Limb Lengthening Forum
Limb Lengthening Surgery => Information About Limb Lengthening => Topic started by: An_Apple_A_Day on November 22, 2013, 11:11:51 PM
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Well at the risk of looking like a class A tit & eating humble pie (I'm used to it by now!) I'd like to take the opportunity to thank you for your contributions Franz.
I would also like to ask you typically in your opinion what kinda of recovery one can hope to achieve if they are conservative with lengthening (say 5cm?).
From my understanding of the process muscles lengthen through serial sarcomere synthesis as appose to the muscles simply stretching.
Do you see people a few years down the line? What is there recovery like? You mentioned arthritis what is the mechanism of this the surgical trauma, the actual increased length of the limb or both?
Sorry for my crudeness about your country earlier. Like I said I was perhaps ignorant.
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Dr. Birkholtz-
Thank you for posting and answering questions on this forum. Can you please elaborate on your following quote.
potential increased arthritis risk after CLL.
During my consultation with Dr. Rozbruch in New York I asked about this question and he told me that cosmetic limb lengthening itself does not pose a risk for developing arthritis. The risk of arthritis comes from the surgeon not taking the proper precautions in aligning the axis of the joints during surgery and monitoring any changes during lengthening. He also said that 5cm is the safest amount to lengthen but up to 8cm does not increase the risk of arthritis. Going beyond 8cm increases the risk of arthritis because of the change in the ratio on the lengthened bone and excess pressure on the joints.
Do you share the same opinion as Dr. Rozbruch?
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Dr. Birkholtz-
Would you also please give your opinion on what happens to the soft tissues (muscles, ligaments, nerves etc.) in the leg during lengthening. Do they simply stretch or are they building new tissue to support the increased length? How long do you estimate for recovery time after lengthening?
What is your opinion on returning to 100% or close to 100% athletic ability after lengthening? Is it possible up to 5cm and can a patient lengthen beyond 5cm and still return to or close to 100% athletic ability?
What is your opinion on the cosmetic or aesthetics of lengthening? How much can a patient lengthen on each bone segment and still look in proportion to the rest of their body before their legs start to look too long for their torso and arms?
Thank you again for posting on this forum and I look forward to your answers.
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Hi guys,
It looks like we've opened a real can of worms! Firstly let me just state that any advice I give on a forum like this cannot constitute professional medical advice, and should be seen as general comments
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Let me try and batch the answer to encompass all your comments. Distraction osteogenesis creates new bone, but also new soft tissues. Unfortunately this happens at different rates for different tissues. Muscles tend to go slowe than bone, so theres probably a combination of new muscle formation and stretching, hence the joint contracture risk.
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Functional recovery is multifactorial but we expect high levels of recovery in lengthenings between 5 and 10 cm.
Cosmetically 10cm still keeps people in proportion.
I would aim for 5-6 cm on femur and 4-5 cm on tibia.
Arthritis is probably due to malalignment, but also increased joint pressures.
This seems to be related to the extent of the lengthening as well.
Hope this answers most of the questions?
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Thanks for the reply. I assume you mean 5-10 cm you are referring to both segments, not 5-10 cm on one limb?
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Yep the 5 could be one segment, but 10 definitely two.
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Dear Dr. Birkholtz,
could you please explain what malalignment means?
Thank you very much in advance
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Dear Dr. Birkholtz,
could you please explain what malalignment means?
Thank you very much in advance
Apologies. Sometimes we use technical terms without explaining their meaning. ;D
Malalignment simply means when a joint's normal direction of action is changed, or pushed out of alignment. This could be the result of surgery, where the joint is now not 'straight' anymore. This means the forces go through the joint at an abnormal angle and can cause arthritis.
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Everyone,
I have been emailing with Dr. Birkholtz and he's answered a ton of questions I've thrown at him. I'm really impressed with the answers he's given so far, and I'll paste his responses here in no particular order. I AM NOT being paid to promote him, or have any deal with him whatsoever- one of the answers he gives even shows he is against doing this sort of practice.
How many cases of Cosmetic Leg Lengthening have you done?
I perform legengthenings for non-cosmetic reasons all the time (appprox 100-200 per year), and am comfortable with distraction osteogenesis as a technique. I arranged to have Precice brought into our country recently, and because I believe that standard exfix techniques have a risk profile too high for CLL, we've not done many CLLs. In fact only 2, one LON tibia (6cm) and one bilat LRS femurs (5cm limited due to knee stiffness). With Precice I believe we can now safely offer CLL widely.
What were the outcomes of the 2 CLL surgeries you did?
My 2 CLLs: LON tibias 6 cm and very happy. femoral LRS, frames came off recently, so too soon to tell.
