Limb Lengthening Forum
Limb Lengthening Surgery => Limb Lengthening Discussions => Topic started by: maximize on April 08, 2015, 03:16:11 AM
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I've been thinking about LL for a while now. In particular, I was thinking about going to see Dr. Guichet about getting a femur lengthening for 3". I was not worried by the cost or even time/difficult recovery. But what concerns me is the prospect of debilitating knee/ankle/foot pain for the rest of my life.
Looking at the biomechanics I have come to the conclusion that misalignment of the joints is possibly inevitable with leg lengthening. This is due to the fact that legs are not straight lines. Legs have a natural inward angulation to them. When we grow as children, our entire legs including all of the joints are remodeling with every step we take to keep the axes of our joints flat and functionally correct. This same process does not happen when you are an adult doing LL. By lengthening one segment in isolation, it throws off the entire structure.
Whether this is going to be significant or not in terms of pain or disability I'm sure will vary from one person to another. I'm sure some people could get this done and never really notice it, either because they aren't doing anything demanding, or maybe their prior alignment was very favorable to the misalignment so they don't notice it.
What I have decided is that as much as I'd like to be 3" taller, it's not a viable option for me unless there is a better technique or something I'm not thinking of.
I've attached a very (VERY) crude diagram to show what I mean. Basically what you see is that in the "before", as well as the "LL non weight bearing" pictures, the joint lines are perfectly horizontal, as they are meant to function. However, once LL has occurred, the only way to maintain normal feet spacing when weight bearing is to then abduct the legs (open them outwards) ie. "LL weight bearing", which then puts ALL the joint lines on angles.
These joints are not meant to function with their axes on these abnormal planes. This is the source of x-legs and I believe the chronic knee and ankle pain many people experience even years post LL once their short term contractures and soft tissue trauma are dealt with.
(http://s28.postimg.org/no6h26oxp/xlegs.gif)
Opinions and further thoughts are very welcome. In particular I'm wondering if there are any LL procedures that can circumvent this issue. It seems inevitable to me. Further diagrams also would be nice if there is something I'm not thinking of. :)
Thanks all for the great forum and all the wonderful discussion. Whether I can get LL or not, I've enjoyed and appreciated it all.
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Interesting to see misalignment yet lengthening is for everybody.
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You can avoid this by lengthening tibiae instead of femurs. The tibia is a vertical bone so lengthening it doesn't change the angle of anything.
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That's called speculation.
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Given my muscle pain in my left leg that has proven hugely inconvenient. Permanent pains down the road are pretty scary prospects. That being said, the people who check back in and are fine seem to outweigh anyone who checks back in with horrible issues(and usually the latter are mysteriously under-documented).
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This has been discussed a few times on the forum, if you read the Dr Birkholtz thread he states this is the reason he doesn't like big lengthening's along the anatomical axis (femur). It is something that those who do LL have to take into consideration.
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Maybe if you're bow legged to start, you'll end up ok.
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You can avoid this by lengthening tibiae instead of femurs. The tibia is a vertical bone so lengthening it doesn't change the angle of anything.
I was thinking about this as well. I think lengtehing the tibia reduces the risk of this problem because it is more vertical than the femur. But it is not 100% vertical either. As per my (again, crude) diagrams, the tibia/fibula have a slight inward angle too.
If I stand straight or bend my unoperated knees a bit with my feet naturally apart, my midline of my knees are clearly slightly lateral to the ankles.
ie.:
(http://www.healthcare.siemens.com/siemens_hwem-hwem_ssxa_websites-context-root/wcm/idc/groups/public/@global/@imaging/@radio/documents/image/mdax/mzgz/~edisp/ysio_ortho_legs-00681688/~renditions/ysio_ortho_legs-00681688~8.jpg)
The theoretical advantage I wonder of doing tib/fib is that if you can control the lengthening in both segments, perhaps if you can lengthen the fibula more than the tibia, you can compensate for this a bit. But it will still throw off the mechanics again. And I understand tib/fib lengthening comes with it's own set of unique risks due to the more complex joint interactions at the knee/ankle. Furthermore, as in the xray below, the tibia can have some interesting natural curvatures to it. This means that the outcome in terms of angulation will vary largely on where it is nailed and where it is broken.
The only way I imagine to maintain full, normal mechanics at the knee and ankle would be to lengthen both the femur and the lower leg, and to somehow do the lengthening more on the outside than the inside of BOTH segments in proportion (which I think is impossible). This would then only throw off the hip a bit, but being a ball/socket joint, I think that would be fine. I can post a diagram to show later.
This has been discussed a few times on the forum, if you read the Dr Birkholtz thread he states this is the reason he doesn't like big lengthening's along the anatomical axis (femur). It is something that those who do LL have to take into consideration.
Thanks. I might have read that already. I'll look again.
Given my muscle pain in my left leg that has proven hugely inconvenient. Permanent pains down the road are pretty scary prospects. That being said, the people who check back in and are fine seem to outweigh anyone who checks back in with horrible issues(and usually the latter are mysteriously under-documented).
I hope you do okay. To be clear I don't think this kind of tiny misalignment would usually cause "horrible issues". I think it would cause the kind of nagging stiffness and achiness that a lot of the diaries I've read seem to end with. This is the sort of stuff you take a tylenol for and keep going. It's sort of stuff most 65-70 year olds have to deal with due to wear and tear. But it's not the sort of stuff most 30 year olds need to worry about.
Maybe if you're bow legged to start, you'll end up ok.
Yeah, I was thinking this perhaps might be true as well.
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We learned that femur lengthening may cause premature arthritis some time ago, however, I have yet to hear from someone who have actually experienced it. Most likely this is an issue over a longer timespan, perhaps 15-30 years post-operation. Indeed this might have been one of the issues the australian bone specialist referred to in that earlier thread made by a discouraged LL-prospect a few weeks ago.
Certainly unnerving but at least joint misalgnment are often treatable, though this is something I will have to learn more of.
Interesting to see misalignment yet lengthening is for everybody.
u r 1 cheeky kont m8
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I would love to hear what Dr. Guichet would have to say about this, since as I understand it, he is now the foremost and most reputable femur lengthener out there. Is anyone in contact or consult process with him that can ask?
As much as this concept of misalignment and x-legs (genu valgum) worries me, I still wish I could get the surgery. I guess one has to weigh how much the psychological pain of being short is relative to the physical pain of having possible chronic joint aches. I'm not sure how to weigh that now.
Also making it difficult to decide, you have the rare specimen like ShyShy who seems to have developed some mild x-legs but yet is functioning well with them. Here's his xray at 1" lengthening and you can already see it developing:
(http://img.imagesia.com/fichiers/jh/day14_imagesia-com_jhpr_large.jpg)
Here's his final picture and it's somewhat evident, but hard to fully judge in this posture:
(http://img.imagesia.com/fichiers/jw/dscn0144_imagesia-com_jwbe_large.jpg)
I honestly don't know what to do with this realization. I will always dream to be taller. I may always wish to lengthen. We all have that drive. But would we regret it when our knees still ache 5-10 years from now?
I would say the solution is to stick to tibias. But tibias are on a slight angle too, so that's not going to stop this effect completely. Also, the complexity of tibia lengthening is greater, as you have to worry about the tibiofibular joints, and the articulation with the ankle which is a more complex joint than the knee/hip. Sometimes with tibias, people get abnormal rotation of the feet (intoeing, outtoeing), and a lot of the people that really get butchered seem to be tibial surgeries. Plus tibias are slower.
How do you guys feel about all of this? How does it affect your decision making process? What are the odds any of us will end up as functional as ShyShy once we too have some degree of x-legs (genu valgum) or intoeing/outtoeing?
I've read so many diaries and almost all of them seem to end with "my knees/ankles still get stiff and/or sore but I'm moving on with my life now so I'm not going to be posting further." What percent do you think tolerate this misalignment without any pain or discomfort at all?
The more I think about this issue the more distraught I become because I can think of no real good solution. :-\
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The best you can do is research the complications and weigh the risks. It comes down to how serious your height neurosis is. Remember theres worse things that can happen than joint pain too.
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As you've already lengthened your legs in Russia, why don't you tell us what Dr Bagirov says about this.
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The best you can do is research the complications and weigh the risks. It comes down to how serious your height neurosis is. Remember theres worse things that can happen than joint pain too.
Yeah I know about the worst that can happen. Nonunions. Nerve damage. Avascular necrosis. Broken nails. But knowing that I'd be going with a top surgeon like Guichet if I did anything, I'm not really worried about that stuff. What bothers me mentally is the idea that even in a best case scenario I may not be able to avoid chronic joint pain, and that this is not going to be predictable. I don't have bowlegs. So my alignment would be worsened by going to x-legs.
For reference I found Dr. Birkholz's discussion on the mechanical axis here:
http://www.limblengtheningforum.com/index.php?topic=137.msg6963#msg6963
To quote the most relevant passage:
Question: "So your saying if anyone does 8cm on their femurs they WILL get knee pain and arthritis in the future?
