Methods compared
LON, motorised nails and Ilizarov or LRS frames, side by side.
Articles / Safety & risks
Limb lengthening risks and complications, with the published rates
A plain account of what goes wrong, how often it is reported, and what is done about it. Literature figures, not our own series.
Reviewed by Dr. Aman Khanna, M.S. Orthopaedics, an orthopaedic surgeon. Limb lengthening is bone surgery, not physiotherapy.
For adults aged 18 and over whose growth plates have closed.
Short answer. Limb lengthening is major bone surgery, and difficulties are common: a review of 795 cosmetic patients found 0.78 problems, 0.94 obstacles and 0.15 complications per patient (PMID 32670567). In one large series most were managed without permanent sequelae (PMID 25183215); some need further surgery, and a few leave permanent effects (PMID 33106069). These are literature figures; our own audited series is to be published.
No operation is without risk. Benefit against risk is judged for each person, and so is whether the risks can be managed. That is decided at consultation from standing long-leg X-rays, an examination and a psychological assessment, and the answer is sometimes no. See who is a candidate.
Problems, obstacles and complications
Surgeons grade the difficulties of lengthening in three steps, from Paley’s 1990 classification (PMID 2403498). A problem is a difficulty that is resolved without an operation. An obstacle is a difficulty that needs an operation to resolve. A complication is an injury during the operation, or a problem that is still unresolved at the end of treatment. In Paley’s own early series of 46 patients and 60 segments, there were 35 problems, 11 obstacles and 27 complications, 10 of them major (PMID 2403498).
| Source | Patients and method | Problems | Obstacles | Complications |
|---|---|---|---|---|
| Marwan 2020, systematic review (PMID 32670567) | 795 patients, 11 studies; Ilizarov 34 percent, LON 32 percent, nail 8 percent | 0.78 per patient | 0.94 per patient | 0.15 per patient |
| Bulut 2025, meta-analysis, external fixation (PMID 39801900) | 489 patients, 7 studies (both groups); no procedure-related deaths recorded | 56 percent | 48 percent | 10 percent |
| Bulut 2025, intramedullary nailing (PMID 39801900) | Same meta-analysis | 37 percent | 42 percent | None significant reported |
| Motallebi Zadeh 2014, bilateral tibial LON (PMID 25081825) | 143 patients | 129 in total | 85 in total | No sequelae; 0.74 per segment, 0.45 without pin-tract infection. 30.8 percent had no problem or obstacle |
| Kocaoglu 2004, LON (PMID 15523010) | 35 patients, 42 segments | 2 | 13 | 3 sequelae; 18 problems, obstacles and complications combined, in 16 of 42 segments (38 percent); 16 of 18 needed further surgery |
| Novikov 2014, Ilizarov frame (PMID 25183215) | 131 patients | Not split by grade in the abstract | 59 complications in 48 patients (37 percent): 37 soft-tissue, 22 bone; 33 needed reintervention | |
| Frost 2021, motorised nails (PMID 33106069) | 983 segments, 782 patients; Fitbone and PRECICE | Own grading, percent of segments: minimal intervention 11, substantial change in treatment 15, goal not reached 5, new pathology or permanent sequelae 3. Total 34 percent, mostly in non-cosmetic patients | ||
Definitions, methods and follow-up differ between studies, so rows cannot be added together or ranked. A referral centre that saw 22 nail lengthenings done elsewhere found hardware failure in 23 percent and malunion or nonunion in 45 percent (PMID 40051788). Those patients were referred because of complications, so that is not a rate for everyone.
Specific risks, and what we do about each
The right-hand column describes what we do. It is not a promise of any result.