How much would it cost for bilateral femur lengthening using PRECICE? What would this pricing include?
Pricing for CLL in our unit is 40K euro for bilat femoral Precice. This includes everything except complications, incl meals and accommodation for 4 weeks. (See forum for details). Physio is included and they will provide you with a home programme.
How much does PRECICE removal cost? What about PRECICE nail replacement?
Ballpark figure for Precice removal would be around 4K euro. Should a precice have to be replaced it would cost approx 15K.
How much is a consultation? Would it be possible to send you x-rays and then consult with you over a skype call instead of flying out to SA for only a consultation?
I will not charge you anything for an email or skype consultation. We will definitely need to see xrays for measurement purposes. These should be done according to a standardised protocol which we can send through via email.
There has been a long ongoing debate in our forums of the healing time of PRECICE vs. Betzbone, Albizzia, etc. Some arguments against PRECICE are the lack of weight-bearing it provides, which will slow down healing because you will most likely be confined to a wheelchair. Some arguments against the Betzbone is the twisting motion of the rod, which seems to affect consolidation as well. What is your take on this? Which do you recommend more?
I think the controllability of the Precice is its key feature. I bieve that with IM nail lengthenings weight bearing is less important than the quality of the osteotomy in providing good regenerate. For this reason I think Precice is the superior product.
Do you work on minimizing scars?
We always operate in such a way as to minimize scars (subcut sutures where possible etc).
How do you prevent ballerina feet that usually comes from tibial lengthening?
Ballerina foot is a euphemistic term for a serious complication of equinus contracture. We have developed special orthotic devices to prevent this. Sometimes we include the foot into the exfix frame and occasionally we perform a percutaneous tendon achilles lengthening upon frame removal to correct this.
Do you have any pictures of your guesthouses I could look at?
Guesthouse price quoted is for a guest room next to the hospital in the office building where my office is situated. Of course accommodation in the area varies somewhat in terms of price and quality. My suggestion would be to use the rooms initially until a bit more mobile (4 wks incl in price) and then spend a couple more weeks in a local hotel or guesthouse with more amenities. The Centurion Hotel may work well for this. You can find them via Forever Resorts SA. This would be approx 100 euro per day for bed and breakfast.
Would it be possible to work out a discount from promoting your services on several different forums at all? sorry guys, I had to ask! ;D
Wrt endorsements diaries etc, I think we should be careful about linking endorsements to monetary value. I know other surgeons do that, but ethically I would prefer for my patients to endorse me(or criticize me) independently!
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Dr Birkholtz, I'm curious to know whether you prefer LON or LATN for combination internal/external methods. Would you say one is "better" than the other for most cases?
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Dr Birkholtz, I'm curious to know whether you prefer LON or LATN for combination internal/external methods. Would you say one is "better" than the other for most cases?
Something I want to know as well! I know Dr. Donghoon Lee prefers LATN according to this post by Walk6 in his diary: "it offers a much quicker recovery time post-frame removal. He informed me that while the frames would stay on for a bit longer during LATN than LON, because there is no nail implanted during the actual lengthening and fixation process, the bone would be much stronger after the fixators are removed and hence recovery would be noticeably smoother for LATN.
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Something I want to know as well! I know Dr. Donghoon Lee prefers LATN according to this post by Walk6 in his diary: "it offers a much quicker recovery time post-frame removal. He informed me that while the frames would stay on for a bit longer during LATN than LON, because there is no nail implanted during the actual lengthening and fixation process, the bone would be much stronger after the fixators are removed and hence recovery would be noticeably smoother for LATN.
I think the two methods both work well. It needs to be done properly though. I would choose the surgeon and then go with the technique he or she advises.
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Dr Franz, and about the reaming, it creates an unnatural hole where the bone marrow should be, correct?
What happens to this after the rods are removed? Will the inner cavity created, not get filled up?
Is this not an issue either?
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Dr Franz, and about the reaming, it creates an unnatural hole where the bone marrow should be, correct?
What happens to this after the rods are removed? Will the inner cavity created, not get filled up?
Is this not an issue either?
Hi there, again a good question.
In adults the long bones have very little functioning (blood-forming) marrow left, and it is basically a fat-filled cavity. Whereas this fat is not so important, what is important is that there are blood vessels that feed the bone itself in this cavity. Of course when we ream and stick a nail in there, it destroys some of the blood vessels. Hence some of the complications like delayed and non-unions we sometimes see with intramedullary nails. Once the nails are removed, the endosteal (marrow cavity surface) blood vessels are restored somewhat.
All of this is uncanny, but does not seem to translate into significant complications or problems in most individuals.