Answer: "No, they will get a change in alignment. This may lead to knee pain and arthritis. It is very individual, but we cannot really predict who will and who wont."
I am thinking internal femurs may be not a good tradeoff. Yes they're faster and simpler. But even done perfectly, they create the greatest shift in mechanical axis.
I'm going to look a bit further into tibial. I see the Guichet and Precise nails can both be used in tibias, though I've never seen diaries with anyone getting either. Those seem like the best tibial options for those of us who don't want or can't afford a cage and wheelchair. Again I haven't found any diaries/experiences for either though. If anyone has any good links on the subjects I'd appreciate it.
I think femur is just going to be off the table for me. I want the height, speed, and ease, but not the inevitable misalignment. The best case scenario with femurs is still too risky. With tibias I'm worried by the stories I read of intoeing/outtoeing. But at least with tibias, theoretically if it's done well, the mechanical axis is almost perfectly preserved.
Things like ballerina ankle on tibial lengthening also don't worry me because it's a soft tissue issue which should eventually stretch out and resolve if you are young/healthy/diligent and do adequate pre-stretching. It's the bone misalignments that are most worrisome, because those are not physio-correctable. And the bone misalignments seem unavoidably greatest with internal femurs.
Overall, looking at the situation, I think I would rather take a few months extra and do internal tibias, even settling for a smaller growth, if it comes with a probability of less mechanical axis disruption. I expect I will eventually in a year or so be going for consults on this. I already know I will never be happy at my current height. I can raise these questions with the surgeons I'm looking at (Paley, Guichet) then. But that's a long time from now. If anyone is having any interactions with their respective surgeons before then and can see what they say, it could be helpful to a lot of us.
I wish there was some perfect solution. I wish we could all be tall and not have to take these giant risks. But in a way we're lucky because LL has never been more advanced or safer. We just have to do our homework now to find and pick the safest routes, since there are so many choices. :-\
Thanks for the feedback, guys. Any other thoughts on all this would be very welcome.
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Not every person has hurt knees. Some have none knee pain after lengthen.
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no knee pain here
btw... if that x ray is considered minor valgus... my left leg is badddddddd.... its much worse than that.... much
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i was going to post an x ray photo to show how my left leg looks... but u cant even upload a photo here
its really annoying... i dont have a photobucket account... but to post any media here,it seems one must create other accounts
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maybe this works
this is not my x ray..
my right leg is fine.. but my left leg x ray from the front looks like this, but mine might be worse
https://www.google.com/search?q=genu+valgum&espv=2&biw=1435&bih=702&source=lnms&tbm=isch&sa=X&ei=FnMlVcaxGYTUsAWp3YGAAg&ved=0CAYQ_AUoAQ#imgrc=tCZP1r09_ym45M%253A%3BTHHwIqgUUGFFJM%3Bhttp%253A%252F%252Fwww.bjj.boneandjoint.org.uk%252Fcontent%252F92-B%252F2%252F273%252FF1%252Fgraphic-1.large.jpg%3Bhttp%253A%252F%252Fwww.boneandjoint.org.uk%252Fcontent%252Ffig-1a-fig-1b-244%3B783%3B1280
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i was going to post an x ray photo to show how my left leg looks... but u cant even upload a photo here
I use this free upload service with no account needed:
http://postimage.org/
Agreed though it's annoying you can't attach directly here since it means none of these photos will reliably be here in 5 years when someone else is looking to read this.
I'd love to see your xrays if you can post them there. Also please let us know how your joints feel. Hope you're doing okay enough.
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if you look above, the front of my x ray looks like that... but only left leg
no aches, but getting leg fixed... its gotta be hurting my walking
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if you look above, the front of my x ray looks like that... but only left leg
no aches, but getting leg fixed... its gotta be hurting my walking
This happened from external tibial extension for you? Did you ever ask your surgeon why they thought it might have occurred? I've read that the Chinese external tibial lengthening procedures allow you to control the medial vs lateral length of the tibia to try and avoid this kind of gross misalignment.
What do you think went wrong in your case? What is your surgeon offering you?
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the person responsible for it... in india... is not offering anything
hed fix it if i paid him full price lol
so getting it done in by a top dr now
can get it fixed in 1 surgery
u do think its bad though... look at it... and thats not it
the side view has a bad alignment as well
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To add another example like ShyShy, here's Christopherbulder who had 7 cm femur lengthening by Guichet and says after 12 years he is "100%".
http://www.limblengtheningforum.com/index.php?topic=2046.36
It's hard to tell with all that muscle, but the alignment really does look good stationary:
https://www.youtube.com/watch?v=J_kkiqWRVvE
Walking looks a bit peculiar, though that could possibly be just because he's so buff/bulky, rather than due to any misalignment:
https://www.youtube.com/watch?v=31aF-Ovbx70
I wonder if any of this (how bad the resulting misalignment will be) is predictable based on the angles of preop xrays? The femurs are just so fast and effective if there was any way to know you could get a result like this with good alignment it would still be the best option. Tibias are just so slow.
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Okay. I just had a shower and after staring down at my legs for 20 minutes here's my final thoughts for now, as I have to get back to work.
This misalignment problem stems from lengthening the bones along their lengthwise axes ie. via internal implants. Internal implants offer numerous obvious benefits. In particular, they are fast, less prone to infection, and can often allow weightbearing. It is no wonder surgeons and patients find them preferrable. However, if the goal is to maintain the biomechanical axis of the legs, this is not the ideal method.
Under perfect circumstances, a more perfect result can theoretically be obtained via an external Ilizarov apparatus, since an Ilizarov can lengthen along a perfect perpendicular up-down plane to maintain the joint axes in their natural positions. Nothing is necessarily tilted with an Ilizarov, because it can function to affect change in almost any direction.
eg. With fractures:
http://www.llrs.org/images/004.JPG
Now obviously, there are downsides to Ilizarov. It is slow. It requires wheelchairs. Infection and scarring risks are high. Bone fractures/splintering can occur. And there have been a lot of people who have been butchered by crapty Ilizarov surgeons. Perhaps it is difficult to precisely control the direction of distraction with some of these devices? I'm not sure. A lot of people have gotten bent legs or broken nails out of Betz internals too.
At least theoretically, in terms of maintaining natural joint alignment, after everything we've discussed in this thread, Ilizarov seems to have the possibility of being a much better ideal outcome for someone starting with normal knee alignment. I would have to study the mechanics of the Ilizarov a bit better, but I think the outcome would depend largely on exactly how and at what angle the apparatus is fixed into the bone.
I'm curious what you guys think about this concept.
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Jeez, dude. Stop thinking so much into this. With such hypochondric attitude you should definitely forget about doing LL. The lateral shift is just about 1 mm per cm lengthened in femurs. There're no studies that actually show or conclude that it does indeed cause knee pain. And how does it even make sense? What about people who are naturally long-legged and have long femurs, do they all suffer from arthrisis? Because wouldn't it be the same, as if someone short-legged lengthened their legs (femurs)?
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Jeez, dude. Stop thinking so much into this. With such hypochondric attitude you should definitely forget about doing LL. The lateral shift is just about 1 mm per cm lengthened in femurs. There're no studies that actually show or conclude that it does indeed cause knee pain. And how does it even make sense? What about people who are naturally long-legged and have long femurs, do they all suffer from arthrisis? Because wouldn't it be the same, as if someone short-legged lengthened their legs (femurs)?
No it is not the same. That's the whole point of the diagram. As I said, when you grow naturally, your growth plates shift to compensate for your growth when weight bearing so that your hinge joints (knees/ankles) will remain parallel to the ground.
This does not happen in leg lengthening because we no longer have growth plates.
I don't think analyzing the risks and benefits of a $80,000-100,000 operation that requires up to 1 year off work being a "hypochondriac". I think it is stupid not to think about all this, when there are so many choices and options out there. And when this is purely cosmetic.
For anyone who actually finds this discussion or these concepts interesting, I've updated my diagram with the Ilizarov. As you can see, at least theoretically, it does offer the advantage of maintaining perfect biomechanical axis. By comparison, all internal lengthening devices will throw off the axis (by definition) to some extent unless you have a favorable (varus) misalignment to begin with.
See next post.
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(http://s2.postimg.org/6b94w2i49/xlegs2.gif)
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As I said, when you grow naturally, your growth plates shift to compensate for your weight bearing so that your hinge joints (knees/ankles) will remain parallel to the ground.
Do you have just any data to back that assumption up? It just sounds like you're taking this out of your ass, sorry.
(We need PЯOOFS)
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Do you have just any data to back that assumption up? It just sounds like you're taking this out of your ass, sorry.
(We need PЯOOFS)
This is simply how growth occurs. The growth plate responds to the pressure of weight bearing and muscular pressures around it. This is why kids with cerebral palsy end up with warped bones as they grow. It's also why physio is so important for kids with spinal cord injuries.
