Z-Lengthening: A Promising Technique for Limb Lengthening Surgery

Limb Lengthening Surgery

Limb lengthening surgery can be life-changing for people with unequal leg length or abnormal bone growth conditions. This procedure is now easier and safer than ever before.

During the exposure of the tendon, the patient is maximally dorsiflexed to obtain a moderate tension at the proximal and distal ends of the exposed tendon. This avoids shear forces that may cause early repair failure.

What is Z-Lengthening?

During z lengthening the tendon is exposed through a posteromedial incision. A surgical blade is aligned longitudinally with the tendon fi-bers at the mid portion and splits it. This longitudinal split is carried distally to the calca- neal insertion of the Achilles tendon, and at this point it is rotated medially and transected transversely.

The two hemisections are then sutured together. This procedure is similar to open Z lengthening, but has the advantage of shorter hospital stay and reduced risk of incision complication. However, percutaneous triple hemisection has some limitations in cases where posterior ankle capsular release is required.

The z lengthening technique has been reported to be a safe and effective procedure for severe equinus deformities, but further research is required on the long-term results and compared with other techniques such as percutaneous sliding tendon lengthening and open Z lengthening.

Preoperative Assessment

Multiple surgical options exist for the treatment of ITBS. However, most techniques aim to either release the iliotibial band or reduce inflammation by excision of underlying bursa without considering its multifactorial etiology.

Preoperative assessment is critical to avoid inappropriate or excessive lengthening of the tendon. In particular, it is important to verify the Silfverskiold test, as patients who can dorsiflex their ankle past neutral with their knee extended will not tolerate an Achilles lengthening procedure.

In general, percutaneous sliding lengthening and Z-lengthening (with a medial longitudinal incision) have been reported to result in good functional outcomes. However, these methods have a few drawbacks including increased trauma and the potential for calcaneal tendon breakage. To address these issues, we developed a minimally invasive technique that combines the benefits of both procedures by performing a percutaneous Z-lengthening with three transverse skin incisions. This approach can be used in a variety of cases and provides better restorative results than both the percutaneous triple hemisection and open Z lengthening.


The aim of z lengthening is to correct fixed ankle equinus by increasing the amount of ankle dorsiflexion, ideally to at least 10 degrees with the knee flexed and 5 degrees with the knee extended. It is important to correctly perform the Silfverskiold test both preoperatively and intraoperatively so that appropriate correction can be achieved and overlengthening of the tendon can be avoided.

The operative technique involves creating a transverse incision at the skin crease of the calf, and then cutting both ends of the ITB to achieve the desired length of the limb. The ITB is then repaired end-to-end using number 2 nonabsorbable sutures.

A multicenter study published in 2008 showed that a combination of ITB Z-plasty lengthening associated with local bursectomy improved the clinical outcomes of iliotibial band syndrome (ITBS) that was refractory to conservative management. It is recommended that this technique be used in the treatment of ITBS. This is a modified surgical technique adapted from the original technique of Barber et al.

Postoperative Care

A combination of Z lengthening and local bursectomy is a new surgical technique to treat refractory iliotibial band friction syndrome (ITBS). This merging surgical procedure addresses 2 of the most accepted pathophysiologic mechanisms: 1) it lengthens the ITB, decreasing the friction between the ITB and lateral epicondyle; and 2) it removes the inflammatory tissue within the ITB sheath, reducing pain and inflammation.

The indications for a z lengthening are similar to those for other comparatively minor procedures such as blepharoplasty and direct brow lifting. The procedure is used to redirect a contracted linear scar across a flexor crease, changing its direction in order to release the flexion contracture and improve functionality; or to change the vector of an undesirable cosmetic scar in order to improve aesthetics. Careful consideration needs to be given to the geometry of the oblique incision limbs and their placement, in order to achieve the desired results. Postoperatively, weight bearing is delayed until the ITB sheath heals, usually in 6 weeks’ time. A progressive rehabilitation program is then started, including regaining full range of motion and quadriceps isometric strengthening exercises.

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