The more important potential risk involved with reaming is that of fat embolism. This is where fat is displaced into the blood stream during reaming and can cause significant respiratory problems. There are techniques to reduce this risk. Discuss this with your doctor, and if he does not know how to do this, look elsewhere. This complication can be fatal in rare instances.
The idea is not to scare you, but to give you as much info as you need to make safe decisions...
Hope this helps!
Warm regards.
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Hi Dr Franz ,
I recently did LL with LON on my tibia.. during my distraction phase i had swelling for almost 3 months on my left leg. The reason for the swelling was that my frame was installed on my left leg in a way that my calf was pressed from below as i always use to put my leg on a soft pillow. So , calf is like a second heart that pumps blood for blood circulation and since my calf was pressed most of the time the swelling didnt went away ..
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The problem is that any technique has its limitations and potential complications. It is important to have a surgeon who can prevent and manage complications well.
My adult patients spend around one and a half months per cm of length in a frame. In other words between six and nine months for 5 cms. This is a long frame time. I would not advocate this for femurs, as the risk of knee stiffness is very high.
For tibias ilizarov/Truelok/TSF frames work well and we encourage early full weight bearing on the frames.
The long frame times make LON and LATN attractive.
Apart from the reaming and potential infection risks, tibial nails have around a 50% chance of persistent knee pain. Only half of these patients improve when nails are removed.
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What i mean to say is that i had swelling for 3 months on my left leg during LL through LON . Now its almost 9 months after surgery and i feel 70% numb. Is it normal?
When will i feel my skin again ?
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What i mean to say is that i had swelling for 3 months on my left leg during LL through LON . Now its almost 9 months after surgery and i feel 70% numb. Is it normal?
When will i feel my skin again ?
Please bear in mind that ethically I can not dispense detailed medical advice via a forum like this without knowing your case in minute details. Hopefully what youre dealing with is a neurapraxia (stretching) of a nerve which can recover. It can take a long time in a lower limb (1yr plus). Unfortunately it may be permanent.
Lets hope for the best!
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I have to admit that I'm very impressed and happy to see an LL-doctor answering out questions.
I did LL on my tibias, LON - 7cm, in India with Dr Sarin and I am currently now 11 months post first surgery.
I can't run or jump. Only walk. My ankles are very stiff, especially the right.
1) Do you think I will be able to sprint and go for a 1 hour jog again?
I exercise every day. Physical therapy, cycling, swimming, gym, Taekwondo and long power walks.
2) Have you seen patients recover so they can move very quick to the sides while running like American football/basketball players do to fool their opponents?
3) Is it a bad idea to split the patellar tendon again when I want to remove the IM-nails?
My doctor in Sweden says they don't remove IM-nails and it's no problem having them in your legs for the rest of your life.
4) What is your opinion about this? Remember, I am very active and would very much like to go back and compete in Taekwondo, a martial art.
Thank you for taking the time, very much appreciated!
/Sweden, now 180cm.
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Dr. Birkholtz are you aware of any prolonged pain in the hips, knees etc. after internal femur lengthening (5-6.5cm)?
I would also like to clarify the numbers you gave for tibia lengthening. Are you saying 50% of patients will experience knee pain throughout their life using LON, LATN or internal nail for tibia lengthening?
Thank you for your contribution to this forum.
Thanks for the kind words. Hip and knee pain following femoral lengthening is less well defined and it is difficult to know what percentage have this.
The anterior knee pain rates quoted is unfortunately permanent.
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I have to admit that I'm very impressed and happy to see an LL-doctor answering out questions.
I did LL on my tibias, LON - 7cm, in India with Dr Sarin and I am currently now 11 months post first surgery.
I can't run or jump. Only walk. My ankles are very stiff, especially the right.
1) Do you think I will be able to sprint and go for a 1 hour jog again? Very difficult to say. 7cm for tibias is a long distance which fundamentally changes the muscle function. In my practice recovery can occur up to 2 yrs after incident. Of course we deal more with trauma and nonunions, but it should be similar.
I exercise every day. Physical therapy, cycling, swimming, gym, Taekwondo and long power walks.
2) Have you seen patients recover so they can move very quick to the sides while running like American football/basketball players do to fool their opponents? Agility and proprioception are what you are talking about and this can form part of the recovery, but these are complex actions and may not recover fully.
3) Is it a bad idea to split the patellar tendon again when I want to remove the IM-nails?If they were split during insertion, it is better to go through the same approach for removal.
My doctor in Sweden says they don't remove IM-nails and it's no problem having them in your legs for the rest of your life.