You can get abnormalities irrespective (eg. scoliosis), but the hinge joints (knee, and mostly ankle) are BIOLOGICALLY DESIGNED to work along a flat plane. It is not natural to need to tilt that due to internal femur leg lengthening as shown. By definition, it will create some degree of valgus deformity, and you will have to compensate for that. How big the deformity and how well you compensate is obviously individual.
Dr. Birkholz has said the same thing about how this misalignment happens with internal lengthening as quoted here:
http://www.limblengtheningforum.com/index.php?topic=2090.msg33500#msg33500
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I think risking some pains in the future due to misalignment from internal LL is probably better than dealing with the complications of external femur lengthening. Even Dr Birkholtz said that internal femur lengthening is preferable to external femur lengthening, even though the latter doesn't give you the misalignment problem.
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I think risking some pains in the future due to misalignment from internal LL is probably better than dealing with the complications of external femur lengthening. Even Dr Birkholtz said that internal femur lengthening is preferable to external femur lengthening, even though the latter doesn't give you the misalignment problem.
Certainly for femur I understand external lengthening is not a viable option. But the question I am now wondering is if we should be going back to whatever the best modern external Ilizarov tibial lengthening option is, rather than internal femurs. It may still be that the risks of any Ilizarov procedure outweigh the valgum (x-legs) problem of internal lengthening. Again, I know a lot of people have been butchered by bad Ilizarovs. But for a good Ilizarov if such a thing exists I'm not sure.
The thought of getting leg lengthening AND preserving anatomic function of all the joints is appealing, even if it costs more time and requires you to pop more antibiotics.
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This is simply how growth occurs.
This ain't no proof. You didn't give me any links or studies regarding what you're claiming with 100% confidence.
I think risking some pains in the future due to misalignment from internal LL is probably better than dealing with the complications of external femur lengthening. Even Dr Birkholtz said that internal femur lengthening is preferable to external femur lengthening, even though the latter doesn't give you the misalignment problem.
To be fair, if you assume the misalignment problem is real and it causes long-term knee pain, external femurs would indeed be totally superior. Complications of external femur lengthening are the same as with internal lengthening, plus general complications of external fixation, but nothing specific to external femurs, expect temporary ROM limitations. The main problem of EFL I consider is discomfort. I'm talking about classic Ilizarov frames here, no monorail. But then again the 'misaligment problem' is highly speculative.
Also... I've heard Dr. Mongral talking about nail insertion and fixation under an angle, so actually you don't need externals anyway. It's just that we don't see surgeons (even the best ones) doing it. Must have something to do with them also viewing the 'misaligment problem' as speculative, idk.
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Also... I've heard Dr. Mongral talking about nail insertion and fixation under an angle, so actually you don't need externals anyway. It's just that we don't see surgeons (even the best ones) doing it. Must have something to do with them also viewing the 'misaligment problem' as speculative, idk.
That's an interesting idea. Putting a nail in on an angle however wouldn't be sufficient to circumvent this issue for femurs, since femurs are on such a great angle already. But for tibias, theoretically it could work. Problems would be passing the nail through the tibia such that the nail is perfectly perpendicular to the ground when standing normally, while still having that nail confidently placed such that it's not deviating too far from one side of the bone to the other as it transits through the tibia.
Intramedullary rods are meant to be just that - intramedullary. Putting the lengthening rod through even a tibia on a perpendicular to the ground would require it to drill extensively through the cortical bone which would decrease confidence in ability to tolerate weight bearing and increase risk of the bone splintering/fracturing when weight bearing occurs.
In that case, you would lose most of the benefits of having the internal fixation in the first place. Though it might still be a valid option if the surgeons don't mind drilling it so that large portions are running through the cortex, with a more cautious protocol regarding weight bearing.
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itsmylife
yet again....
sigh
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yes i think its my life has come back...again :-\
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I have no idea who that is. Nor do I understand what the problem would be with trying to identify and work through pros and cons of different surgical approaches on a site dedicated to discussing leg lengthening.
I had not seen anyone diagram this potential issue before or have a focussed discussion about it. I had some ideas I wanted to share and stimulate further thoughts about. If you don't think the discussion is useful, you don't need to participate.
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its my life, just give up, and give us a break now
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yes i think its my life has come back...again :-\
Don't be paranoid they write nothing alike, ItsMyLife lacks the emotional intelligence to fake a different personality.
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they have exactly the same personality
paranoid.. fixated on every possible worst case scenario and also overposting
this person just got here and is on pace to post over 20 times today... this fits the pattern
the writing is somewhat different, and could be a different person... but theres very strong similarities
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its my life, just give up, and give us a break now
Anyone want to give me the brief notes on who this is and why people are finding this discussion problematic?
I'm guessing it's because talking about possible negatives of different surgeries is considered a faux pas?
Is it better to never think about this stuff and then end up surprised you have x legs after 3 inch internal femurs are done?
As for my posting style, I'm posting a lot because I've been thinking about this a lot, and I'm sharing my thoughts as I go. I've contained all my posts to one thread so I don't see a problem, and I'm pretty much done talking now because I've said everything that I was wondering about.
Now I'm just curious if we can stop trying to analyze each other's personalities and actually discuss the alignment issue with external vs internal fixation. I'm still curious for any thoughts.
In particular I'm wondering if there are modern safe Ilizarov procedures that could be better long term alignment options than the current gold standard of Guichet internal femurs.
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come on guys. what kind of talk do you want to hear on this forum then?
rants? proportions? "how does it feel after LL?"? "new LL doctor in Antartica"?
being educated about what you're planning to go through is not a bad idea.
he's not trying to advertise anything you see...
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it's the obsession
ithere will be always some kind of minor issue with this surgery... it's a given... theres no need to even discuss it
if someone is looking for the perfect way to get this surgery... it becomes tiresome..... theres no perfect way... i honestly dont think theres even a superior way.. they all have pros and cons
anyone who needs to find a way to have the perfect outcome is not going to have this surgery
you have to take the risks involved... there's no mathematical way to analyze this and improve outcome... its very simple
try to be prepared
pick a good dr
have good aftercare
accept reality that it takes time to get recovered
its that simple
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To be fair, if you assume the misalignment problem is real and it causes long-term knee pain, external femurs would indeed be totally superior. Complications of external femur lengthening are the same as with internal lengthening, plus general complications of external fixation, but nothing specific to external femurs, expect temporary ROM limitations. The main problem of EFL I consider is discomfort. I'm talking about classic Ilizarov frames here, no monorail. But then again the 'misaligment problem' is highly speculative.
There has to be some reason why many highly regarded limb lengthening surgeons prefer internal femurs to external femurs, though, despite the mechanical axis deviation issue present with internals. Even Drs Herzenberg and Paley won't do external femurs for cosmetic reasons, and they did the study about mechanical axis deviation with internal femur nailing: http://www.ncbi.nlm.nih.gov/pubmed/22933497
I want to e-mail Dr Paley about it but he probably won't go into detail unless I book a consultation with him.
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There has to be some reason why many highly regarded limb lengthening surgeons prefer internal femurs to external femurs, though, despite the mechanical axis deviation issue present with internals. Even Drs Herzenberg and Paley won't do external femurs for cosmetic reasons, and they did the study about mechanical axis deviation with internal femur nailing: http://www.ncbi.nlm.nih.gov/pubmed/22933497
Thank you very much for that reference. That's a really good way of quantifying it. So for a 7.5 cm internal femur lengthening, you get a 7.5 mm deviation of the axis.
At the risk of further irritating those who think I talk too much, ;) I'm going to speculate on the question you raise, because I think it's interesting. I think the reasons these reputable surgeons love internal femurs are the following:
1) They are fast
2) They are very reliable and give predictable results
3) Less infection
4) Less nonweightbearing time, which leads to less depression and atrophy
5) Few surgeries required in most cases
6) Less surgeon-dependent "maintenance" than an Ilizarov that requires regular adjustment and monitoring
The "cost" of having a slight misalignment of the mechanical axis is mostly paid by the patient, not the surgeon. The surgeon has already told you there is a risk of arthritis or joint aches, so it is not really his direct problem or liability if a mild genu valgum deformity leads to those mild complications for you over the next few years.
The surgeon's liability is more related to the acute recovery period - contractures, limb deformities, fractures, infections, etc. So from a surgeon's perspective, it makes sense to favor an approach with the most consistent results and fewest short term problems. Even from a patient perspective this may be ideal. Many patients will still probably be happy with internal femurs even if they get mild chronic knee pain because the surgery and recovery can go so relatively smooth, and they got their height without losing a limb.
But for those of us who really want to try to maintain our joint axes in normal alignment, I am thinking the most ideal available option may be tibial LATN. This approach involves lengthening based on an Ilizarov cage, which in the right hands should be able to let you lengthen as in my diagram above, without shifting the axes at all (though margin of error of Ilizarov is unknown to me at this time). Then with the nailing after the lengthening, you get the benefits of early weightbearing and less nonunion. Personally, I also think the long tibia looks better than the long femur, though I know this is subjective and not that important in the scheme of things.
