Abstract Introduction: Internal lengthening nails have enhanced the patient experience in limb lengthening, but soft-tissue complications such as neuropathies and joint contractures continue to limit the degree of correction achievable in a single procedure. In progressive conditions like congenital limb deficiencies, limb length discrepancy (LLD) may recur over time, necessitating repeat interventions. This study evaluated outcomes in patients who underwent two consecutive internal femoral lengthening procedures. Materials and Methods: Seven patients who had sequential internal femoral lengthenings were retrospectively reviewed. Diagnoses included congenital femoral deficiency ( n = 4), fibular hemimelia ( n = 1), and physeal growth arrest from trauma ( n = 1) or infection ( n = 1). Data collected included demographics, total length gained, bone healing index (BHI), and the interval between procedures. Results: The cohort comprised four males and three females, with a mean age of 9.9 ± 5.1 years at the first lengthening. The left femur was lengthened in five cases. The median interval between procedures was 46 months (interquartile range: 25 months). The BHI was generally higher during the second lengthening than during the first (median 28.2 vs. 25.6 days/cm), although the direction and magnitude of the change differed between patients. However, bone regenerate maturation after the second lengthening was less predictable, showing a wider BHI range (12.5–42.8 days/cm). Conclusion: Repeat femoral lengthening using an internal lengthening nail is both feasible and safe, with comparable bone healing to the initial procedure. Increased variability in healing during the second lengthening warrants further study to identify factors influencing bone regeneration consistency.
Abstract High-energy Gustilo–Anderson Grade IIIB open tibial fractures with massive segmental bone loss (>10 cm) present a major reconstructive challenge. We report a 49-year-old female with a 15 cm tibial defect and extensive soft tissue loss. A sequential orthoplastic approach was utilized. Initial debridement and spanning fixation were followed by a robust, large-volume latissimus dorsi (LD) free flap for definitive soft tissue coverage. Six weeks later, a mono-focal Ilizarov bone transport was initiated. The stable LD flap permitted safe pin placement and distraction. The transport successfully bridged the 15 cm defect, achieving full consolidation at 18 months. This staged strategy – prioritizing stable free flap coverage before delayed ilizarov bone transport – is a highly effective limb salvage alternative for massive defects, resulting in a high likelihood of union with excellent functional outcome and amputation avoidance.
Abstract Context: Hemiepiphysiodesis has been a successful approach for the management of lower extremity coronal malalignment around the knee. This procedure has reportedly been effective in correcting deformity caused by different pathologies. Aims: This study examines the effect of underlying pathology on the rate of correction following temporary hemiepiphysiodesis. Settings and Design: Records of skeletally immature patients who underwent temporary hemiepiphysiodesis with at least 1-year radiographic follow-up were retrospectively reviewed. Subjects and Methods: Lower extremity mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were measured preoperatively and on the final radiograph obtained before implant removal or before a second procedure was performed on the same limb. Statistical Analysis Used: Rate of change of MAD, LDFA, and MPTA was examined as a function of pathology, deformity direction, age, and body mass index using linear mixed models. Results: One hundred and forty-five patients (257 limbs) were included. The mean ± standard deviation age at surgery was 11.9 ± 3.5 years. The mean rate of correction was 1.48 ± 1.00 mm per month and did not differ based on direction of the initial deformity ( P = 0.55). The mean rate of change in LDFA was 0.29° ± 0.27° per month and MPTA was 0.28° ± 0.26° per month. A faster rate of correction of LFDA and MPTA was noted for younger children ( P < 0.001) and those with rickets ( P < 0.03). A faster rate of correction of MAD showed a trend toward significance for younger children ( P = 0.069). Conclusions: In children with coronal plane deformities treated with guided growth hemiepiphysiodesis, faster correction is expected for children with rickets and younger children.