4) What is your opinion about this? Remember, I am very active and would very much like to go back and compete in Taekwondo, a martial art. Generally the rods can stay in. The problem is that the locking screws are painful when making contact. Especially against a training bag, or when soemone blocks you. Fore these reasons it may be better to remove them.
Thank you for taking the time, very much appreciated!
/Sweden, now 180cm.
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Dear Dr. Franz Birkholtz,
Do you know if reaming of the bone will cause a fat embolism in the future years later from doing femurs with interal lengthening?
is this an issue only with internal femoral method?
rexdime:
"Even if a post LL patient doesn't get blood clots or thrombus or an embolism that can cause death, the more fat or bone marrow that is released from the operation, the higher chance that it will enter your blood stream.
You can look at 10 years later, this fat and bone marrow will still be in your blood stream and say it hasn't done any damage yet, and I don't think the body knows how to get rid of this from your blood stream either.
You will think that everything is perfectly fine, but I am guessing that your chance of having a heart attack or a stroke will be a lot higher than if you never had a broken bone before. I think you can say this is one of the Side effects of doing LL , but I doubt many doctors warn their patients before LL of this risk , I might be wrong since I never done it before.
I know this young lady who had a stroke about a year ago and she didn't know why, she had no high blood pressure and she was healthy, but today the left side of her body is paralyzed and needs to be on a wheel chair everywhere she goes"
thank you
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Dear Dr. Birkholtz,
Thank you so much for your time and effort!
Could you possibly explain the pros and cons of separating the femoral bone with an internal saw vs. using an osteotome?
Are you planning on using the Precice 8cm in the near future?
Best regards.
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Hello Dr. Birkholtz, just to add to what masche is asking you. Here is what Dr. Paley says about bone healing. Please give us your opinion and thank you again for posting on this forum and answering all these questions.
"Delayed or failure of consolidation: Slow or failed bone healing can occur with any lengthening surgery. This complication can usually be prevented by making drill holes at the level of the planned osteotomy before reaming the bone. This is a technique I introduced in 1990. Stable fixation is also important so the choice of nail length and diameter are important as well as the level of the osteotomy. Even the type of osteotomy affects the rate of bone healing. Cutting the bone with multiple drill holes and an osteotome is the most minimal invasive way while using an intramedullary saw or performing an open osteotomy have higher failure rates."
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Dear Dr. Franz Birkholtz,
Do you know if reaming of the bone will cause a fat embolism in the future years later from doing femurs with interal lengthening?
is this an issue only with internal femoral method?
rexdime:
"Even if a post LL patient doesn't get blood clots or thrombus or an embolism that can cause death, the more fat or bone marrow that is released from the operation, the higher chance that it will enter your blood stream.
You can look at 10 years later, this fat and bone marrow will still be in your blood stream and say it hasn't done any damage yet, and I don't think the body knows how to get rid of this from your blood stream either.
You will think that everything is perfectly fine, but I am guessing that your chance of having a heart attack or a stroke will be a lot higher than if you never had a broken bone before. I think you can say this is one of the Side effects of doing LL , but I doubt many doctors warn their patients before LL of this risk , I might be wrong since I never done it before.
I know this young lady who had a stroke about a year ago and she didn't know why, she had no high blood pressure and she was healthy, but today the left side of her body is paralyzed and needs to be on a wheel chair everywhere she goes"
thank you
Hi, strokes and heart attacks are multifactorial. Fat embolism syndrome is an acute condition related to fractures or surgery and does not manifest later.
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Hello Dr. Birkholtz, just to add to what masche is asking you. Here is what Dr. Paley says about bone healing. Please give us your opinion and thank you again for posting on this forum and answering all these questions.
"Delayed or failure of consolidation: Slow or failed bone healing can occur with any lengthening surgery. This complication can usually be prevented by making drill holes at the level of the planned osteotomy before reaming the bone. This is a technique I introduced in 1990. Stable fixation is also important so the choice of nail length and diameter are important as well as the level of the osteotomy. Even the type of osteotomy affects the rate of bone healing. Cutting the bone with multiple drill holes and an osteotome is the most minimal invasive way while using an intramedullary saw or performing an open osteotomy have higher failure rates."
Dear Masche and handy,
i agree completely with dr paley on this.
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Dr. Birkholtz,
Thank you so much for participating on this forum. The diffierence you make in people's lives by providing quality advice, information, and warnings is invaluable and unfathomably appreciated.
I was wondering what your take is on cosmetic arm lengthening. As you know, some people who desire cosmetic LL are not so ideally proportioned for the surgery, but still would love to be taller. Arm length is sometimes a limiting factor, and some have researched cosmetic arm lengthening as a means to maintain a proportional appearance.
