Limb Lengthening in Turkey

Limb lengthening is a surgical procedure in which a bone is cut and its two parts are gradually moved apart so that new bone forms in the gap. The process, from surgery to regaining normal movement, takes months and requires close follow-up and regular rehabilitation. Many cases are treated without surgery first, and lengthening is not the first option for most cases of leg length discrepancy. The surgeon determines eligibility after examination and imaging, because the procedure is not suitable for everyone.

This guide explains the procedure within the field of orthopedic and joint surgery in Turkey: when it is considered, which techniques are available, what the documented risks are, which factors determine the cost, and what questions to ask the surgeon before traveling.

What is limb lengthening surgery?

Lengthening relies on the bone’s ability to build new tissue when its two parts are slowly moved apart. The surgeon cuts the bone into two segments and attaches a device between them. Small adjustments are then made several times a day, separating the segments slightly each time. The gap fills with new bone, while the muscles, skin, and soft tissues gradually adapt to the new length.

It can be performed on the bones of the leg and thigh, as well as the arm and forearm. This article focuses on the legs, because the femur (thigh bone) and tibia (shin bone) are the bones affected in most cases of length discrepancy.

What is leg length discrepancy, and when does it need treatment?

More than half of people have a slight difference in leg length, which usually causes no problem. In the smaller group whose difference exceeds about 2 cm, it may affect comfort and quality of life.

Causes of discrepancy:

• A fracture that healed in a shortened position: This is more likely after multiple or open fractures.
• Growth plate injury in children: It may slow or stop bone growth.
• Bone infection: It affects bone growth, and is more serious if it occurs in infancy.
• Bone, neurological, or joint inflammatory conditions in childhood: These include cerebral palsy and polio.
• Congenital conditions: Such as congenital femoral deficiency and some skeletal disorders.
• Hip diseases: Such as Legg-Calvé-Perthes disease.
• Unknown cause: Sometimes no specific cause is found.

Symptoms: A limp may appear, or the person may stand with one hip higher than the other, or with one knee bent, or walk on tiptoe on the shorter side. The person may also tire quickly because walking requires more effort. Some studies link the discrepancy to lower back pain, while other studies do not support that link.

Diagnosis: The difference is usually measured with the patient standing barefoot, by placing graded wooden blocks under the shorter leg until the pelvis is level. The doctor may request X-rays, or a special X-ray that measures bone length with a ruler (a scanogram). In complex cases, a CT scan may be used. In growing children, the assessment is repeated every 6 to 12 months to see whether the difference is increasing or stable.

Is lengthening the first option?

In most cases, no, and medical references confirm this.

• Small differences (less than about 2 cm): Treatment is usually nonsurgical, because the risks of surgery may outweigh the benefits. Observation or a shoe lift, inside or outside the shoe, may be enough. A shoe lift is inexpensive and easy to remove.
• Slowing or stopping growth of the longer leg (epiphysiodesis): A relatively simple procedure that does not require cutting the bone. It suits only those who still have open growth plates, meaning children and adolescents who are still growing. It requires precise timing and may slightly reduce final height.
• Shortening the longer leg: Done after growth is complete by removing a section of bone. It has a limit: up to 3 inches in the femur and 2 inches in the tibia.
• Lengthening the shorter leg: Usually reserved for large differences because it is more complex.

Sources do not agree on a single number. One systematic review states that a difference under 2 cm is treated with orthotics, 2 to 5 cm with growth modification, and more than 5 cm calls for lengthening. Another official medical reference states that lengthening is considered at a difference of more than about 5 cm, and that smaller differences are usually managed with shortening or growth restriction. These are approximate figures, and the actual decision depends on other factors:

• The size of the difference.
• Age and remaining growth.
• The cause, if known.
• The presence of a neurological problem.

In some neurological conditions, it may even be helpful for the weaker leg to stay slightly shorter, because it clears the ground more easily when walking.

Who may be a candidate, and who may not?

The surgeon determines eligibility after examination and imaging. Not everyone with a length difference is a candidate for lengthening.

Lengthening may be considered for:

• People with large differences that affect walking or posture, or that cause pain.
• People whose shortening results from a congenital condition, an old growth plate injury, a previous bone infection, or a fracture that healed short.
• Some people with skeletal disorders that affect bone length.