Disadvantage of tibial LATN is primarily it's slower than femoral internals, there's still some total down time, and you have pin infections/risk. Also, I imagine it's more difficult for the surgeon, and requires more skill and monitoring to get a good result, as an Ilizarov can require periodic readjustments to maintain axis. You are at your surgeon's mercy with this approach to get it correct.
Issues with LATN I want to understand better would be: What is the margin of error with the Ilizarov distraction? ie. Can it reliably produce a straight vertical lengthening without significant axis/rotational deviations? Also how well do the talotibial, talofibular, and tibiofibular (ie. ankle) joints typically function after tibial LATN?
A femoral LATN would be another option but most seem to avoid Ilizarov cages on the upper leg due to how cumbersome they become and difficulties with moving around, wheelchairs, etc in them.
Then after a perfectly done tibial LATN, a tibial internal nail like Precise 2 or Guichet would provide potentially the next least amount of mechanical misalignment.
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I have emailed a handful of lengthening doctors about this a few minutes ago. Mainly just asking if there are any permanent complications of external femurs or LON/LATN femurs with monorail. If there are not aside from more pain and more physical therapy required then I think I might opt for external femurs anyway. Bluebarbie is doing it and I hope she makes a good recovery.
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I have emailed a handful of lengthening doctors about this a few minutes ago. Mainly just asking if there are any permanent complications of external femurs or LON/LATN femurs with monorail. If there are not aside from more pain and more physical therapy required then I think I might opt for external femurs anyway. Bluebarbie is doing it and I hope she makes a good recovery.
Cool. Thanks Sean. From what I understand of the procedure, LON will cause the same axis deviation as internal nails, since again, you will be lengthening purely along the tilted axis of the bone, and not in a straight up and down plain as I think is more desirable to maintain joint alignment. Not sure about monorail.
Bottom line I'm thinking for me at this point:
- Internal femurs: Predictable and safe but they guarantee axis deviation (which may or may not be a problem for each person).
- Internal tibias: Theoretically would offer less axis deviation than internal femursand also likely be safe but no one is doing these because they're slow and more complicated to administer than internal femurs (adds complexity of patella, fibula, ankle).
- LATN tibias: Not as predictable or as safe as internals and again brings in the patella, fibula, ankle complexity, but has the potential if done well for perfect post op joint alignment.
- LATN femurs: No one seems to really want to touch these, but they might be best of all for the joints if they can be done safely and well, since you can theoretically maintain the axis perfectly, and it avoids the ankle, patella, and fibula. Any significant error in axis, rotation, or angulation to the femur is going to be a real problem though so precision is key.
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Well Dr Singh in Singapore is doing LATN femurs for Bluebarbie so perhaps they aren't so dangerous. And he's letting her go to 7 cm. If she has a good result it will make me confident enough to go that route.
I think doing LATN femurs gives you crooked femur bones though.
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Well Dr Singh in Singapore is doing LATN femurs for Bluebarbie so perhaps they aren't so dangerous. And he's letting her go to 7 cm. If she has a good result it will make me confident enough to go that route.
I think doing LATN femurs gives you crooked femur bones though.
Crooked would be fine if it's the right kind of crooked. This is how I imagine it should be (exaggerated of course). In real life the distortion would be more subtle, so they should still be able to put a nail down it to fix it once positioned.
(http://s14.postimg.org/3ygp54opt/femur_latn.gif)
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Knee pain is a very real risk when doing internal tibias.
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I'll have to post pictures in my diary at some point....but I don't have x-legs when I stand with my feet apart after internal femurs. However, I think for me this is due to my having genu varum (bow legs) before LL, which LL indirectly improved (in my case). My knees are closer together, yes, but when I stand with feet apart, I don't have x-legs the way Shy seems to a bit.
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Even Drs Herzenberg and Paley won't do external femurs for cosmetic reasons, and they did the study about mechanical axis deviation with internal femur nailing: http://www.ncbi.nlm.nih.gov/pubmed/22933497
I want to e-mail Dr Paley about it but he probably won't go into detail unless I book a consultation with him.
Hi Kilokahn,
I e-mailed Dr. Paley a few hours ago asking about the safety of doing LATN femurs and linked him to the study you posted about mechanical axis deviation. I just got a reply from him.
E-mail sent to me by Dr. Paley. Those concerned about this issue should read below.
This is the response I received from Dr. Dror Paley:
"The methods of combining ex fix and internal fixation were developed by me. I used to use these methods. I no longer use these for cosmetic lengthening. The results with Precice are second to none and the issue of axial deviation over a nail is a non issue despite my publication. We have a new publication that will come out in Sept that will lay that issue to rest. If I were doing this procedure today I would NEVER consider using an ex fix. I would only do it with the newest, SAFEST, and fastest method for efficacy and recovery. That method right now is the Precice. We use the P2.1 which is the newest model. I would recommend that if you are serious about this come in for a consultation and also read the attached material."
I can attach a screenshot of the e-mail if you guys need proof.
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Nice one. Checkmate, OP.
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Well let's wait for the study. ;D
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As someone planning femur lengthening I want what Paley's saying to be true which seems to be that lengthening internal femur does not cause misalignment. However, why have other doctors been saying it does? Why have patients who were bow legged noticed change in their alignment after doing internal femurs if it supposedly doesn't alter anything? Does Paley have a deal going with Precise? This is fundamental geometry here lengthening along the anatomical axis would clearly shift the alignment. I look forward to reading his paper.
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My back is fked up someone made a post about that, I just dead ATG squats for 4 plates without proper form. Hey if you LL you probably aren't doing worse for yourself then a power lifter + juice jus sayin.
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I don't think Dr. Paley was saying it doesn't cause a misalignment, but that whatever misalignment caused is a non-issue or won't cause premature arthritis like is thought. I'm eager to read his publication coming out though.
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Thanks again for contacting Dr. Paley, Sean. That was a helpful reply. It followed mostly along what I expected him to say: internal LL is faster, safer, more reliable, etc. But it's good to hear it direct from a guy with so much experience/expertise. I think he does have an arrangement with Precise. He installed the first Precise nails in existence, and I presume he's worked with them to create the device. He may even own some of the invention, though I really don't know and don't care too much. I trust Paley is saying what he truly believes. He seems like a very ethical man who is committed to getting the best results for his patients.
I've been thinking continually about all of this and I have a number of further thoughts.
Tibial Lengthening and the Anatomical Axis
I've looked at it in more detail, and it appears the angulation of the tibias in a healthy anatomically correct person are far more vertical than I was giving them credit for. For example, in this xray here, we see the tibias are practically perfectly vertical. The only abnormality to them is that they have a somewhat "S" shaped curvature. But from direct top to bottom it is virtually perfectly vertical. The femurs by contrast are on an approximately 7-9° angle.
(http://s12.postimg.org/qwkjwl2t9/full_leg.jpg)
Here's another interesting xray of a person with bow legs (perhaps much like YellowSpike was preop), which was fixed via a high tibial osteotomy. I find it interesting, because they probably could have gotten close to the same correction from an internal femur lengthening. But the point is, in the post op xray, the tibias are now almost perfectly vertical, as it seems they probably ought to have been. The femurs appear to be post op at approximately 5°.
(http://www.cumbriankneeclinic.co.uk/images/leg-xray-showing-high-tibial-osteotomy.png)
The verticality of normal tibias is important because it means that well done internal tibias should properly preserve the anatomical axis of the hips/knees/ankles. It would therefore not be necessary to use Ilizarovs to keep the alignment.
I am fixated on maintaining alignment for a number of reasons which should be obvious but I'll touch on later. Internal tibias (for myself) may then be a favorable approach. Uppland, you say knee pain is a real possibility with internal tibias. The question is exactly why, and whether this is due to soft tissue pain which may resolve with physio or bone damage/deformity that is permanent. Further questions I want to answer include:
- How slow will an internal tibia be?
- Would an internal Guichet tibia be better than an internal Precise tibia, since Guichet is more weight bearing?
- How exactly is the rod drilled into the tibia? If it is inserted in any way that damages the articular surface of the tibia, that's going to be the fastest way to knee arthritis, so then this option becomes less appealing.
- Does the lack of a full nail through the fibula predispose the fibula to deformity during this procedure that could lead to ankle arthritis long term?
Internal vs External Femurs
I looked at Bluebarbie's thread and honestly I'm sorry to say I am horrified at what has been done to her. I think her thread is a perfect (unfortunate) example of why monorails shouldn't be used. The surgeons have installed the monorails on a massive angle in one of her legs, and now they have no way to correct this. They have told her "it will be fixed when the nail is inserted". But in the meantime she is developing bone callous which will start consolidating. There is no controlled or accurate way they will be able to fix this misalignment during the nailing process. What they are telling her makes no sense.
