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What is Quadrilateral?

Quadrilateral limb lengthening surgery is a procedure performed to simultaneously lengthen the tibia and femur bones in the leg. By operating on both the femur and tibia at the same time, individuals can achieve lengthening in both segments. Some surgeons may prefer to perform the lengthening of the two segments in separate surgeries, such as lengthening the femur first and then the tibia after a two-week interval, or vice versa. However, in our clinic, we perform this procedure in a single surgery. Performing two separate surgeries would mean subjecting the individual to anesthesia twice. Receiving anesthesia twice within a short period can not only strain the body but also potentially affect bone healing. Additionally, undergoing surgery twice would result in experiencing pain from both operations. To avoid these issues, it is much more reasonable to lengthen both segments in a single surgery.

In quadrilateral lengthening, there are two techniques used:

Precice + Precice and Hybrid (LON + Precice):

Precice + Precice:

Precice + Precice: Applying the Precice technique to both segments is considered the easiest and most comfortable method of limb lengthening. The amount of lengthening may vary depending on the individual, but it typically begins at 1mm for each segment. It is important to exercise caution when it comes to weight-bearing on the feet, as the load-carrying capacity of the nails should be taken into account. Since there are no nails that can bear the full weight in both segments, difficulties may arise in terms of weight-bearing. It is crucial to strictly adhere to the directives provided by the doctor and physiotherapists and remain under their supervision throughout the process. 

The Precice nail has the capability to achieve up to 8 cm of lengthening. Consequently, from a technical standpoint, a total lengthening of 16cm can be attained, with 8cm from the femur and 8cm from the tibia. However, reaching 8cm of lengthening from the tibia anatomically may not be impossible, but it can prove to be challenging. This is primarily due to the tension exerted on the Achilles tendon, which typically allows for a lengthening of around 6-7cm. It is important to note that the actual lengthening achieved may vary from person to person, depending on individual factors and characteristics.

Hybrid (LON + Precice):

The hybrid technique in quadrilateral limb lengthening involves applying the LON method to one segment and the Precice technique to the other segment. Technically, there are two possible variations: LON in the femur and Precice in the tibia, or Precice in the femur and LON in the tibia. However, our recommendation is to prioritize Femur Precice and Tibia LON.

The rationale behind this recommendation is based on the comfort and daily life aspects of the patient. Having Precice in the femur offers a more comfortable experience in everyday activities. It allows for greater ease in movements, such as sitting, standing, and walking. On the other hand, having LON in the tibia allows for better flexibility in side-lying positions and sitting on the edge of a chair. This arrangement provides a more comfortable and functional outcome during the lengthening process. However, if LON is chosen for the femur, it can restrict side-lying positions and may reduce overall comfort during the lengthening phase.

It’s worth noting that the maximum achievable lengthening is still considered to be up to 16cm. However, the specific lengthening amounts may vary from person to person based on individual factors such as bone quality, soft tissue condition, and patient goals. As a general guideline, femur lengthening can be around 8cm, while tibia lengthening can range from approximately 6-7cm. These recommendations can be further customized and tailored to the unique needs and circumstances of each patient, with close consideration given to their overall health, functional requirements, and desired outcomes.


While technically possible, we choose not to utilize the LON + LON technique for several reasons. Firstly, this method would involve a total of eight pin insertions, resulting in eight open wounds, which significantly increases the risk of infection. Additionally, from a comfort standpoint, the presence of multiple pins can impede the rehabilitation process and diminish overall comfort during the lengthening phase. Moreover, this technique is known to be a challenging and demanding process, carrying higher risks. Considering these factors, we prefer not to utilize the LON + LON technique in order to prioritize patient safety, minimize complications, and optimize the overall success and well-being of the individual undergoing quadrilateral limb lengthening.


Physiotherapy for Quadrilateral Lengthening

Physiotherapy plays a vital role in quadrilateral limb lengthening procedures. When we lengthen two segments at the same time, the soft tissues stretch and become tight more quickly compared to just one segment. We need to focus on specific muscle groups, which are the Achilles tendon in the leg and the hamstrings at the back of the thigh. These muscles can become strained and tight during the lengthening process. 

To prevent problems with the Achilles tendon, we use exercises and treatments to keep it flexible and reduce discomfort. For the hamstrings, we work on exercises that improve thei

r flexibility and prevent tightness, which can affect how well you move your leg. It’s important to address both the Achilles tendon and hamstrings together because they are connected and can influence each other. 

During femur lengthening with the Precice method, we sometimes use a special device called Alter-G. It helps you bear some weight on your leg while still allowing you to move comfortably. This device can make your recovery faster and more pleasant. 

Quadrilateral limb lengthening requires more frequent physiotherapy sessions and a focus on exercise. We closely monitor your progress and adjust the treatment as needed. Our goal is to make sure you reach the desired length while keeping you comfortable, mobile, and happy in the long run. 

By customizing physiotherapy to suit the challenges of quadrilateral limb lengthening, we provide comprehensive care that meets your specific needs. It’s important for the surgical team, physiotherapists, and you to work together to achieve the best results and make the most of this procedure.