Video Feedback-Supported Rehabilitation After Bilateral Femoral Lengthening

Cosmetic limb-lengthening surgery has become increasingly common among individuals seeking an increase in height. The Lengthening Over Nail (LON) technique reduces the duration of external fixation and provides greater mechanical stability. However, the lengthening process affects not only bone tissue but also muscles, tendons, connective tissues, blood vessels, and the nervous system.

During distraction osteogenesis, approximately 1 mm of lengthening is generally performed each day. The resulting continuous mechanical tension on the soft tissues may lead to quadriceps tightness, reduced knee range of motion, loss of muscle strength, pain, and impaired functional performance. Joint stiffness, muscle-tendon problems, contractures, and alterations in gait may also occur during femoral lengthening. Therefore, intensive and structured rehabilitation is an essential component of the treatment process.

Video feedback allows individuals to observe their own movement patterns, recognize movement errors, and modify their motor strategies. Although visual and video feedback approaches have demonstrated beneficial effects on gait and motor performance in several patient populations, their effects have not been investigated in individuals undergoing cosmetic bilateral femoral lengthening.

This study is designed as a prospective, parallel-group, assessor-blinded randomized controlled trial. A total of 32 participants aged 18-45 years who undergo cosmetic bilateral femoral lengthening using the LON technique will be assigned to two groups through computer-generated block randomization at a 1:1 ratio.

Both groups will participate in rehabilitation sessions 5 days per week, with each session lasting 50 minutes. The control group will receive 50 minutes of conventional physiotherapy. The intervention group will receive 40 minutes of conventional physiotherapy in addition to 10 minutes of video feedback-supported gait training. Conventional physiotherapy will include active and passive range-of-motion exercises, stretching exercises for the quadriceps and hamstring muscles, isometric strengthening exercises, gait training, and neuromuscular electrical stimulation.

During video feedback-supported gait training, participants will be recorded while walking along a 10-meter walkway. Recordings will be obtained in the frontal and sagittal planes. Participants will review their gait videos with the physiotherapist and receive standardized verbal and visual feedback regarding step width, step symmetry, lateral trunk deviation, shoulder alignment, pelvic position, Trendelenburg sign, hip and knee movements, foot contact, and gait rhythm.

Assessments will be conducted before surgery (T0), at approximately 4 cm of lengthening (T1), at approximately 8 cm of lengthening (T2), and 2 weeks after external fixator removal (T3). All assessments will be performed by an outcome assessor who is blinded to group allocation.

The primary outcome will be walking performance measured using the 10-Meter Walk Test. Secondary outcomes will include the Lower Extremity Functional Scale, Tampa Scale for Kinesiophobia, Body Awareness Questionnaire, quadriceps muscle strength measured with a handheld dynamometer, and pressure pain threshold measured with a pressure algometer.

The study will determine whether adding video feedback-supported gait training to conventional physiotherapy provides greater improvements in walking performance, functional status, movement-related fear, body awareness, quadriceps muscle strength, and pressure pain threshold than conventional physiotherapy alone.

Inclusion criteria

• Aged between 18 and 45 years
• Scheduled to undergo cosmetic bilateral femoral lengthening surgery using the Lengthening Over Nail technique
• Able and willing to participate regularly in the preoperative and postoperative assessments and rehabilitation program
• Able to understand the study procedures and follow the physiotherapist's instructions
• Willing to provide written informed consent

Exclusion criteria

• - Presence of a congenital, neurological, or rheumatological disorder
• Previous major orthopedic surgery affecting the lower extremities
• Presence of cerebral palsy, muscular dystrophy, peripheral neuropathy, or another neuromuscular disorder
• Advanced deformity, contracture, or osteoarthritis affecting the hip, knee, or ankle
• Psychiatric illness or cognitive impairment that may affect participation or adherence
• Any medical or postoperative complication preventing regular participation in the rehabilitation program
• Considered unsuitable for continued participation by the treating physician or research team