| Risk | What the literature reports | How we reduce it or manage it |
|---|---|---|
| Pin-site infection (LON and frame only; not motorised nails) | In 143 bilateral tibial LON cases, 0.74 complications per segment fell to 0.45 when pin-tract infection was excluded (PMID 25081825). A femoral frame group had more pin-site infections than a PRECICE group (PMID 27694593). | Pin care is taught, and pins are checked in person, during your Surat stay while the frame is on. Early infection is treated early. Deep infection can need surgery. |
| Joint stiffness and contracture | Ankle equinus was the commonest problem and obstacle, and subtalar stiffness among the commonest complications (PMID 32670567). One of seven patients who returned to a UK service after surgery abroad needed a quadricepsplasty for severe knee stiffness (PMID 42229514). | Physiotherapy starts in hospital and is supervised throughout your Surat stay. At home, your local physiotherapist continues it on our written advice and reports joint range, which we review. Lengthening is slowed or paused in Surat if range falls. |
| Axial deviation and deformity of the new bone | Deformation of the new bone after treatment was among the commonest complications (PMID 32670567). Axial deformity and fracture of the new bone are listed as frame-alone problems that LON aims to reduce (PMID 31506759). | Alignment is checked on X-rays during lengthening in Surat and on your X-rays at home, and the nail acts as an internal splint once the frame is off. An early deviation can be corrected; a late one can need surgery. |
| Premature consolidation | The bone fuses before the target length. Reported in a matched Fitbone and PRECICE comparison (PMID 40224160) and in mechanical-nail femoral lengthening (PMID 20638660). | X-rays during lengthening show it early and the rate can be adjusted. If the bone has fused, a further operation can be needed. |
| Delayed consolidation and nonunion | Malunion or nonunion in 45 percent of 22 referred nail lengthenings (PMID 40051788, referral series). A rate above 1.5 mm a day went with poor new bone (PMID 20638660). Lengthening above 6 cm went with more complications in LON (PMID 15523010). | The rate is set at about 1 mm a day and adjusted from X-rays in Surat. After you fly home, healing is followed by monthly X-rays and video (proposed protocol), and weight-bearing rises only as X-rays allow. Bone grafting or extra fixation can be needed. |
| Nerve or blood-vessel injury | Neurological and vascular injury are listed among the difficulties of lengthening (PMID 2403498). One tibial compartment syndrome followed nail insertion in 57 mechanical-nail lengthenings (PMID 20638660). | Sensation and muscle power are checked in person during the Surat stay. After you return, your local clinician records them and we review their notes and photographs. Report numbness, tingling or weakness at once: stop any lengthening turns, message or call us the same day, and go to a local emergency department or orthopaedic service if it persists or worsens. Restart only on the surgeon’s written advice. Recovery cannot be guaranteed. |
| Deep vein thrombosis and pulmonary embolism | A UK survey of 24 surgeons counted one deep vein thrombosis in 454 adult intramedullary lengthenings; 85 percent of the surgeons thought the evidence too thin to guide prevention (PMID 34025795). | Early walking with aids, a clot-risk assessment before surgery, and preventive medicine when that assessment advises it. Calf swelling, chest pain or breathlessness is an emergency (see below). |
| Nail breakage and implant failure | Mechanism failure in 4.3 percent of 2,495 externally controlled motorised nails: Fitbone 3.3 percent of 641, titanium PRECICE nails 4.2 percent of 1,761; 97.2 percent of failures needed surgery, mostly nail exchange (PMID 41869489). In a 28-patient LON series, both distal locking screws broke in one case (PMID 31506759). | Weight-bearing is limited at first and increased as X-rays show bone filling the gap. Implants are checked on X-ray in Surat and at home, and a failed implant is exchanged. |
| Fracture of the new bone | Late bowing and refracture are recognised late complications of frame-based lengthening (PMID 2403498). Keeping a nail in the bone is meant to reduce them (PMID 31506759). | The nail stays in the bone through consolidation. Running and impact sport wait until X-rays show mature bone. |
| Psychological outcomes | In a review of 760 adults, retrospective, self-reported studies reported satisfaction between 88.8 and 98 percent and better body image and self-esteem (PMID 40275369). Centres report psychiatric evaluation in selection (PMID 30399986) and recommend psychosocial support alongside surgery (PMID 39801900). | A psychological assessment is part of the work-up, and we may advise against surgery. Tell us if mood, sleep or pain become hard to manage. |
The amount of lengthening and the risk
More centimetres mean more time in lengthening, more stretch on nerves, muscles and joints, and a longer wait for the new bone. In LON, lengthening of more than 6 cm, a preoperative score above 6.5 on Paley’s system, or lengthening of more than 21.5 percent of the original bone length each went with a higher chance of complications (PMID 15523010). In a series done mainly for limb-length discrepancy, goals above 20 percent of bone length led to problems in every segment, with an average of 1.3 obstacles and 0.9 complications per segment (PMID 10739273).
Our planning rule is up to about 6 cm per segment, decided from X-rays. It is our rule and not a published limit; at typical lengths it is about 12 to 18 percent of a tibia or femur. The tibia and femur are separate segments, lengthened in separate stages, so a larger total gain means more operations and more recoveries, not one larger one. The height-after-LON tool shows how segments add up.