She's wealthy. If I was her, I'd be sending my xrays to Paley or Guichet and asking them what they can do to fix it ASAP, perhaps in this case via external Ilizarov. I don't mean to sound cynical or unsupportive but I think she looks like she's getting butchered, and if she doesn't do something soon she will regret it. I'm going to tell her that too.
Ilizarov externals have so many adjustable attachments to the bone it can shift the bone in almost any direction to correct misalignments like what Barbie's going through now. So for her now that might actually be a good corrective option.
But reviewing threads from people who have had them for primary lengthening in Russia, China, etc. I am beginning to understand better why the modern surgeons are less eager to rely on them. Bluecrimson in his thread was saying it can take up to 2 years to get back to "normal" from what he's seen.
They do seem to perform external femur Ilizarovs at the Ilizarov Scientific Centre in Russia. If I were to get Ilizarovs, I presume that's where I'd get them. But if the surgeons control the axis during such Ilizarovs by serial xray and approximation, it becomes such an almost artistic endeavor since it depends so much on the skill and attentiveness/awareness of the surgeon. That can be dangerous, which is probably part of why Paley doesn't want to touch them unless to correct deformity.
(http://i.dailymail.co.uk/i/pix/2008/07/28/article-0-02198F0A00000578-248_468x286.jpg)
http://www.dailymail.co.uk/health/article-1039416/Tall-order-The-bizarre-Russian-clinic-offers-leg-lengthening-surgery-STAND-pain.html
Paley's Pending Study:
I agree with Sean that Paley's not saying the axis deviation doesn't happen. Rather, he's saying it's a "nonissue". Like everyone else, I am eager to see what he plans to publish to show this. I expect it will be reassuring. However, I don't think he will be able to truly prove that this deviation is is a nonissue. The Precise is too new a device. The only way to prove it's a nonissue would be to follow a cohort of Precise femur lengthened patients for 20 years and then show they don't have increased arthritis or knee pain rates. No one can do that though because the technique hasn't existed long enough.
What I'm guessing he's going to be publishing instead is a comparison of maybe 20 patients lengthened by tibial Ilizarov to 20 patients lengthened by internal Precise femur and show that the knee pain, stiffness, and range of motion is not significantly different between both groups after 1-2 years or so. That would be useful to see, but it still wouldn't completely put to rest concerns about the genu valgum deviation of internal femurs.
A genu valgum deformity/deviation will put increased stress on the lateral compartments of the knee and ankle. As theuprising phrased it, this is again a matter of fundamental geometry. The only way to know what the long term effects are is to wait 20 years. But we shouldn't even need to do that. Most orthopedic surgeons can tell you that genu varum puts you at risk for medial compartment arthritis, and genu valgum puts you at risk for lateral compartment arthritis. I simply can't see a way around this. The weight bearing through the two knee compartments needs to be balanced to maintain the longest duration of joint health.
(http://odra.ca/wp-content/uploads/2012/09/GenuValgum_Varum2.jpg)
As I've said, I really want to be taller. But personally I'm not yet so desperate I'm willing to take the risk that an axis deviation could lead to knee/ankle/hip problems in the long run. Right now, I'm putting my hopes into the possibility of Guichet/Paley tibial internals. I'm looking into more detail at the operative techniques linked here:
http://ellipse-tech.com/precice-physicians/
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I don't think Dr. Paley was saying it doesn't cause a misalignment, but that whatever misalignment caused is a non-issue or won't cause premature arthritis like is thought. I'm eager to read his publication coming out though.
I remember in my consultation with him he actually said that the mis alignment would fix my slight bow legs as a freebie.
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I remember in my consultation with him he actually said that the mis alignment would fix my slight bow legs as a freebie.
TRS could explain this better than me so if you're reading feel free to correct any details but I'll give it a shot. There is alignment issues not only from hip to knee but also from knee to ankle. In TRS case his femur lengthening resolved his hip to knee misalignment but he still had his bow leg issues which would have to be resolved through tibial realignment surgery.
What I'm saying is your bow legs will still exist it's that the femur lengthening pushed your knees together. The knee to ankle alignment will still be out.
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(http://i.dailymail.co.uk/i/pix/2008/07/28/article-0-02198F0A00000578-248_468x286.jpg)
Holy crap is that external bilateral femurs? I'd like to see her walking!
The only way to prove it's a nonissue would be to follow a cohort of Precise femur lengthened patients for 20 years and then show they don't have increased arthritis or knee pain rates. No one can do that though because the technique hasn't existed long enough.
I think they call it 'argument from ignorance'. It has never been established that internal femoral lengthening does indeed cause knee arthrisis due to a lateral shift of the axis. But you're asking him to prove it wrong, when it's merely speculation.
They have told her "it will be fixed when the nail is inserted". But in the meantime she is developing bone callous which will start consolidating. There is no controlled or accurate way they will be able to fix this misalignment during the nailing process. What they are telling her makes no sense.
The funny thing is that the misaligment she has developed is actually a 'good one', which follows her mechanical axis. So she can let it heal in that way and it will be OK. Though... on the right leg I'm afraid the valgus is too strong, so her feet will shift out instead. I too I'm wondering how they're going to insert the nail with such a misaligment. But could be they know something we don't.
Most orthopedic surgeons can tell you that genu varum puts you at risk for medial compartment arthritis, and genu valgum puts you at risk for lateral compartment arthritis. I simply can't see a way around this
The thing is, even when going for the 'max amounts', which I'd say is 7-8 cms, the lateral shift is quite small. You aren't going to develop a genu valgum or a 'knock knee' or 'x legs', because of a 7 mm lateral shift. To get something like on that picture you'll have to lengthen really a lot. The difference between pic 1 (normal) and pic 2 (genu valgum) is a whooping 15 degrees in tibia angle. Just imagine how much lengthening you'd need in your femurs to bring your tibias from 0 to 15 degrees. Though there's one thing I want to point out: the amount of later shift depends also on your femur angulation, females should expect a higher lateral shift.
Plus, any lateral shift that you'd get after internal femoral lengthening you could compensate by lengthening tibias externally and correcting them to a valgus. As your feet shift in when you lengthen femurs by anatomical axis, you shift them out with external tibias. Problem solved.
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I remember in my consultation with him he actually said that the mis alignment would fix my slight bow legs as a freebie.
I think those of you with bowlegs (genu varum) are lucky. You might be the only "ideal" candidates for internal femurs in terms of potentially improving rather than worsening the mechanical axis.
There is alignment issues not only from hip to knee but also from knee to ankle. In TRS case his femur lengthening resolved his hip to knee misalignment but he still had his bow leg issues which would have to be resolved through tibial realignment surgery.
What I'm saying is your bow legs will still exist it's that the femur lengthening pushed your knees together. The knee to ankle alignment will still be out.
If you have varus knees (bowlegged) but the horizontal plane of the knee and ankle are perfectly flat (horizontal) in this position, then pushing the knee inward will still tilt both of these planes on a slight angle like I showed in my earlier diagrams. On the plus side, the hip will now be more vertically aligned with the knee/ankle. Whether this is overall a plus or minus is hard to conceptualize. I think you'd have to look at all the exact details of an individual's particular planes/angles.
I think they call it 'argument from ignorance'. It has never been established that internal femoral lengthening does indeed cause knee arthrisis due to a lateral shift of the axis. But you're asking him to prove it wrong, when it's merely speculation.
As to whether this discussion is "argument from ignorance", I would strongly disagree. I will let some quotes from the following eMedicine article speak for me. If you like, the article has full journal references so you can see where they got their information from. It is a reputable medical reference site even among doctors.
Ref: http://emedicine.medscape.com/article/1251668-overview
"The anatomic axis of the lower extremity is defined by the femorotibial angle, which averages 5° of valgus."[/b] (ie. In normal people, there is a 5° femur angulation relative to the tibia.)
"During normal gait, adduction places force predominantly on the medial compartment.[4, 5, 6, 7, 8, 9, 10] For weight-bearing stresses to be shifted to the lateral tibial plateau of the knee requires the development of a valgus deformity." (ie. Usually walking stresses the medial compartment and that's usually where OA (osteoarthritis) develops. Almost the only time you will develop lateral compartment OA is when you have a valgus deformity.)
"Usually, a genu valgum deformity is the result of a dysplastic lateral femoral condyle that contributes to pathologic loading of the lateral compartment of the knee and subsequent bone and cartilage destruction. An experimental model has demonstrated that the mechanical overloading of a single compartment of the knee leads to degenerative change in that compartment.[16, 17, 18, 19, 20]" (ie. Too much pressure on the lateral compartment from a genu valgum puts the lateral compartment at risk for deterioration.)