Abstract Background: Circular external fixation constructs are increasingly designed to be more compact while maintaining mechanical stability. In hexapod systems, limited ring space and strut clearance constrain fixation placement, making fixation cube-hole position (offset) and half-pin divergence key design variables. However, limited guidance exists on how these factors should be balanced when a constant bone-capture (excursion) distance must be maintained. This study evaluated the stiffness–footprint trade-off across five fixation cube-hole configurations under a constant excursion constraint. Methods: A benchtop circular external fixation construct was assembled using a 150-mm reference ring and a 38-mm Delrin cylinder as a bone surrogate. A 5.0-mm half-pin was mounted via a five-hole fixation cube. Five configurations were tested while maintaining a constant excursion of 65.52 mm. As cube-hole position moved proximally, ring–block offset decreased (65.52–17.52 mm) and required divergence increased (0°–30°). Axial compression testing was performed, and stiffness was calculated from the slope of the load–displacement response within the 2–10 lb linear region (peak load 12–15 lb). Three repeat trials of a single construct assembly were performed per configuration. Configuration-depentdent mechanical behaviors were compared using one-way Analysis of Variance ANOVA with Tukey post-hoc testing. Results: Axial stiffness varied markedly across configurations. One-way ANOVA demonstrated large between-configuration differences ( F [4,10] =5540.4, P < 0.001; η 2 = 0.999). Post hoc comparisons showed clear separation between all configurations (Tukey HSD, all P < 0.001), with minimal overlap in measured stiffness values. The orthogonal configuration (0°) was least stiff (293.6 ± 0.8 lb/in). Stiffness increased with divergence, peaking at 20° (486.7 ± 0.1 lb/in; +65.7% vs. baseline). Further divergence to 30° reduced stiffness but remained above baseline (+43.5%). All pairwise comparisons were significant ( P < 0.001). Footprint decreased progressively from 2025.0 mm 2 to 788.6 mm 2 (−61%). Conclusions: While the tested comparisons represent technical repeats rather than independent construct replicates, these results indicate consistency in the measurements within each configuration and the separation between configurations. Moderate half-pin divergence (≈20°) maximized axial stiffness, while greater divergence (30°) minimized footprint with preserved rigidity. These findings support configuration optimization in circular and hexapod fixation.
Abstract Limb lengthening is a well-established surgical procedure used to address congenital and acquired limb length discrepancies. Despite advancements in external and internal fixation techniques, the process remains physically and psychologically demanding, with prolonged recovery and a risk of complications. Clinically applicable rehabilitation guidance remains limited and fragmented within the literature. This narrative review provides a structured and practical overview of rehabilitation in lower limb lengthening, integrating current evidence with clinically relevant strategies across the preoperative, intraoperative, and postoperative phases. Key components of care include patient education, prehabilitation, structured rehabilitation protocols, and early identification and management of complications. These elements are essential for optimizing functional recovery and reducing complication risk. A structured, phase-based rehabilitation approach may improve clinical outcomes following limb lengthening.
Abstract Extramedullary limb lengthening using a motorized lengthening nail offers an alternative in situations where narrow canals or atypical femoral morphology preclude intramedullary fixation. Although this technique has been described in pediatric settings, its use in skeletally mature patients remains limited. A 22-year-old female patient with Conradi–Hünermann syndrome presented with an approximately 7 cm leg length discrepancy. Due to atypical femoral anatomy, intramedullary nail placement was not feasible. A corrective trapezoidal wedge osteotomy was performed, and a Precice™ magnetic lengthening nail was implanted in a retrograde, extramedullary, and submuscular plane. Distraction commenced on the postoperative day nine and was adjusted according to the quality of the regenerate bone on serial radiographs. A total of 40 mm of lengthening was achieved over 10 weeks without loss of alignment, implant failure, or other complications. The patient advanced to full weight-bearing by 4.5 months, underwent elective nail removal at 1 year, and demonstrated maintained alignment and functional improvement at a 26-month follow-up. Although an off-label application, extramedullary limb lengthening using a motorized lengthening nail in an “off-label” manner can be safely and effectively performed in carefully selected adult patients with complex femoral anatomy. This case highlights the feasibility and successful outcomes that can be achieved with preoperative planning and surgical execution.
