distraction phase. Physical therapy is offered at the Paley Institute's Rehabilitation Department and is included in the cost estimate.

Staying in West Palm Beach

In order to minimize complications and ensure a smooth, successful treatment, Dr. Paley requires all patients to stay in West Palm Beach for the duration of the distraction. The length of time of the distraction phase for femoral lengthening is one day for each millimeter of planned lengthening (e.g. 65mm = 65 days). We don’t start lengthening between 0–7 days after surgery (latency period), depending on the age of the patient (if we don’t start lengthening until day 5, you can expect 70 days for 65mm, 85 days for 80mm, etc.). Tibial lengthening is 0.75mm per day compared to 1mm per day for femoral lengthening. For tibial lengthening, the distraction phase for 65mm is 13 weeks plus the week for the latency period, and 16 weeks for 80mm.

Patient Aides

It is very difficult to do this surgery by yourself, particularly in the first couple of weeks. You either need to come with someone who can help look after you or else you will need to hire a home health aide. We can help you arrange for this. Please contact Jennifer Scott at jscott@paleyinstitute.org for information on home health aides. The hourly cost for home health aide is approximately $18/hour. In the first week after discharge from the hospital, you will require more hours of help, and less as time goes on. You will need to budget for this if coming alone. At the very least, everyone needs help for the first two weeks after discharge from the hospital. If you do not have anyone with you, this will cost you at least 16 hours a day of help. At $18 an hour the cost can be approximated to $4,000 for two weeks.

Weight-Bearing Precautions

During distraction, the bone ends are held separated by the implantable rod. This rod is secured to the bone by screws at either end. The diameter of the rod range can be 8.5mm, 10.7mm, or 12.5mm. The screws have a diameter ranging from 4–5mm. With enough repeated loading, the screws of any implant will bend or break. No implant is immune to this; the heavier the patient, the greater this risk. This is true of any implantable lengthening nail no matter what the material it is made of and no matter what you are told by the manufacturer or the surgeon.

We permit full weight-bearing (WB) only when we see complete bridging of the bone on the x-ray. At that point the bone is taking the load and protecting the rod. During lengthening we allow WB using crutches or a walker and unweighting of the legs using the arms. The amount of WB allowed depends on several factors: the weight of the patient, the diameter of the rod, and the bone being lengthened. For the largest diameter, PRECICE 2, 12.5mm, we allow up to 75lbs (34kg) on each leg. This means that when a patient is standing on two legs with two crutches on the ground, they can take up to 150lbs (68kg). However, when walking and transferring load from one leg to the other, the patient must use two crutches on the ground and unweight themselves to the 75lbs (34kg) weight with each step. Patients must never walk with one crutch during the distraction phase, no matter how much they weigh. During the consolidation phase, the same rules apply until Dr. Paley increases the WB quota. To know how much WB is being done, a patient can stand on a bathroom scale until it reaches the desired number (e.g. 75lbs). For the smaller diameter rods (10.7mm and 8.5mm), no more than 50lbs (23kg) is allowed per leg.

Driving

Patients undergoing implantable limb lengthening can drive once they are not taking narcotics during the day. They do, however, need to be able to get in and out of the car on their own, using crutches or a walker to transfer to a wheelchair independently. They must learn and be able to do this while abiding by the weight-bearing restrictions above.

Physical Therapy

Physical therapy is required daily, 5 days per week, throughout the entire distraction phase. Physical therapy at the Paley Institute is included in the cost estimate for 5 days per week. Seven days a week is available for an additional payment of $220 per session; please inquire into this availability if interested.

During the consolidation phase, the patient needs to continue with physical therapy but less often (2–3 days per week). This is usually done closer to home since most patients depart from West Palm Beach once the lengthening is finished. If you plan to stay locally for some time during consolidation, we can arrange additional physical therapy at our center. Any additional therapy beyond the cost estimate must be paid in advance. Daily home exercises are required by the patient throughout both the distraction and consolidation phases. The physical therapists at the Paley Institute will instruct you on these home exercises. For more information on physical therapy at our center, please see Rehabilitation & Physical Therapy.

The Lengthening

The lengthening is done by the patient at their residence where they are staying. Ideally, the lengthening is done in 0.25mm increments, four times per day, instead of a full 1mm once per day. The lengthening is done using a special device called the external remote control (ERC). Our orthopedic technologist trains each patient how to use the ERC device until they are comfortable using it on their own. Each patient receives one to take with them and returns this device at the end of lengthening. The ERC must be returned at the end of the lengthening to avoid being billed by Ellipse Technologies for this $10,000 device. There is no charge for the ERC device as long as it is returned after lengthening.

Follow Up Appointments

Follow up appointments during lengthening are scheduled every two weeks. You will see Dr. Paley and the physician's assistants on an alternating schedule. 

X-Rays

X-rays are taken every two weeks. One x-ray of each lengthening segment is taken.

Return Home

Once the lenghtening has concluded, Dr. Paley will clear you to return home immediately.