Recently, in a discussion, it was brought up by several sources that cosmetic forearm lengthening is not safe and sensible at this point in time. One reason being that the pronation and supination capabilities of the forearm would never recover. Is this true? If so, why would this capability not recover with sufficient physical therapy once the radius and ulna have completely consolidated?
Also, what is your take on cosmetic lengthening of the humerus?
I look forward to your responses.
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FINALLY,
We found a DR, that is generous enough to respond to our concerns.
Thank you so much for your time!!!
Dr. I have a couple of questions
1. On femoral lengthening how do you prevent valgar deformity and vulgus deformatiy from forming on our knees while lengthening?
2. Do you use forteo on patients that have a very small bone cloud or nonunion?
3. What do you think about the weight bearing ability of the alibizza nails for the 13mm diameter nail given that betz/guicet both allow weight bearing with crutches?
4. Do you use titanium nail replacements if the precice nail gets bend and can you get titanium screws in the proximal and distal portion for added support
5. The precice2 nail is 75 pounds weight capacity per leg is that for all the diamaters of the nails? Also if you weigh more than 150lbs are you in a wheelchair bound during the whole time of lengthening?
6. Is it possible to lengthening to lengthening at home and take the erc device with you?
Thank you so much for your time!!
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Dr. Birkholtz,
Thank you so much for participating on this forum. The diffierence you make in people's lives by providing quality advice, information, and warnings is invaluable and unfathomably appreciated.
I was wondering what your take is on cosmetic arm lengthening. As you know, some people who desire cosmetic LL are not so ideally proportioned for the surgery, but still would love to be taller. Arm length is sometimes a limiting factor, and some have researched cosmetic arm lengthening as a means to maintain a proportional appearance.
Recently, in a discussion, it was brought up by several sources that cosmetic forearm lengthening is not safe and sensible at this point in time. One reason being that the pronation and supination capabilities of the forearm would never recover. Is this true? If so, why would this capability not recover with sufficient physical therapy once the radius and ulna have completely consolidated?
Also, what is your take on cosmetic lengthening of the humerus?
I look forward to your responses.
Stay away. The forearm has too many fine structures in it and permanent damage can occur and lead to loss of hand function. Not worth it for cosmetic reasons!
Pro and supination are dependent on the curved bones in the forearm. As we can ot lengthen around corners, lengthening will always permanently affect pro and supination.
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FINALLY,
We found a DR, that is generous enough to respond to our concerns.
Thank you so much for your time!!!
Dr. I have a couple of questions
1. On femoral lengthening how do you prevent valgar deformity and vulgus deformatiy from forming on our knees while lengthening?
2. Do you use forteo on patients that have a very small bone cloud or nonunion?
3. What do you think about the weight bearing ability of the alibizza nails for the 13mm diameter nail given that betz/guicet both allow weight bearing with crutches?
4. Do you use titanium nail replacements if the precice nail gets bend and can you get titanium screws in the proximal and distal portion for added support
5. The precice2 nail is 75 pounds weight capacity per leg is that for all the diamaters of the nails? Also if you weigh more than 150lbs are you in a wheelchair bound during the whole time of lengthening?
6. Is it possible to lengthening to lengthening at home and take the erc device with you?
Thank you so much for your time!!
Accurate surgery will prevent deformities, but this is one ofthe potential complications of cll.
I do not use forteo.
I have no experience with Albizzia so cannot really comment.
Yes this is possible to replace precice with titanium if bent. Something like trigen nail from Smith and Nephew.
The 75 pounds would probably not be for the thin nails. The recommendation is not to exceed 75 pounds per nail until some bone consolidation takes place.
Lengthening at home is only really possible for our South African patients. The follow ups are essential in preventing complications and continuinh physio.
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Dear Dr. B.,
I remember that you previously mentioned a patient doing external femurs using the LRS Monorail? I was wondering if you would recommend such a device for lengthening if the patient were to commit to 5 cm. Were the patient scars extremely visible? How much did that patient pay? Thanks, I'm just curious because we have a patient here from India who is doing quad external lengthening.
Thanks,
Arche (almost typed my real name haha)
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Exfix for femurs is really not ideal. Scarring and knee stiffness are big risks. The cost would be cheaper - around 32k, but i really would then prefer for you to get LON tibia.
The patient in question had scarring and stiffness
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Dear Dr. Birkholtz,
Will you be OK if patient wants to lengthen humerus? How much it will be with precise and and non-precise? I am not thinking about doing it but want keep that as an option. My wingspan is short. I might transform way out of proportion when I do both femur and tibia which is my current plan.
Thank you!