Abstract Purpose: Tibial fractures in skeletally immature patients are challenging to treat. The circular hexapod external fixator (CHEF) allows immediate weightbearing, early range of motion, and software to adjust post-operative alignment. This study aimed to evaluate outcomes and cost for adolescent tibia shaft fractures treated with CHEF. Methods: This was an IRB-approved, multicenter, retrospective case-series of tibial shaft fractures treated with CHEF in patients aged 10-17 years-old from 2010-2021. Patient demographics, radiographic data, and financial data were investigated. Results: Thirty-eight cases were included. Mean age was 14 years. Average treatment duration was 4 months with 7 months mean follow-up. Twelve (31%) were open fractures and 21 (55%) developed pin site infections. All fractures healed with <10 degrees of deviation in all planes. Open fractures were associated with higher energy mechanisms ( p <0.001), additional operative procedures ( p =0.008), and greater sagittal deviation ( p =0.049). Greater coronal deviation was linked to complications ( p =0.037). Average RUST score was 10. RUST scores were higher in the open physes group (11 vs 9) ( p =0.027). Median and IQR for total costs were $75,000 and $26,000. Conclusion: CHEF’s were shown to provide full weightbearing and early range of motion with minimal complications. Pin site infections were the most common complication and correlated positively with secondary procedures. CHEF’s allowed minimal angulation or translation with no cases of nonunion. Significance of Study: Largest case-series on CHEF use in adolescent patients displaying high success rates with minimal complications and an exploratory study on the RUST tool in pediatric patients.
The Fitbone™ lengthening system (Orthofix Medical LLC, Lewisville, TX, USA) utilizes a telescopic, stainless steel, motorized intramedullary device that is powered by transcutaneous electricity. The system utilizes a unique approach for bone preparation and stability. As each step of surgery and aftercare has distinctive features, this work aims to share technical suggestions for successful femur lengthening with this implant system.
The objective of this study was to perform a meta-analysis evaluating rates of infection clearance in single stage revision of infected tibial non-union with antibiotic cement coated intramedullary nailing (ACCIN) compared to Ilizarov external fixation methods. A systematic review was performed of the Medline, Embase, and Cochrane databases to identify relevant articles. Eligibility criteria included studies of adult patients, written in the English language, with cohorts and outcomes clearly stated. The primary outcome measure was clinical resolution of infection; secondary outcomes included bony union and management of bone loss. This study was conducted adhering to the PRISMA guidelines. The Cochrane ROBINS-I tool was used to assess bias of the included studies, and funnel plots were created to assess study heterogeneity. A total of sixteen papers ( n =331 cases) reporting the outcomes of single stage treatment of infected tibial non-unions were identified and reviewed according to the selection criteria stipulated above. Ten utilizing Ilizarov external fixation methods ( n =242 cases) and six utilizing antibiotic cement coated intramedullary nails (ACCIN) ( n =89 cases) were included in the final analysis. Mean age, sex, time to follow-up, clinical resolution of infection, and union rate were analysed for heterogeneity using Cochran’s Q statistic, the I-square test, and two-way ANOVA analysis of means. Included studies in both cohorts were homogeneous for sex, resolution of infection, and union rate. These variables where further analysed with Chi Squared crosstab and weighted means analysis. No significant differences were identified in the rate of successful resolution of infection or bony union when comparing the single-stage Ilizarov method (93.8%, 87.6%) to the single-stage ACCIN (87.6%, 82.0%) ( P =0.193, P =0.065). The time, resource, and convenience benefits of single stage limb reconstruction procedures for infected non-union of the tibia are only advantageous if eradication of infection and bone union are consistently achieved. This meta-analysis suggests that treatment of infected tibial non-unions using single-stage debridement achieves comparable clinical control of infection, regardless of whether the limb is stabilized by insertion of antibiotic cement coated intramedullary nails or if instead stabilized in concert with Ilizarov methods. These results indicate ACCIN should be considered non-inferior to Ilizarov methods when used in singlestage protocols in these challenging cases. However, for tibial bone defects > 2cm Ilizarov methods may be more likely to achieve union and simultaneously eradicate infection.
Objectives:The purpose of this pilot study was to evaluate the reliability of artificial intelligence (AI) software in measuring lower limb alignment parameters using EOS imaging in an orthopedic setting.Methods:Twenty EOS long-leg images were included, representing 40 legs, from 10 patients with varying degrees of lower limb deformities. Two readers performed manual measurements twice. The same dataset was also analyzed using a commercially available AI-based software, leg angle measurement assistant. The agreement between manual and AI measurements was assessed across nine parameters, including 3 length and 6 angular measurements. Intraclass correlation coefficients (ICCs) assessed inter- and intrarater reliability, and Bland-Altman plots evaluated bias.Results:The AI system failed to generate results in 25% of cases. In the AI-manual comparison, reliability varied across parameters. Angular measurements showed poor-to-moderate agreement, with ICC values ranging from 0.30 to 0.70. Length measurements, however, demonstrated excellent agreement, with ICC values ranging from 0.97 to 0.99. The reliability and agreement between manual measurements ranged from good to excellent, both within and between readers. For AI analysis, repeated measurements showed an intraobserver ICC of 1.Conclusion:The AI tool showed potential as an aid for long-leg alignment analysis when applied to EOS images, particularly for length measurements, though it struggled with angular measurements. This may stem from differences between EOS and traditional radiographs affecting accuracy. Further refinement and EOS-specific training are needed, especially for cases with implants and severe deformities.