When to seek emergency care
Go to the nearest emergency department, or call your local emergency number, for any of these. Then message us.
- Chest pain, breathlessness or coughing blood.
- A calf or thigh that is suddenly swollen, hot or painful.
- A foot that is cold, pale or blue, or that has lost feeling or movement.
- Severe pain that tablets do not control, or a leg that feels tight and hard.
- Fever with spreading redness, pus or a foul smell at a pin site or wound.
- A sudden crack, a sudden change in the shape of the leg, or a nail or pin coming through the skin.
For changes that are not emergencies, such as a stiffening knee or ankle or a wound that is becoming red, message us the same day with photographs or X-rays. For new numbness or tingling, stop any lengthening turns, message or call us the same day, and go to a local emergency department or orthopaedic service if it persists or worsens; restart only on the surgeon’s written advice. We are a message line on WhatsApp, not an emergency service.
The written complication pathway
Patients travelling for surgery need a plan for a complication after they fly home. A study from a UK limb reconstruction service followed seven patients who returned after cosmetic or reconstructive lengthening abroad; two needed major surgery, and the authors reported a net cost to the NHS of about 36,000 pounds (PMID 42229514). The service’s own summary adds that only one patient returned to the original provider and none had a pre-travel consultation (RNOH news, 3 June 2026). We cite it as the reason the pathway exists, not as a statement about any provider.
Before you travel you receive, in writing:
- the warning signs above, and who to contact first;
- how X-rays and photographs are sent and reviewed remotely;
- a brief for your local physiotherapist and, if needed, a local surgeon;
- how a revision operation would be handled and costed.
The detail, including the proposed review schedule, is on the aftercare when you fly home page.
Our own figures
Our audited series is to be published. Until then, the figures on this page are literature figures from other centres, in other patients, with other definitions. They are not our results and they are not a prediction for you.
References
- Paley D, et al. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990:81-104. PMID 2403498
- Marwan Y, et al. Cosmetic stature lengthening: systematic review of outcomes and complications. Bone Joint Res. 2020;9:341-350. PMID 32670567
- Bulut H, et al. Meta-analysis of complications and functional outcomes in cosmetic limb lengthening. J Orthop. 2025;65:41-45. PMID 39801900
- Giorgino R, et al. Aesthetic lower limb lengthening techniques: a systematic review of efficacy, complications, and patient satisfaction. J Orthop Surg Res. 2025;20:415. PMID 40275369
- Novikov KI, et al. Cosmetic lower limb lengthening by Ilizarov apparatus: what are the risks? Clin Orthop Relat Res 2014 472. 3549;-56. PMID 25183215
- Motallebi Zadeh N, et al. Bilateral tibial lengthening over the nail: our experience of 143 cases. Arch Orthop Trauma Surg 2014 134. 1219;-25. PMID 25081825
- Kocaoglu M, et al. Complications encountered during lengthening over an intramedullary nail. J Bone Joint Surg Am 2004 86. 2406;-11. PMID 15523010
- Farsetti P, et al. Lower limb lengthening over an intramedullary nail: a long-term follow-up study of 28 cases. J Orthop Traumatol. 2019;20:30. PMID 31506759
- Kocaoglu M, et al. Results of cosmetic lower limb lengthening by the lengthening over nail technique. Acta Orthop Belg. 2017;83:231-244. PMID 30399986
- Frost MW, et al. Systematic review of complications with externally controlled motorized intramedullary bone lengthening nails (FITBONE and PRECICE) in 983 segments. Acta Orthop. 2021;92:120-127. PMID 33106069
- Kostin E, et al. Mechanism Failures in Externally Controlled Motorized Intramedullary Lengthening Nails: A Systematic Review. JB JS Open Access. 2026;11. PMID 41869489
- Al Ramlawi A, et al. Complications after cosmetic limb lengthening, a specialized center experience. J Orthop. 2025;61:7-11. PMID 40051788
- Laubscher M, et al. Outcomes following femoral lengthening: An initial comparison of the Precice intramedullary lengthening nail and the LRS external fixator monorail system. Bone Joint J 2016 98-B. 1382;-1388. PMID 27694593
- Fragomen AT, et al. A Comparison of Femoral Lengthening Methods Favors the Magnetic Internal Lengthening Nail When Compared with Lengthening Over a Nail. HSS J. 2018;14:166-176. PMID 29983659
- Calder P, et al. Fitbone vs Precice: Is There a Difference in Regenerate Healing? Strategies Trauma Limb Reconstr. 2024;19:156-160. PMID 40224160
- Kenawey M, et al. Leg lengthening using intramedullay skeletal kinetic distractor: results of 57 consecutive applications. Injury. 2011;42:150-5. PMID 20638660
- Iliadis AD, et al. Thromboprophylaxis in Intramedullary Limb Lengthening Surgery. Strategies Trauma Limb Reconstr. 2020;15:151-156. PMID 34025795
- Guerreschi F, et al. Cosmetic lengthening: what are the limits? J Child Orthop. 2016;10:597-604. PMID 27837313
- Yun AG, et al. Attempted limb lengthenings beyond twenty percent of the initial bone length: results and complications. J Pediatr Orthop. 2000;20:151-9. PMID 10739273
- Calder P, et al. Health tourism in limb reconstruction - a recognised burden on the NHS. Ann R Coll Surg Engl. 2026. PMID 42229514
Also cited: Royal National Orthopaedic Hospital, news item of 3 June 2026, rnoh.nhs.uk, accessed 9 October 2026.