****"A study by Khan et al in patients with early symptomatic knee osteoarthritis showed a clear relationship between local knee alignment — as determined from short fluoroscopically guided standing anteroposterior knee radiographs — and the compartmental pattern and severity of knee osteoarthritis. In this study, each degree of increase in the local varus angle was associated with a significantly increased risk of having predominantly medial compartment osteoarthritis, and a similar association was found between the valgus angulation and lateral compartment osteoarthritis in 47 knees.[14]"**** (ie. Every single degree of increased varus or valgus relative to normal alignment significantly increases your risk of OA. Varus misalignment increases medial compartment risk. Valgus misalignment increases lateral compartment risk.)
Messing with the angles of the knees/ankles is not a small matter. The mechanics can be very sensitive. But as said, fortunately, if you are starting with a good natural alignment, well done internal/LON/LATN/Ilizarov tibias should be able to almost completely avoid these problems. And if you are starting out varus (bowlegged), you may actually benefit from internal femurs.
The funny thing is that the misaligment she has developed is actually a 'good one', which follows her mechanical axis. So she can let it heal in that way and it will be OK. Though... on the right leg I'm afraid the valgus is too strong, so her feet will shift out instead. I too I'm wondering how they're going to insert the nail with such a misaligment. But could be they know something we don't.
Given how many people have been crippled by shady and incompetent leg lengthening surgeries, it's possible, but I think the more likely explanation is unfortunately that they don't know what they're doing. She should seek the consult of an expert like Paley, Guichet, or the Russian Ilizarov Institute.
The thing is, even when going for the 'max amounts', which I'd say is 7-8 cms, the lateral shift is quite small. You aren't going to develop a genu valgum or a 'knock knee' or 'x legs', because of a 7 mm lateral shift. To get something like on that picture you'll have to lengthen really a lot. The difference between pic 1 (normal) and pic 2 (genu valgum) is a whooping 15 degrees in tibia angle. Just imagine how much lengthening you'd need in your femurs to bring your tibias from 0 to 15 degrees.
Agreed, but that diagram is just exaggerated for illustration purposes. In real life as quoted above, every single degree of deviation counts.
Though there's one thing I want to point out: the amount of later shift depends also on your femur angulation, females should expect a higher lateral shift.
Very true, and that raises another interesting point: The degree of expected deviation from internal femur lengthening should be completely predictable based on preoperative radiographs and expected amount of lengthening. Based on the studies on how degrees of deviation predispose to OA, the risk of OA should also be predictable to some extent as well.
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To bring this discussion even one step further, if you DO have an internal femur lengthening procedure, develop a valgum deformity, and notice in 2-3 (or 10) years your knees are feeling sore, particularly to the lateral compartment, you are not completely screwed. A femoral wedge osteotomy (removing a wedge of bone from the lower femur to reangle it) may straighten the knee. Doing so can at least partly reverse the damage being caused by the valgum to the lateral knee compartment. But it is not pleasant or easy.
Ref: http://emedicine.medscape.com/article/1251668-overview#aw2aab6b7
"The rationale of corrective osteotomy is to unload the diseased lateral compartment by overcorrecting the pathologic malalignment of the lower extremity and to facilitate the reparative capacity of the knee joint once it is mechanically unloaded. The regeneration of articular cartilage and proliferation of fibrocartilage has been demonstrated during repeat arthroscopy, compared with previous arthroscopic findings in knees that were overcorrected by an osteotomy.[39, 40, 41, 42, 43, 44, 45, 46]" (ie. Damage caused to the cartilage by genu valgum can repair itself to an extent once the genu valgum is corrected.)
"Valgus malalignment of the knee joint is often corrected by a distal femoral osteotomy, with a medial closing wedge fixed internally (see the image below)... It has been shown to be safe and effective in correcting deformity and slowing progression of knee arthritis. To bring the knee joint line parallel to the floor by osteotomy, the deformity usually has to be corrected in the deformed distal femur itself.[16, 42, 49, 52, 53, 54, 55, 56, 57, 58, 59, 60]" (ie. To properly fix this misalignment, you need to go back, chop off the lower end of the femur, take a small wedge out to reangle it, and then refix it together. Pic below. This will possibly cost you a small amount of height gain from all the sawing, plus it's another major operation you'd need on both sides, if someone is willing to even provide it to you for only a few degrees correction and after cosmetic LL sugery.)
(http://img.medscape.com/pi/emed/ckb/rheumatology/1230552-1251668-1387.jpg)
The suggestion above of correcting it via tibial varusing during a tibial Ilizarov could also be valid. But then again, you need to do both upper and lower legs, and tibial Ilizarov isn't that much fun from what I gather. And again, you are opening yourself up to risk that your surgeon will not control the device precisely enough to give you the exact correction you need.
Seems better to me to just pursue methods of LL that don't (or at least more minimally) shift the axis of the hips/knees/ankles to begin with.
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I think those of you with bowlegs (genu varum) are lucky. You might be the only "ideal" candidates for internal femurs in terms of potentially improving rather than worsening the mechanical axis.
Yeah I was fairly significantly bowlegged before (not ridiculously so, but it was noticeable if you looked enough at it), and now my legs are perfectly straight. And, I don't have x-legs when I stand with my feet apart. So if anything, I'm hoping the realignment has helped me a bit.
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For anyone with unoperated, natural, well aligned knees who doubts or wonders how a subtle valgum would affect their hips/knees/ankles/gait, I suggest a simple experiment. It's not perfect, but I think it's the best you can do without actually operating on yourself.
Pick up a pair of cheap dollar store foam sandals. Cut a small wedge of foam off from the sandals to run along the whole outside of your feet like this:
(http://www.gp-training.net/rheum/gait/gait5.jpg)
(http://www.lermagazine.com/wp-content/uploads/2012/02/2OA-Figure-1.jpg)
Put the wedging material in your shoes. Now walk around with that for the next week or two. Maybe the next month or year. Do that and then report back how natural your gait now feels, and how naturally or not your knees and ankles hinge.
I just tried it for a few minutes, and I could be mistaken but I think I might have been starting to develop the same kind of subtly "strange" looking gait we have seen from some lengtheners that have done internal femurs. eg. Like the video that was posted ITT a bit earlier. Not sure. Could be placebo. It certainly feels different though.
I'm not suggesting performing this experiment will accurately emulate what happens from the shift in axis caused by internal femur lengthening surgery. The only thing that can show you what that would feel like would be to actually get the surgery and see. But I think it should make it evident if you try it that even subtle valgus stresses/deviations can change the mechanics quite noticeably.
On the other hand, if you have already had internal femurs done and are experiencing knee/ankle pain, perhaps you may wish to try the opposite and apply a medial wedge (to the inside of your foot) to see if it helps relieve your discomfort like this:
(https://hypercatcycling.files.wordpress.com/2010/05/before-after-wedges.jpg)
If it helps, custom orthotics can be designed with a medial wedge like this, and it may be the simplest, easiest method to manage any discomfort caused by the valgus shift.
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Damn. You are making some good and important observations!
I was planning on lenghtening my femurs only 6cm because I was already concerned on biomechanical functionality due to the tibia to femur ratio and proportions.
I was sure I wanted to do femurs because i guess using aomething like 2cm insoles or boots would helph that ratio..
Unfortunately and from what you are saying using insoles or boota wouldn't make a different when it xomes to the problem you are pointing out... Or would it?
There god I will only do it in 4-5 years time when ll is way more expensive but more studies have been done.
What are your thoughts when it comes of using insoles to helph this voth cases after lenghtenig femurs? Would it help both, one of them or none?
Well at least when it comes to tibias using insoles or boots would only make things worse
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this is getting tiresome and obessive
ask a surgeon.... a real dr what they think is best..
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I just had another thought brainstorming solutions for this subject that I am finding exciting. In fact, it could be groundbreaking. Let me share. I hope you will find the concept as intriguing as I do. :)
Current Internal Options:
Most of us would prefer to lengthen via internal fixation (eg. Guilet, Precision) for the speed, safety, and lack of wearing an external cage.
As stated, a internal tibial lengthening procedure should theoretically maintain the anatomical axis perfectly if well done. But when I was reviewing the journal articles on this, I was seeing even with this approach there can be slight deviations. It's understandable why, given that the exact angle of distraction will depend on the angle of the rod in the tibia. Drilling the rod into the tibia isn't exactly a perfect science, and a lot of tibias have a slight "S" curvature to them that could slightly alter the angle as the rod goes in. The point being, not even internal tibias will probably be "100%" perfect every time. But they should be pretty damn good. Tibia lengthening is slow though, and I'm not confident that a deformity couldn't occur to the fibula during distraction affecting the lateral ankle.
By contrast, internal femurs are fast, effective, and safe. Since only the femur is involved, there is minimal joint complexity. It's much easier to gain mechanical access to drill the hole for the device to be inserted (no patella, peroneal nerve, no fibula to fix, etc), so surgically it's as simple as can be. The problem is as stated, this approach guarantees that you will have axis deviation. Perhaps this may truly be a nonissue for many of us. But I think all of us would prefer not to have this axis deviation if there is a way to avoid it.