Introduction:Major surgical interventions are known to impact body weight through various mechanisms. In distraction osteogenesis, clinicians have observed patients losing weight during active lengthening. This study characterizes body weight changes during tibial lengthening in a controlled animal model.Materials and Methods:Following institutional ethical approval, unilateral tibial lengthening was performed in nine 3-month-old New Zealand White rabbits (initial weight range: 3.15-3.4 kg). Tibiae were distracted at a rate of 0.75 mm/day, delivered in three increments of 0.25 mm to achieve 20% lengthening. Animals received equal daily food rations with additional nutritional enrichment. Body weights were recorded at baseline (day 0) and at subsequent time points: Days 21, 28, 35 (end of distraction), 49, 63, and 77.Results:The mean baseline weight was 3.27 kg. By day 35, mean weight decreased to 3.15 kg, reflecting a 3.7% reduction. A gradual recovery followed during consolidation, with weights increasing to a mean of 3.41 kg by day 77. The trajectory of weight change showed a strong correlation with treatment timeline (R & sup2; = 0.9733).Conclusions:These findings demonstrate a consistent pattern of transient weight loss during distraction osteogenesis with recovery during the consolidation phase. Awareness of this pattern may guide perioperative nutritional support and enhance bone regeneration outcomes in limb lengthening patients.
Context:Motorized intramedullary nails are the gold standard for bone lengthening, yet few studies have evaluated their impact on quality of life.Aims:This study assessed the influence of motorized intramedullary lower limb lengthening in patients with short stature and their complications.Settings and Design:We retrospectively reviewed 44 bone segments (34 femurs, 10 tibias) performed in 17 patients by a single surgeon (2011-2022).Subjects and Methods:Clinical and radiological data, including final alignment, limb discrepancy, and consolidation index, were analyzed. Patients completed the SF-36 health questionnaire. Complications were classified using Paley's, modified Clavien-Dindo, and Lascombes' classifications.Results:Mean age at surgery was 17 years (13-27). Mean lengthening was 67 mm (femur) and 57 mm (tibia) with bone healing indices of 40.5 days/cm and 43 days/cm. No blood transfusion was needed; final alignment and limb length were satisfactory. Paley's classification showed 22 and eight problems, 18 and three obstacles for femurs and tibias, respectively. According to Clavien-Dindo classification, there were 22 and eight Grade 1, 18, and 3 Grade 3b. According to Lascombes' classification, there were 22 and eight Grade 1, five and two Grade 2a, 13, and one Grade 2b, five and no Grade 3a. Mean SF-36 global health was 66, physical component 77, social component 76.4, pain component 75.1, and emotional component 62. Ninety-one percent of patients would recommend this treatment to a relative, and 100% would do it again.Conclusions:Motorized intramedullary lengthening nails offer high patient satisfaction and favorable outcomes in selected short stature patients. Complications are generally manageable without reintervention. With proper patient selection, this technique can be recommended.