Questions people ask
How risky is limb lengthening?
It is major bone surgery with a high rate of difficulties and a lower rate of serious ones. In 795 cosmetic patients the mean was 0.78 problems, 0.94 obstacles and 0.15 complications per patient (PMID 32670567). Whether the risk is acceptable for one person depends on their anatomy, goals and health, and is decided at consultation. Some people are advised not to proceed.
What are the most common complications?
In a systematic review the commonest problem and obstacle was ankle equinus (a tight, pointed-down ankle), and the commonest complications were deformation of the new bone after treatment and subtalar joint stiffness (PMID 32670567). Pin-site infection is the other frequent difficulty when a frame is used: it accounted for the gap between 0.74 and 0.45 complications per segment in 143 bilateral tibial LON cases (PMID 25081825).
How often is a second operation needed?
Plan for further surgery. In 131 Ilizarov patients, 33 of 59 complications needed a reintervention (PMID 25183215). In a LON series, 16 of 18 complications needed further surgery (PMID 15523010). In a review of 983 motorised-nail segments, 15 percent had a complication that substantially changed treatment, and 5 percent failed to reach the goal (PMID 33106069). Nail removal is not included in our package price.
Does lengthening more increase the risk?
In published series, yes. In LON, lengthening of more than 6 cm, or more than 21.5 percent of the original bone length, went with a higher chance of complications (PMID 15523010). Goals above 20 percent of bone length were followed by problems in every segment in a series of 35 attempts, though that series was mainly for limb-length discrepancy (PMID 10739273). Our planning rule is up to about 6 cm per segment, decided from X-rays.
Is a motorised nail safer than lengthening over nail?
Some retrospective comparisons favour the motorised nail on frame-related problems (PMID 29983659, PMID 27694593). Motorised nails have their own complications: 34 percent of segments in one review (PMID 33106069), and mechanism failure in 4.3 percent of 2,495 nails (PMID 41869489). We make no claim that one is safer for you. The methods page sets out both.
What if something goes wrong after I fly home?
You are given a written pathway before you travel: who to contact, which signs need an emergency department, and how remote X-ray review and revision work. The summary is below and the detail is on the aftercare page. For an emergency, go to the nearest emergency department first and message us afterwards. We are a message line, not an emergency service.
How long is recovery?
You stay in Surat for the whole lengthening phase, usually six to ten weeks per stage, with supervised physiotherapy; you fly home once lengthening is complete and the frame is off, and the bone consolidates at home with remote review. Twelve to eighteen months from surgery to full activity is our planning figure for cosmetic cases. Published treatment periods vary: 7 to 18 months in one Ilizarov series (PMID 27837313). The distraction phase runs at about 1 mm a day (PMID 29983659), followed by consolidation. See the process article for the stages.
Related pages
Aftercare when you fly home
Tele-follow-up, X-ray review and the written complication pathway.
What is included
The itemised package: included, not included, quoted separately.
Height after LON
An educational estimate, one segment at a time.
Is it safe in India?
What to check about any surgeon and hospital.
The limb lengthening process
Stage by stage, from surgery to full activity.
Contact the surgeon
Send your height, age and any X-rays you have. Candidacy and the plan for each segment are decided at consultation, after a psychological assessment. This page is information, not personal medical advice.