Situations that call for special caution, or for which a specific procedure may not be suitable:

• Small differences: Alternatives to lengthening are often more suitable, as above.
• A short bone or narrow bone canal: Internal nails suit only bones that are long enough and whose canal is wide enough for the nail.
• Open growth plate at the lower end of the femur: This is generally considered a contraindication to one type of nail inserted from the knee side. Studies report that another type, inserted from the top of the femur, may be used in certain circumstances if the canal is wide enough and the upper femur anatomy is normal. The surgeon decides.
• Complex congenital conditions: The authors of one review believe that severe joint complications should be expected more often in conditions such as congenital femoral deficiency and absent fibula. This is their opinion rather than a directly measured result, but it reflects the need for an experienced surgeon and a staged plan for these cases.
• Smoking and previous bone surgery: They may slow bone formation and call for slower lengthening.
• Lack of support after surgery: Medical centers advise arranging for someone to help for several weeks after surgery, and those who cannot may need special arrangements.

Preparation and tests before surgery

• Clinical examination and imaging: The surgeon measures the difference, and X-rays of the bone are taken to determine the required length and plan the appropriate device.
• Medication review: The patient tells the team about all medications and asks which to stop before surgery and when to fast.
• Preparing the home and a helper: The lengthened leg requires a wheelchair or crutches for weeks, and the patient usually needs help with daily activities.
• Smoking: It should be discussed with the doctor, because it is one of the factors that may slow lengthening.
• Patient records: It is advisable to collect previous reports and imaging before traveling, so the initial assessment starts with complete information.

How is limb lengthening performed?

1. The patient is given general anesthesia and is asleep during the surgery.
2. The bone is cut into two segments through a small surgical incision.
3. A lengthening device is attached: either an external fixator with pins and wires, or an internal nail placed inside the bone canal.
4. A short waiting period follows the surgery so the tissues can begin to heal.
5. The lengthening phase begins. With an external fixator it is done manually several times a day; with a motorized internal nail it is done with a remote control.
6. In the consolidation phase, the new bone hardens, and the devices are then removed in a separate short operation.

Limb lengthening techniques

External fixator

A scaffold-like frame surrounds the limb and is connected to the bone with pins, wires, or both. This is the traditional method. It is versatile and can be applied to short or deformed bones, and according to some references it is relatively less costly than internal nails. However, it restricts activity, requires meticulous daily cleaning of the pin sites, and protrudes outside the body.

Its risks include infection around the pins, contracture of nearby joints, and failure of the bone to heal as required. A systematic review notes that pin site infection may reach high rates (up to 80%) in some studies when external fixation is prolonged. The introduction of another review notes that external fixation was associated in older studies with between 1 and 3.2 complications per patient.

Lengthening over a nail

An intramedullary nail is used together with an external fixator for a shorter period. A systematic review of tibial lengthening (6 comparative studies, 494 procedures) found that patients spend significantly less time in the external fixator when a nail is used. However, it found no reliable evidence of a difference in bone healing or complication rates, and noted more deep infections in some studies with the nail.

The absence of evidence of a difference does not mean equivalence has been shown. Most of the six studies were retrospective with methodological limitations, their groups were not uniform, and the authors called for stronger randomized trials.

Motorized internal nail

An expandable nail placed entirely inside the bone, driven by a motor controlled remotely from outside the body, so no external frame is needed. It is a relatively newer technique, and the risk of pin site infection may be lower because there are no external pins.

The evidence comparing it with the external fixator is limited. In a systematic review of femoral lengthening in young patients, only two non-randomized retrospective studies met the inclusion criteria, covering 91 femurs:

• Adverse events: They were relatively lower with the nail (60% to 73%) than with the external fixator (81% to 100%). However, the difference was not clearly statistically significant in at least one of the studies, and it should not be read as proof of equivalence or superiority.
• Length gained: Most patients in both groups reached the target length with no clear difference between them, and the average length gained was slightly greater with the external fixator in both studies.
• Knee movement: Knee range of motion was relatively better preserved during lengthening with the nail in one study, with no difference at final follow-up.
• Age and lack of matching: Nail patients were older (15 to 21 years versus 9 to 15 years), which limits how meaningful the comparison is.
• One condition only: Both studies focused on congenital femoral deficiency, so their findings do not necessarily apply to other causes of shortening.
• A problem specific to the nail: One study reported cases of partial knee dislocation, because the nail does not span the knee. Its authors suggested a preparatory procedure to stabilize the knee before lengthening, though its long-term results are unclear.
• What has not been studied: No study compared quality of life between the two methods, or their cost-effectiveness.

