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Limb lengthening and Muscle Repair (by Dr. Dragan)
What occurs to muscles within the period of lengthening and recuperation?


I frequently receive questions such as:
" Will I be completely normal after the lengthening phase? "
" How does the lengthening phase proceed? "
" What will I be ready to do after the lengthening phase? "

    To answer these questions, I will try to explain the process of lengthening and its challenges. Those prospective patients who come for a consultation at our center and have seen our patients in their final phase of lengthening (7-9 cm), they have noticed that the lengthened muscles often look thin and there is an angular bend in the knee joints.

    Let's first explain why lengthening muscles grow "thin". By analogy, if you take a piece of rubber and start to stretch it, then the stretched object becomes thinner.  The same process occurs with the lengthening muscles. Practically, all objects change their form after stretching. (For the Inquisitive readers can read Part 2 and the Part 7 of the book by J. E. Gordon  “STRUCTURES, OR WHY THINGS DON'T FALL DOWN” Penguin Books, Harmondsworth, 1978)

    Muscle Adaptation

    The patient needs to understand the mechanics of the muscle.  The muscle's tissue is " an ingenious design " of nature. I want to describe the process of what occurs "inside" of the muscle as its stretching.  The muscle experiences a certain stress during the lengthening of a bone. When we grow several centimeters in childhood then the muscles grow and developed together with all the tissues of our body harmoniously. The cosmetic lengthening program concentrates the process of growth of years to fit within the scope of several months.

    The passive resistance to the extension of the muscle is length-dependent (non-linear), as is the resistance to extension of the extracellular matrix networks (connective tissue networks) within the muscle. The collagenous network of muscles (CNM) is a very important factor, determining the flexibility of the muscle. The clinical experience shows, that resistance of the muscle to stretching increases after a lengthening of the bone. It is possible to explain a condition of  CNM. This network adapts to a small stretching easy enough. After approximately 4 centimeters of lengthening the femur, the ability of CNM to continue extension is reduced. Now it is necessary for the process of lengthening to be very smooth, without jerks. The collagenous networks should have time for their relaxation, "to droop". Ultimately, the adaptive capabilites of a muscle are huge. But stopping the lengthening process is necessary to maximize this capacity. Constant but wisely distributed stretching is requisite for a good adaptive result.

    The Appropriate Degree of Lengthening.
    The result of lengthening should be noticeable.
    The result of collective effort should be worthy of the difficulties of the achievement.

    After 4 cms of lengthening the device needs more effort to work properly. The patient starts to experience a range of sensations from unpleasant to painful ones. It is important to note, however, that different patients do not have an identical threshold of sensitivity. And if the process of lengthening for one patient is just a minor discomfort than for others stretching is a painful procedure. Accordingly, we can adjust the speed of the lengthening to help mitigate pain. The reason is that we can imagine the way the stretched tissues of the muscle influence the nerve endings. This is a natural signal from the muscle in reply to a new, unusual condition.

    A powerful process of adaptation to new conditions is started in the body. This process will last till full rehabilitation. There is a reorganization in the muscle. i.e. the stretched structure of the muscle comes back to the normal structure, but in a new, lengthened state. The new cells of the muscle then appear. The new structure of  CNM weaken the muscle and return its flexibility. Full rehabilitation requires the full motivation of the patient during his/her recuperation. Now it is clear why it is necessary to do exercises up to the surgery: you increase the adaptive abilities of the collagenous network in the muscle by means of the stretching exercises; the trained network will start to resist later. Exercises help to increase the blood supply to the muscles and that is very important for the recovery period. After the operation, exercises should be often repeated, but not too intensively. The main task is stimulation of the adaptational processes and stimulation of "the building materials" is for rehabilitation.

    Walking on crutches is also a very good form of adaptive muscle stimulation. Constant use of an external support is one of the best exercises to achieving total recovery. The patient can start to use crutches in the first weeks after surgery. At the height of lengthening, when the extension of muscles is maximal, the use of crutches is complicated because of incomplete unbending of the legs. But, in several weeks, after partial muscular adaptation and straightening of legs, has occured it is very important to start over again and to use crutches. It is important to note, that each millimeter of lengthening requires an enormous amount of effort during rehabilitation. Thus while the desire to obtain the maximal amount of lengthening is often desired by the patient it will also require more recovery time. It is necessary to balance a patient's desires for an increased height with both your individual strength and the opportunity for rehabilitation. On preparing for the program of lengthening - think beforehand about your obligations at home. You should have enough time for full rehabilitation.

Even if you move around easily on crutches, the wheelchair will be useful for decreasing stressful physical loading and allowing the body to rest. And finally, remember that muscles are practically equal in everyone.  The reaction to stretching of the muscles is universal. Rates of recovery may differ in individual patients but the process of muscle adaptation will lead all patients to recover with time and proper effort.