Twenty-six bifocal lengthenings in 18 patients were reviewed in an attempt to identify the major indications, including extreme shortening, shortening with deformity and shortening with joint stiffness, soft tissue scarring, or obesity. A management classification is described and almost all cases considered would fit into the “high-risk linear” or “high-risk complex” groups. Despite the complexity of the cases, the theoretical advantages of this technique such as reduced soft tissue tension, and increased fixator stability leading to faster and more reliable consolidation, appear to be borne out in practice. In nonpathological states bone healing indexes of 21.5 days/cm for tibias and 22.4 days/cm for femurs were recorded. A major problem is knee stiffness during femoral lengthening resulting from the proximity of the distal screws to the joint with transfixation of the fascia lata and vastus lateralis. Bifocal lengthening may well become a standard technique for lengthenings >6 cm.