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Dr B I was wondering if a patient could get precise femurs done, then after lengthening
get the femur nail removed and have their tibia's lengthened in the same op?
Thanks
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Dr B I was wondering if a patient could get precise femurs done, then after lengthening
get the femur nail removed and have their tibia's lengthened in the same op?
Thanks
That is possible, provided the knees have returned to normal and the bone healing is sufficient.
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Dear Dr. Birkholtz,
Will you be OK if patient wants to lengthen humerus? How much it will be with precise and and non-precise? I am not thinking about doing it but want keep that as an option. My wingspan is short. I might transform way out of proportion when I do both femur and tibia which is my current plan.
Thank you!
Humeral lengthening for pure cosmetic reasons is really not recommended. If you keep your femoral and tibial lengthenings within safe limits, it will not be necessary to adjust humerus.
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Are monorail fixators on tibias just as feasible as the classic ilizarov fixators for external only of 5.5 cm? I run a small business and one of my concerns is that the bulky ilizarov frames may be too much of an office distraction. For that reason I was considering LATN so I could consolidate once the frames are off without people knowing what exactly I did, but the risk of permanent knee pain does worry me and I'm thinking of suk it up and working near employees with frames on. I think monorails would be less "in your face", and perhaps more comfortable for extended wear, but then again I've got quite a bulky wrestler type of build and I don't want to risk my tibias snapping or something.
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Are monorail fixators on tibias just as feasible as the classic ilizarov fixators for external only of 5.5 cm? I run a small business and one of my concerns is that the bulky ilizarov frames may be too much of an office distraction. For that reason I was considering LATN so I could consolidate once the frames are off without people knowing what exactly I did, but the risk of permanent knee pain does worry me and I'm thinking of suk it up and working near employees with frames on. I think monorails would be less "in your face", and perhaps more comfortable for extended wear, but then again I've got quite a bulky wrestler type of build and I don't want to risk my tibias snapping or something.
LRS(monorail) fixators are strong and we fully weightbear on them. They have not snapped yet. The issue with LRS is the risk of malalignment.
An option to consider might be LATP (lengthening and then plating), where the exfix is converted to a locking plate internally after distraction. Cost would be similar to LON. This eliminates the risk of anterior knee pain.
Any infix(nail or plate) following exfix has a risk of infection.
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Hey Dr.Birkholtz,
Just wondering if Precice 2 has any mechanical/functional advantage over Precice other than giving longer length?
Precice was modular and when it failed it usually did it at the joint between the modular sections. In precice 2 this has been adressed, making the nail much stronger. Eventually omce they run out of stock on precice, i think they will convert to only having precice 2.
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LRS(monorail) fixators are strong and we fully weightbear on them. They have not snapped yet. The issue with LRS is the risk of malalignment.
An option to consider might be LATP (lengthening and then plating), where the exfix is converted to a locking plate internally after distraction. Cost would be similar to LON. This eliminates the risk of anterior knee pain.
Any infix(nail or plate) following exfix has a risk of infection.
With LATP is the main benefit over externals a somewhat reduced fixation time? The frames still have to stay on with the plate until the bones consolidate, right?
Also, I've read in a few sources that there is a higher risk of refracture with externals than with LON/LATN. Say I lengthened 5 cm and it took 10 months wearing the fixator before it was removed. Would this mean that even after fixator removal I wouldn't be able to bear significant weight until months afterward? I don't plan on doing barbell squats at the gym right after, but I'm wondering if I'd still have to be careful not to run or anything like that for a long while afterward so as to avoid refracturing the bone.
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With LATP is the main benefit over externals a somewhat reduced fixation time? The frames still have to stay on with the plate until the bones consolidate, right?
Also, I've read in a few sources that there is a higher risk of refracture with externals than with LON/LATN. Say I lengthened 5 cm and it took 10 months wearing the fixator before it was removed. Would this mean that even after fixator removal I wouldn't be able to bear significant weight until months afterward? I don't plan on doing barbell squats at the gym right after, but I'm wondering if I'd still have to be careful not to run or anything like that for a long while afterward so as to avoid refracturing the bone.
LATP has the advantage of shorter frame times, as the plates serve the purpose of stability during consolidation.
We allow full weight bearing throughout exfix only treatment. The frames are removed when bone consolidation is complete. After removal the bone is strong, but we do suggest protected weight bearing for 6 weeks. The refracture rate quoted is really when the frames are removed too early before full regenerate consolidation. Once consolidated completely, the bone is stronger than before the surgery!
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Long frame times do not necessarily equate to permanent muscle damage. We encourage early functional rehab including full weight bearing which promotes muscle function.