How is the most suitable technique chosen?

No technique suits every case. The choice depends on:

• The patient’s age and the structure and length of the bone.
• The cause of shortening and whether deformities need correction.
• The amount of lengthening required.
• Previous operations.
• The team’s experience with each technique.

You can ask the surgeon why a particular technique was chosen for your case, and what the alternatives are.

Anesthesia and hospital stay

Surgery is performed under general anesthesia. Some medical references state that the initial hospital stay is usually about three days. No reliable source was found that gives a uniform duration for the operation itself. It varies with the case, the technique, and any corrective procedures performed alongside lengthening, and the surgeon determines it after assessment.

Treatment stages and recovery

Duration is measured in months rather than weeks, and it increases with the length required. The figures below are general estimates that vary from patient to patient.

• After surgery: The patient stays in the hospital for a few days. The lengthened leg cannot be walked on for several weeks, and a wheelchair or crutches are used.
• Waiting period: With an external fixator, lengthening begins about 5 to 10 days after surgery.
• Lengthening phase: With an external fixator, the bone lengthens at about 1 mm per day, roughly one inch (2.5 cm) per month. Some references state that the lengthening phase usually lasts about two months. X-rays are taken regularly to check that new bone is forming at the right pace, and the doctor may adjust the plan if growth is too fast or too slow.
• Consolidation phase: Lengthening stops and the new bone hardens. This may last up to three months, and weight on the limb is increased gradually under the doctor’s guidance.
• How long the device stays: In most cases about three months per inch of length gained, which is about six months for two inches. The devices are then removed in a short operation, and a cast or brace may be used for several weeks afterward.
• Physical therapy: It is essential throughout all three phases to preserve joint movement and muscle strength, and it includes daily home exercises.
• Pain: There may be pain after surgery and during lengthening, managed with pain relievers determined by the doctor.

Expected results

There is no single figure that describes the success of lengthening, because results vary with the case, the technique, and the team. Sources differ in tone: some references describe good results when working with an experienced team and following post-operative instructions, while others note that lengthening carries a relatively higher rate of complications and additional surgeries than other options.

In a large systematic review of motorized internal nails (41 studies, 782 patients, 983 bone segments), about 5% of segments did not reach the planned length because of a complication. Patients should understand that the length gained cannot be guaranteed in advance, and that the functional goal (more balanced walking with less pain) matters as much as the length itself.

Risks and complications

Sources agree that lengthening is a procedure with notable complications, and recommend reading the numbers with caution because most studies are case series rather than comparative trials. The broadest data we found come from a Danish systematic review published in 2021. It covers motorized internal nails only, and included patients aged 8 to 74 years, so its figures do not necessarily apply to the external fixator or to lengthening over a nail:

• A complication of any kind: It occurred in about 34% of bone segments, roughly one complication per three segments, and about 42% when counted per patient.
• Complications that substantially changed the treatment plan: About 15% of segments, including an unplanned additional operation.
• Failure to reach the planned length: About 5%.
• New disease or permanent effects: About 3%, mostly joint-related complications such as contracture or partial dislocation.
• Most common types: Device-related complications (about 12%), then bone-related (about 8%), then joint-related (about 6%).
• Joint contracture: It appeared in about 5% of segments.
• Deep vein thrombosis: Four cases were recorded, and it is one of the serious complications.
• Variation between studies: Complications were relatively lower in studies with more than 40 patients (about 30% of segments) than in studies with fewer than 20 patients (about 49%). This is a comparison between studies, not between surgeons, but the authors considered it consistent with the idea that experience in this narrow specialty affects outcomes.
• Limitations of the review: The authors acknowledged that the level of evidence is low, that most studies did not use a standard system for reporting complications (29 of 41 studies), and that true rates may differ.

