Whether patients should lengthen femurs or tibias first depends on how much time and money they have and what surgery option they’re getting.
Tibias take double the time to heal than femurs and are approximately $10,000 more expensive to operate on [5]. Femur lengthening is also safer, so most patients prefer to lengthen their femurs first if they’re getting bilateral (either both femurs or both tibias) lengthening surgery.
However, if getting quadrilateral (both femurs and tibias simultaneously) lengthening surgery, surgeons will operate on the tibia first to give them a head-start on healing.