Background:Limb salvage surgery (LSS) has transformed the management of extremity bone tumors by offering oncologic safety comparable to amputation while preserving function. However, in low- and middle-income countries, LSS implementation remains constrained by resource and infrastructure limitations. This study reports the early experience of establishing a dedicated LSS program at a tertiary center in North India, evaluating its oncologic safety, functional outcomes, and practical feasibility.Materials and Methods:A retrospective review was conducted of 10 patients who underwent LSS for primary bone tumors between May 2020 and April 2023. During the same period, 18 patients underwent surgery for primary bone tumors, of whom 10 (55.5%) met inclusion criteria. Tumor sites included the proximal humerus (n = 3), distal femur (n = 2), proximal femur, distal humerus, proximal tibia, distal fibula, and pelvis (one each). Histologic subtypes comprised osteosarcoma (n = 5), chondrosarcoma (n = 2), and giant-cell tumor (n = 3). Osteosarcoma patients received six cycles of the ifosfamide-adriamycin-cisplatin (IAP) chemotherapy regimen. Reconstruction employed a modular megaprosthesis (RESTOR, Adler) in eight cases, pseudoarthrosis in one, and fibular head autograft in one. Primary outcomes were local recurrence and functional recovery, assessed using the Musculoskeletal Tumor Society (MSTS) score at 12 months; secondary outcomes included perioperative complications and prosthesis survival.Results:The mean operative time was 4.5 h; with average blood loss 650 mL and mean hospital stay 8 +/- 2 days. After a mean follow-up of 22 months (range 12-36), the mean MSTS score was 82.7 +/- 7.4% (range 73.3%-93.3%), reflecting good postoperative function. One patient (10%) experienced local recurrence of osteosarcoma in the proximal humerus; no distant metastases were observed. Minor wound complications occurred in two patients and resolved conservatively. No prosthesis-related failures (loosening, fracture, or deep infection) were recorded.Conclusion:This initial institutional experience demonstrates that a multidisciplinary, protocol-based LSS program can be safely implemented in a resource-limited tertiary-care setting. The approach yielded excellent functional outcomes, low complication rates, and oncologic results comparable to international benchmarks. The findings highlight that with coordinated surgical-oncologic collaboration and access to modular prostheses, limb salvage can replace amputation as the standard of care for resectable primary bone tumors in India.
Introduction: Major limb amputations are among the most disabling surgical procedures currently performed. In particular, proximal limb amputations (PLAs) impose enormous functional and social challenges on patients and their families, as they leave minimal options for functional prostheses, especially in the low-resource settings. The authors report on the indications of a series of patients who underwent PLAs at a resource-limited hospital. Methods: Data from the hospital medical records and histopathology database of patients who underwent PLAs (forequarter, hindquarter amputations, or hip or shoulder disarticulations) at a hospital in a middle income country in the sub-Saharan African region over a 14-year period was retrospectively evaluated to determine the indications for surgical procedures and early outcomes. This article did not aim to assess the specific outcomes in this cohort, due to limited data. Results: A total 48 PLAs (nine forequarter amputations, five hemipelvectomies, and one shoulder and 18 hip disarticulations) were performed in 44 patients. The 27 males and 17 females had a mean age of 41 years. The most common indication was malignancy (63.6%) and the second most common was infection (16.8%). Conclusion: We assessed the indications for PLAs at our site, with the most common indication being malignancy. In addition to a lack of preventative screening for malignancy and effective infectious disease control, limited disability optimization and support in this community (ex . reliable prostheses) likely decrease surgical effectiveness. Therefore, PLA-associated risks in this cohort highlight the importance of early oncologic detection, infectious disease control, and chronic disease management in low-resource settings, where robust surgical outcome data are often unavailable.
Background: Motorized intramedullary lengthening nails (MILNs) are a convenient option for limb lengthening. One MILN manufacturer states the nails should be removed 1 year following surgery. However, there is no scientific evidence specific to the optimal bone condition for nail removal. This study aimed to identify the optimal conditions for MILN removal for stature-lengthening patients. Methods: A retrospective review was performed of patients who underwent simultaneous bilateral lower extremity stature lengthening with MILN over a 10-year period. We excluded patients whose nails have not yet been removed. Data on the patient’s age, sex, details of the surgery, follow-up time, the timing of nail removal, and complications were collected. Results: Sixty-four patients were included with an average age of 31.6 ± 12.4 years, and an average follow-up time of 1.6 ± 0.8 years. A total of 142 bone segments included 122 femurs (85.9%) and 20 tibias (14.1%). The average lengthening achieved was 67.5 ± 10.8 mm (range 42–80 mm). The median time to nail removal was 387.5 days with an average of 522.1 ± 406.2 days (range 231–3480). MILNs were removed prior to 1 year for 36 (25.3%) and after 2 years for 14 (9.9%) segments. One patient experienced a fracture through regenerated bone following MILN removal. Conclusions: The appearance of four cortices seems fully protective of post-removal fracture, whereas fewer than four cortices may pose a risk for postremoval fracture. Cortical development seems more important than total implant retention time. Prolonged nail retention does not appear to cause adverse events.