New bone (regenerates) are often wider than the original bone. This is a good thing. It means your surgeon knows what he's doing and you're creating good quality bone. Will have no effect on function.
Hi Dr. Franz,
On doing externals only, you bypass the need for an internal nail, correct? Does this make it a less invasive process? How is the healing time on this vs LON/LATN? Is is significantly longer? I like the idea of using no nails through the knee. Are there issues of nonunion or the bone not growing straight for a smaller length gain such as 5cm. I apologize if you've already answered these questions within the forum, but I'm really interested in doing externals only for a 5cm gain. What was the price for this? Thanks!
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Hey Dr.B!
Can you please clarify this question raised by thetallerman?
Hey guys since Femurs do not run straight up and down like the tibias as seen in this picture (attached) but in fact run at a slanted angle, if you were to lengthen for example, 5 cm in them, would the actual gain be 5 cm, or it would it be more or less? Can math whizzes help me out on this and also give the reason behind their answers. Thanks guys and looking forward to the responses. It's just I would hate to lengthen a certain amount and then when I measure myself post-lengthening I don't get the amount I thought I would.
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Hi Dr. Franz,
On doing externals only, you bypass the need for an internal nail, correct? Does this make it a less invasive process? How is the healing time on this vs LON/LATN? Is is significantly longer? I like the idea of using no nails through the knee. Are there issues of nonunion or the bone not growing straight for a smaller length gain such as 5cm. I apologize if you've already answered these questions within the forum, but I'm really interested in doing externals only for a 5cm gain. What was the price for this? Thanks!
Hi,
Externals only means there are no internal devices used. The consolidation time is the same, but the big difference is that exfixes are worn for the entire time. In adults this is around 6-9 months for 5 cm.
there is a small chance of subsidence and length loss, which can be compensated for by overlengthening by 5-10mm. Deformity is possible, but unlkely.
Cost is 30K USD for new frames and 25K for re-used ones.
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Hey Dr.B!
Can you please clarify this question raised by thetallerman?
Great question,
Yes with exfixes we lengthen along the mechanical axis which should correspond pretty much to patient height. With femoral nails, we tend to lengthen along the anatomic axis, which might not correspond perfectly to height gain (it is oblique). It is well described too that patients end up with 5-10 mm less than expected. I would suggest going 1cm beyond target length and then backing the nail up by 5mm. This would ensure quick consolidation. The downside of long lengthenings along the anatomic axis (like with precice, guichet, betzbone, iskd), is that we change the mechanical alignment of the femur, as we lengthen along a different axis. This means that intramedullary lengthenings in the femur beyond 5-6cm will inevitably lead to slight malalignment. This may in time lead to arthritis.
In short, keep to reasonable distances and go to a doc that understands this.
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Thank you very much for taking your time to answer these questions Dr Birkholtz.
What is your opinion on quadrilateral lengthening ? Is it safe if it is kept under 5 cm (I was think 5.5(femur) + 4.5(tibia)(absolute max)) and is done using safe "less strenuous" internal devices such as precise ? What are the disadvantages of lengthening quadrilateraly compared to doing one lengthening and returning 3-4 months into consolidation for the second.
Would the inability to push your self as hard in physio with 6 broken bones be an issue ?
Would combining recovery times increase total recovery time or reduce it ?
What would you recommend.
Thank you Doctor :)
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Thank you very much for taking your time to answer these questions Dr Birkholtz.
What is your opinion on quadrilateral lengthening ? Is it safe if it is kept under 5 cm (I was think 5.5(femur) + 4.5(tibia)(absolute max)) and is done using safe "less strenuous" internal devices such as precise ? What are the disadvantages of lengthening quadrilateraly compared to doing one lengthening and returning 3-4 months into consolidation for the second.
Would the inability to push your self as hard in physio with 6 broken bones be an issue ?
Would combining recovery times increase total recovery time or reduce it ?
What would you recommend.
Thank you Doctor :)
Hi,
Quad lengthening is dangerous because it is a massive operation. You suddenly increase risk of fat embolism tremendously. Also this almost definitely means blood transfusion. It does not really save that much in cost, and might mean less total length achieved. I do not recommend it.
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Doctor,
A question for you to answer when you can. Do femur and tibia lengths of equal measurement ever occur naturally in a population? And if so, have you any idea what the rate of occurrence would be? All resources I've read state the femur as the longer of the two, without exception. Is there anything anatomically disadvantageous to having equal length bones or a tibia that is slightly longer than the femur (~1cm)?
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Doctor,
A question for you to answer when you can. Do femur and tibia lengths of equal measurement ever occur naturally in a population? And if so, have you any idea what the rate of occurrence would be? All resources I've read state the femur as the longer of the two, without exception. Is there anything anatomically disadvantageous to having equal length bones or a tibia that is slightly longer than the femur (~1cm)?