So what's my proposed solution? How can we improve the cutting edge of modern internal femur leg lengthening? Well I sort of brushed against the solution a bit earlier and I just connected it now. Some of you may perhaps think this is crazy, but bear with me. I think if you consider it fully, it may make a compelling argument.
Without further ado, here's my great big new idea ... Surgeons, if you like the idea, please feel free to apply liberally... Just please don't claim to name it after any one of you if it catches on... And please do PM me for co-authorship credits if you publish on it... :)
NEW IDEA - Internal Femur Lengthening Followed by Distal Femoral Opening Wedge Osteotomy (During Nail Extraction):
In my proposed new approach to lengthening, internal femur lengthening is first performed as usual. In this way, you get all the benefits of rapid growth, safety, and avoiding ankle/equinus/peroneal/patellar problems. You rehabilitate from this femur lengthening as usual for 1 year. When you reach the 1 year point and are ready to have your nail removed, final full leg sets of xrays are taken while standing in natural anatomical position. These xrays are then used to calculate and assess the degree of post-op genu valgum (or perhaps paradoxically varus if you have an abnormal alignment to begin with). The deviation is carefully assessed and measured for.
Then when you go in for your nail extraction, in addition to taking the nail out, if the misalignment is deemed significant, the surgeon performs a carefully calculated small bilateral distal femoral opening wedge osteotomy to perfectly correct it:
(http://www.recipe.ru/catalog/images/1086_Distal_Femoral%20Opening%20Wedge%20Osteotomy.jpg)
(https://d30s4oigopvds.cloudfront.net/taxon-images/distal_femoral_opening_wedge_osteotomy/distal_femoral_opening_wedge_osteotomy_0-large.png)
Re-alignment could be verified for perfection in the OR during the osteotomy with temporary pinning and portable xray before final fixation is applied. You can then get a rapid safe internal femoral lengthening, combined with a totally perfect (to the surgeon's skill level) correction of your axis bilaterally. Furthermore, since it's an opening wedge osteotomy, you don't lose a millimeter of height. In fact, you may actually gain a tiny bit more.
This adds one extra layer of surgery, but since it's done at the time of nail extraction, you're under anesthetic already anyway. The osteotomy procedure alos doesn't appear to be that complicated. Furthermore, it's rigidly fixed, so should be back to full normal weight bearing shortly post op. It could probably be optional whether or not you want the fixation metal for the osteotomy removed at a second follow up.
This could even provide superior alignment of the axis compared to internal tibias, because if you get a mild deviation during internal tibias, there is no way to correct that at the end. This approach offers a way to get a rapid femur growth and then completely fix any degree of misalignment no matter how great, as long as the finishing osteotomy is well planned and performed. In other words, if you can accept the idea of the osteotomy during nail removal, I think it's pretty much a perfect solution for rapid, safe femur lengthening while maintaining neutral knee/ankle axis alignment.
I'm pretty happy. I think this is an awesome solution that should be offered electively to any person who wants it done. I think this would be a great approach if a reputable surgeon could be convinced to consider it. I hope if they like it, they won't mind that it wasn't their idea first. :D
Also, I wasn't going to say this, but if it helps add weight to further consideration of this idea (which I think could potentially be quite good), then I will say it. I am a real doctor. Not a surgeon, but yes a real doctor. During med school and residency, I assisted in the OR for numerous hip replacements, knee replacements, arthroscopies, etc., did tonnes of ortho exams, joint injections, casting fractures, etc., and assisted consults in numerous orthopedic surgery offices. So I have at least some limited background in orthopedics.
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I'd still do external tibias all over again before doing them internally. At least if you go to a doctor that offers a Taylor Spatial Frame or a six-axis correction system like a hexapod, your doctor can do a perfect realignment with the computer software once the lengthening is complete.
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To be honest when I was making my previous post I thought about it. But not like you did. Mine were:
1. doing the Distal Lateral Femoral Opening Wedge Osteotomy at the time of the LL operation. It was stupid because we didnt know how much we were going to lenght.
2. Doing long time after. As you said before 2-3 (or even 10) years later
The way you said it was just perfect. Doing it when removing the nail! But what would be the new risks? The new price?
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Well in the old forum they already wrote about this. The name of the topic was: Bow Legs & Knock Knees Correction
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Well in the old forum they already wrote about this. The name of the topic was: Bow Legs & Knock Knees Correction
Just read that thread. It looks like it was just a very general discussion of how major varus and valgus deformities can be corrected in orthopedics. It's not really touching on our specific points ITT.
I'm still laying claim to the idea of performing distal femoral opening wedge osteotomies as part of routine practice during nail removal for internal femoral leg lengthening. :D
If this catches on, remember, you saw it here first. ;)
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I'd still do external tibias all over again before doing them internally. At least if you go to a doctor that offers a Taylor Spatial Frame or a six-axis correction system like a hexapod, your doctor can do a perfect realignment with the computer software once the lengthening is complete.
KiloKAHN, I just read your thread. Wow. Thanks. I didn't even know such advanced external tibial fixation devices existed. Based on that I think the two best approaches for preserving/correcting axis during leg lengthening could be in order:
1) Tibial Taylor or Hexapod - If you can wear it 8 months to lengthen 6 cm and don't mind the pins/apparatus.
2) Internal Femurs with Distal Femoral Opening Wedge Osteotomies (DFOWO) - Faster with bigger gains, and still with good post-op alignment, although as proposed above, this option doesn't technically exist yet. ;)
I would guess the Tibial Taylor/Hexapod approach would be slightly superior in terms of final alignment given that they can be fine tuned by computer. With the femoral method I suggested, the surgeon's hands are the final arbiter of your alignment, so there is opportunity for human error. Additionally, the Internal Femurs with DFOWO approach will still by design force a mild probably 1-2° abduction (opening) of both hips. I don't think that would cause any issues at all, since the hips are freely ball-and-socket. But this abduction is avoided with a strictly tibial approach, so from a purist perspective on alignments, a computer assisted external tibial approach might probably be most ideal (though very slow).
Do you know anyone using the Taylor device for cosmetic leg lengthening? It looks more advanced than the Hexapod.
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I don't know of any diaries where a TSF was used. They're quite expensive so I'm told they're not usually done for simple lengthenings. You might end up paying around the same price for a TSF as you would for an internal device.
As far as I know the hexapod does the same exact thing, according to my surgeon, who's used the TSF before when they were donated to him from a UK clinic. I'm guessing the main difference is the material it's made out of. But they both use computer software and are six-axis so the result would be the same.
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I've looked a bit more into the subject of using distal lateral femoral open wedge osteotomies to correct the valgus shift that can be induced by internal femoral lengthening.
For anyone that's interested in details, a full article is here describing the procedure in depth:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899363/
To illustrate again what a valgum looks like (a, b) and what a distal femoral opening wedge osteotomy can do to recreate an ideal alignment (c), here's one pic from the linked article:
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899363/bin/264_2009_820_Fig2_HTML.jpg)
Here's a small diagram showing the hardware:
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899363/bin/264_2009_820_Fig3_HTML.gif)
The main points I've learned from reading about the procedure are:
- This can be an exceptionally precise procedure. The angles are all planned out in advance. A small metal spacer (eg. between 5-17 mm) can be introduced to the edge of the osteotomy to guarantee you are getting the amount of wedging you want.
- Primary risk is incurred during the "splitting" process to open up the osteotomy. This risk is that if this is not done cleanly/well, the bone can just fracture straight through. Not sure what the probability of this is. Probably very low in healthy bones. But obviously you'd want someone who's done this before operating on you.
- Big point: In order to protect the alignment post-osteotomy, it's suggested that are completely non-weightbearing for 4 weeks, and 6-8 weeks total to get back to full normal weight bearing, or as x-rays indicate consolidation has occurred.
My final impression is that this procedure is the definitive solution to the potential problem of valgus shift during internal femoral lengthening. It could be best applied by getting the internal femurs done and then rehabbing for 1-2 years. After 1-2 years, if the valgus is significant/bothersome (or the individual worries it will in the future), nail extraction and distal femoral opening wedge osteotomy are booked to occur during the same procedure.
I don't know what Dr. Guichet's or Dr. Paley's experience with performing this kind of osteotomy would be. I'm guessing they would be capable of performing it, but probably haven't done it much before since it's not their field of expertise. If so, if it was me, I would probably see if I could get another surgeon with expertise in this to attend during the nail extraction and perform it with Dr. Guichet/Paley assisting.
It's a tossup for me between going this route vs a comparatively noninvasive approach like tibial Ilizarov with Hexapod.
The internal femurs even with time for the corrective wedge osteotomy is probably going to be faster. With Guichet, it's almost exclusively weightbearing. The femur approach also allows you to still wear heel lifts for another 1-2 nonsurgical inches without it looking ridiculous. The main downsides of this approach are first that the realignment osteotomy will require two months of downtime. Plus then you've got permanent hardware in your knee, or you have to go back for a third operation to remove it. It also involves a lot of drilling/cutting into the femurs.