Introduction: Growth modulation surgery with hemi-epiphyseal tether plating in late-onset tibia vara (LOTV) has variable results in prior literature. We sought to confirm that skeletal maturity, patient body mass index (BMI), and deformity severity could be used to predict the odds of deformity correction in our patient population. We also hypothesized that a larger, more rigid implant design would also predict success. Methods: We retrospectively reviewed patients with LOTV treated with lateral tension band plate (LTBP)-guided growth at a tertiary pediatric multihospital facility over a 10-year period. Pre- and postoperative radiographic deformity markers, implant data, and demographic data were recorded. Included patients had final radiographs for analysis at minimum 2-year follow-up or last radiographs prior to hardware removal/subsequent surgery. Treatment success was defined as normalization of varus alignment or any valgus overcorrection of the limb. Uni- and multivariate analysis was performed to identify odds of a successful outcome based on recorded risk and treatment factors. Results: Forty-seven patients (74 limbs) met our inclusion criteria for review. Sixty-one percent (45) of limbs were successfully treated. Severity of deformity, skeletal maturity, and preoperative BMI all significantly correlated with treatment outcome. A 1º increase in medial proximal tibial angle (MPTA) or 1º increase in valgus mechanical tibiofemoral angle increased the odds of successful treatment by 1.22 ( P < 0.001) and 1.2 ( P < 0.001), respectively. When adjusting for MPTA and preoperative BMI on multivariate analysis, >3 years of growth remaining increased odds of successful treatment 27.2 times ( P = .001). Implant design (screw size, cannulated or solid screws, screw number, and plate type) did not correlate with odds of treatment success. Conclusion: In our patient cohort, less severe deformity, greater age of growth remaining, and decreased patient BMI all predicted treatment success of LOTV with LTBP which corroborates prior studies’ results. We were not able to find a significant treatment effect from different implant options; however, this effect may be limited by our sample size. This information gives helpful insight into narrow treatment indications with this technique for LOTV and provides families with better estimates of success based on preoperative risk factors.
An adolescent patient presented with left patellofemoral instability with a patella osteochondral fracture in the setting of genu valgum and an elevated tibial tubercle to trochlear groove (TT-TG) distance. The patient underwent left medial patellofemoral ligament reconstruction and patellar osteochondral fracture open reduction and internal fixation with a concomitant oblique-plane proximal tibial osteotomy with frame osteosynthesis to achieve varus-producing correction and tibial tubercle anteromedialization. The patient experienced full recovery with complete healing of the osteochondral fracture, stabilization of the patellofemoral joint, and restoration of anatomic coronal and axial plane alignment. She reported significant improvements in mobility and pain. This case report highlights the novelty of this combined procedure in adequately addressing recurrent patellar instability in the setting of multiplanar deformity, uniquely utilizing a single oblique cut osteotomy with frame correction to correct valgus tibial deformity and elevated TT-TG.
Context:Patients seeking elective surgery for stature lengthening, a controversial topic, often rely on online searches for medical information.Aims:This study investigates the quality and variability of online information regarding limb lengthening to increase stature and examines trends in related online searches.Settings and Design:A systematic web search was conducted to identify websites offering cosmetic limb lengthening. An extraction template was used to summarize each eligible website.Materials and Methods:The quality and reliability of each site was assessed using the DISCERN instrument, a validated tool for assessing the quality of consumer health information across 16 domains with scores ranging from 16 (least favorable) to 80 (most favorable).Statistical Analysis Used:Descriptive statistics were used for this study.Results:The search found 36 websites offering cosmetic limb lengthening. The United States (14) and Turkey (7) had the highest number of websites. The mean total DISCERN score was 46.5 (Range: 26.5-63). Most websites mentioned surgical complications (89%) and rehabilitation requirements (81%), but fewer reported costs (47%). From January 2016 to March 2024, search terms such as "limb lengthening," "height lengthening," and "taller surgery" increased by 2.59, 2.67, and 1.83-fold, respectively.Conclusions:There is variability in the quality, reliability, and content of online information about limb lengthening for stature enhancement. Consensus guidelines from professional organizations may improve the public-facing online content available to individuals seeking cosmetic limb lengthening.