Official references list other risks: muscle or nerve damage, infection at the incision site or in the bone, pin site infection with external fixators, poor bone healing, and blood vessel injury. For this reason, it is recommended to check the skin color, temperature, and sensation of the foot and toes regularly.

The medical team should be informed immediately if any of the following appear:

• Blood, pus, or fluid draining from the pin sites.
• Redness or red streaks around the wounds or pins.
• Fever.
• Chest pain or shortness of breath.
• Nausea or vomiting.
• Numbness or tingling in the lengthened limb.
• Pain or swelling in the lengthened limb.

Factors that affect results

• The surgical team’s experience in limb lengthening specifically: A narrow specialty, not just general orthopedic experience.
• The cause and complexity of the case: Congenital and complex cases carry higher risks, in the opinion of some researchers.
• The amount of lengthening and the targeted bone: They affect treatment duration and bone healing.
• Smoking and previous surgeries or injuries: They may slow lengthening.
• Adherence to physical therapy and follow-up: An essential element for preserving joint movement and muscle strength.
• Readiness for close follow-up over months: Success depends on accurate X-rays and adjustments during the lengthening and consolidation phases.

Cosmetic height lengthening

Lengthening is sometimes performed purely to increase height in people whose height is within the normal range. This is different from medical treatment, as it is elective surgery on a healthy limb. It carries the same risks described in this article. We advise thinking about it very carefully and discussing it with a specialized surgeon before any decision. We also have a separate article about height increase surgery in Turkey.

Cost of limb lengthening in Turkey

The preliminary estimated cost of limb lengthening in Turkey ranges from 22,000 to 68,000 US dollars. This is a wide range because treatment extends over months and involves multiple stages, and because cases vary greatly. It is a preliminary, non-binding estimate and not a final offer, and the final price is set after your case and test reports are assessed.

Factors that explain this variation:

• Type of device: Internal motorized implants cost relatively more than external fixators, according to some studies. But their overall cost-effectiveness has not been adequately studied.
• Number of bones to be lengthened and the amount of lengthening: One leg or both legs, and the femur or the tibia.
• Preparatory and accompanying procedures: Such as correcting a deformity or stabilizing a joint before lengthening.
• Device removal surgery: A separate operation after treatment is complete.
• Length of hospital stay and the time required in Turkey: They affect the cost of accommodation and related expenses.
• Imaging and tests: Repeated X-rays throughout follow-up.
• Physical therapy and rehabilitation: The number and duration of sessions.
• Complications: Any additional unplanned operation or procedure.
• Surgeon experience and hospital level.
• What the package includes and excludes: This is the most important thing to ask about in a range this wide.

Ask any center clearly: does the price include surgery, the device, accommodation, X-rays, physical therapy, follow-up, and device removal surgery, and what happens if you need an additional operation?

Limb lengthening in Turkey and the role of O9 Medical

Some patients may consider having limb lengthening in Turkey as part of orthopedic and joint surgery. However, the level of experience in limb lengthening specifically varies from one center to another, and it should not be assumed that every center offers it at the same level. What distinguishes this procedure from most operations is that it is a treatment lasting months, so choosing the team and the follow-up plan is no less important than the surgery itself.

To choose a center, you can review orthopedic and joint surgery hospitals in Turkey. If the patient is a child or adolescent, the pediatric orthopedics page may also be useful.

O9 Medical helps you understand the available options, organize the steps for contacting centers, and obtain the information needed for the initial assessment. The medical decision remains with the surgeon who examines you, and we make no promises about outcomes. If you would like to know the steps, you can contact the O9 Medical team at any time, without obligation.

Questions to ask the surgeon before deciding

• What is the team’s experience in limb lengthening specifically, and how many cases similar to mine have they treated?
• Which technique do you propose for my case and why, and what are the alternatives?
• How will follow-up and X-rays be done during the months of lengthening and consolidation, and how often?
• How long must I stay in Turkey, and when will I be allowed to travel?
• How are complications managed if they appear after I return to my country, and who will follow me there?
• Will you communicate with my local doctor and share reports and images with them?
• What happens if the device fails or I need an additional operation?
• When and how are the devices removed, and is the removal surgery included in the agreement?
• What exactly does the cost include, and what does it not include?
• How do I contact the team in an emergency after leaving the hospital?