By contrast, the Ilizarov with Hexapod is comparatively noninvasive with very little cutting/drilling. I also personally prefer the look of long tibias. But it's very slow for comparable gains, such that even with good progress, at 10 months you can still have your frames on. Plus you have to spend 6-8 months under medical supervision in a foreign country.
It's a tough decision. Both approaches should maintain the hip/knee/ankle axis well. But they are very different pathways. Thoughts?
For my own part, I think I am leaning towards internal femurs, perhaps weightbearing with Guichet, and then following that with a slight realignment osteotomy in 1-2 years during nail removal if needed.
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You don't think the wedge will make it easier to get femur fractures or anything? It looks like they'd be more sensitive to that sort of thing when you cut a bit of the bone out.
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You don't think the wedge will make it easier to get femur fractures or anything? It looks like they'd be more sensitive to that sort of thing when you cut a bit of the bone out.
You are not actually cutting a bit of the bone out. Cutting the bone out would be a "closing" osteotomy. That would cost you height. The beauty of the "opening" osteotomy, is you are doing just that - opening up more space, and thus you will actually gain at least a few more mm through the procedure.
Here is a picture of how the "opening" is done:
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899363/bin/264_2009_820_Fig8_HTML.jpg)
As long as everything is well fixated together when done, you should ossify the few mm gap on your own within the 8 weeks or so they suggest for sufficient recovery. But that is why you must be nonweightbearing for at least 4 weeks post op.
In the case of a big valgus deformities, where you need more than 7.5 mm wedging, they suggest using a small bone graft from the iliac crest (where bone grafts are usually harvested from) to fill the gap and prevent nonunion. Below 7.5 mm it depends who you ask they say whether there is still benefit from grafting or if it is fine to just leave it open with just the metal spacer and it will fill easily enough with bone on its own.
I expect it should be fine for most of us with no graft at this small a wedge, because as a wedge, it will start to fill from the narrowest aspect and continue outwards from there. I suspect a graft would only be universally necessary in, for example, an elderly woman with poor bone/healing quality.
I'm not sure which category we'd typically fall into in terms of how much correction we'd need. It would be easy enough to calculate though with some simple math though, and I will do this at some point in the future.
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I had a thought...
You're showing the effect of mechanical axis deviation from norm, when someone is standing with their feet together. So as we've figured the tibia is angled 0 degrees, but only when standing with your legs closed (obviously deviatons also occur). When you spread them apart, tibia gains more angle. So what happens when you lengthen femurs internally is that you just have to spread your legs more to put feet together now. Where I was going with that... You don't usually see people standing with legs completely closed feet together, right? That means their tibias are already angled and in comparison with someone who has done internal femurs, it would be no different angle, because you're standing with your legs apart anyways. Now you could say: it's walking that matters, not standing. Lets think about that...
http://www.youtube.com/watch?v=NVwPtlhOZHs
http://www.youtube.com/watch?v=rC6vZ3lJWHM
So they're walking with their legs spread, knees not connecting together, feet are more spread in the first video.
Now imagine if they lengthened 7 cms in their femurs along anatomical axis. As their feet and knees aren't being put together, which should btw mean that they are walking with an angle in their tibs as is, they shouldn't feel too much difference after LL. What do you say? I think your mistake was basing all your assumptions on a model of someone standing with their feet together, which is when the tibias are angled 0 degrees.
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I'll clarify a bit:
The mechanical axis is defined as a straight line going through the femoral head and the middle of the ankle joint. In a well aligned leg, when you draw a line connecting the middle of the femoral head to the middle of the ankle, you will also go straight through the middle of the knee:
(http://boneandjoint.org.uk/sites/default/files/styles/large/public/Fig%201_3.jpg)
This alignment is important, because having it means the primary points of load bearing of the leg will pass weight and hinge efficiently (femoral head, knee, ankle). According to eMedicine (http://emedicine.medscape.com/article/1251668-overview) "the mechanical axis averages 1.2° of varus". This means the line that goes through all these weight bearing points when you are standing in a natural position is for most people on a tiny 1.2° varus tilt relative to the perpendicular.
If you start with a good mechanical axis and then lengthen along the axis of the femur, you will inevitably throw these three points of alignment out of wack into a mild genu valgum (as per my diagram in the OP). You will be misaligned when standing in any position and even when walking. Whether you will notice this or it will cause damage to your joints may vary from person to person. I posted explanation and evidence for why I believe it has the potential to be a significant long term problem on page 4.
The only way I can see to properly get the alignment back after such internal femoral lengthening is to do a distal femoral opening wedge osteotomy to the lateral aspect of the femur during follow up as described above. (Or the other valid option for maintaining the axis is to avoid the femurs altogether and do, for example, internal tibias or Ilizarov tibias with Hexapod. But as discussed, those options both come with other challenges.)
I can perhaps put together some proper Photoshops in the future if this doesn't make it clear.
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I know what mechanical axis is. I don't think you understood what I was talking about. In fact, you ignored all of the points I've made.
Initially you were claiming that after lengthening femurs along anatomical axis, "spacing feet naturally now creates angulation to joint lines". But you're looking at only one position (feet together) and also ignoring the fact that you're going to have the very same 'angulation to joint lines' if you stand in ANY position other than the initial one with your feets closed. Let me show...
(http://i.imgur.com/67BH78Q.jpg?1)
Here we have someone standing with their feet together, no angulation to joint line, right? We have a perfectly straight line. But then he spreads his legs/feet apart...
(http://i.imgur.com/8oqwmGk.jpg?1)
And now he has the very same angulation in knee joint, which he'd get after IFL. And I could also argue that this position is more natural and usual, than the one with feet together.
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I think the exaggerated nature of the diagrams I used to demonstrate this are throwing off the discussion. Let's stick to more anatomically correct diagrams. This diagram shows the natural alignment of a good mechanical axis with the feet naturally apart as one would generally stand (with the ankles pretty much directly under the femoral heads, and the knees lining up along that axis perfectly with their joint line perfectly horizontal):
(http://boneandjoint.org.uk/sites/default/files/styles/large/public/Fig%201_3.jpg)
Do you recognize that if you lengthen the femur along it's anatomical axis, when standing with the feet similarly spaced so the ankles are still under the femoral heads (as they must be for natural stability and weight bearing), you will no longer be able to draw this straight line through the exact middles of the femoral head, knee, and ankle?
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There is a lot of good info in this thread. But there is another variable to consider. How does ballspan affect the mechanical axis and does it eventually cause joint pain?
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There is a lot of good info in this thread. But there is another variable to consider. How does ballspan affect the mechanical axis and does it eventually cause joint pain?
The issue of the anatomical ballspan is a complicated one that frequently split the scientific consensus. Many questions remain before a unified theory about balls can be presented: do we measure ballspan in cold or warm temperature? What about hairy balls? Are the balls balls beyond the balls and just how many balls are there?
One thing is for certain though: with a proper ballspan, there is no limit to how far you can go. Godspeed and may your balls never shrink or drop below your knees.
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The issue of the anatomical ballspan is a complicated one that frequently split the scientific consensus. Many questions remain before a unified theory about balls can be presented: do we measure ballspan in cold or warm temperature? What about hairy balls? Are the balls balls beyond the balls and just how many balls are there?
One thing is for certain though: with a proper ballspan, there is no limit to how far you can go. Godspeed and may your balls never shrink or drop below your knees.
Lol!!! I agree, the issue of ballspan is indeed a complicated issue.
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I just want to provide a brief update on my thought process regarding this issue (in the interest of continuing to think out loud for whatever it's worth to anyone else).
I've looked at the distal femoral opening wedge osteotomy a bit more, and I know now why it's not offered. It's no small surgery. You're looking at large, deep incisions (at least 5-6" long), and significant tissue spreading to good exposure of the bone for plating. And then you've got that hardware in you which could cause pain by itself. Going back to remove the hardware is going to be equally invasive and risky.
So basically the best options as I see them in LL are:
1) Get internal femurs and live with the valgum shift. Realize it could put you at risk for chronic joint pain secondary to axis misalignment. But there's no way to know if it will for sure.
or:
2) Get external tibias via Hexapod or Taylor Spatial Frame. Internal tibias are an option too but with the risk of anterior knee pain like MDOW has secondary to patellar tendon or bursa damage.
Unless my preop xrays show a major varus to my knees, I'm almost certainly going to go with the second option. It's slower and more painful in the short run, but done by a competent doctor I think it has the lowest probability of any LL surgery of causing chronic joint/nerve/pain problems.
I'd rather take an extra few months to get my lengthening done that way and suffer in the frames than take a shortcut and pay for it in 5-10 years (and for the rest of my life).
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Bump for a very interesting post and to bring to peoples attention!