Dear Poly,
You are absolutely right. The ratio is normally 0.8, ie tibia 80% of the length of the femur give or take.
There is probably a very good biomechanical reason for this. Having said this, I am not aware of any long-term negative effects if the tibias are longer than normal.
F
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Hi Dr Birkholtz,
For prospective patients looking to lengthen tibias, do you think it's always the case that lengthening with a TSF is better than lengthening with the traditional Ilizarov frames?
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Hi Dr Birkholtz,
For prospective patients looking to lengthen tibias, do you think it's always the case that lengthening with a TSF is better than lengthening with the traditional Ilizarov frames?
Very good question. The TSF or TLHex devices are hexapod circular external fixators. They allow very accurate threedimensional computer based corrections. This means that the likelihood of deformity is less. They are however quite expensive. A compromise would be to use TSF or TLHex rings, but with Ilizarov distaction components. This is cheaper and allows us the ability to slot in the hexapod struts to optimize the alignment should it be necessary. This is done in the office. Because we use the hexapod struts short term, there is the option to use second hand components for this phase. Of course anything that goes into the bone must be new!
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Hello Dr. Birkholtz.
I hope you had a wonderful weekend. Also, I had a few questions about biomechanics involving LL and athletic recovery and was wondering if you'd be willing to answer them for me. I am a dedicated runner and accept that I will possibly lose some degree of athletic ability from this surgery. However, in order to create the best biomechanical ratio for speed and comfortable running, along with optimum heat desipitation, would you recommend the lengthening of the femurs or tibiae? I was hoping that improved bodily ratios could help me counterbalance the loss of muscle strength after LL. What do you think? Also, how much athletic recovery do you believe is possible after cosmetic LL for 4CM versus around 7CM on tibiae and how much for these same amounts on the femurs? Thank you so much for your time and help. They mean a tremendous deal to the members of this forum.
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Hello Dr. Birkholtz.
I hope you had a wonderful weekend. Also, I had a few questions about biomechanics involving LL and athletic recovery and was wondering if you'd be willing to answer them for me. I am a dedicated runner and accept that I will possibly lose some degree of athletic ability from this surgery. However, in order to create the best biomechanical ratio for speed and comfortable running, along with optimum heat desipitation, would you recommend the lengthening of the femurs or tibiae? I was hoping that improved bodily ratios could help me counterbalance the loss of muscle strength after LL. What do you think? Also, how much athletic recovery do you believe is possible after cosmetic LL for 4CM versus around 7CM on tibiae and how much for these same amounts on the femurs? Thank you so much for your time and help. They mean a tremendous deal to the members of this forum.
For optimal function the tibia to femur ratio should be around 0.8. Unfortunately every persons response to lengthening is different and matching predicted outcomes to patients accurately is almost impossible to do consistently. I think it is dangerous to expect CLL to improve athletic ability. If anything, it tends to diminish.
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Dr Birkholtz what is your opinion on lengthening individuals who have mild bow legs. Are you able to both lengthen and correct the bowing
or is it 2 separate operations?
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Dr Birkholtz what is your opinion on lengthening individuals who have mild bow legs. Are you able to both lengthen and correct the bowing
or is it 2 separate operations?
Usually relatively mild deformities can be addressed with the lengthening surgery, especially during exfix techniques where we can use advanced computer based hexapod fixators like the TSF or TL-Hex. It can even be done with internal nails, using a small acute correction of deformity. This is not always possible with nails though.
Ilizarov/Hexapod based deformity correction with lengthening is what we do all the time for malunions in the practice. We do upwards of 150 circular fixators per year, placing us in the top bracket of surgeons as far as numbers are concerned.
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Both. Larger lengthenings have more complications both during lengthening and longer afterwards.
Hopefully you will be OK. Sounds like youre doing very well so far.
In lay mans terms, what kind of complications? Is there a risk my legs will fall off in the next few days? Appreciate the kind response, but would be grateful for specific examples.
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In lay mans terms, what kind of complications? Is there a risk my legs will fall off in the next few days? Appreciate the kind response, but would be grateful for specific examples.
I think you will appreciate that complications are very difficult to predict and individualize and every person would be different. For this reason, it is impossible to put accurate percentages to the complications.
In general, longer distractions have higher complication rates. Potential complications related to longer distractions may include the following:
increased pain during and after distraction
increased muscle stiffness
increased joint contractures and stiffness
a shift in the mechanical axis of the limb, leading to malalignment
delayed union of a regenerate
nonunion of a regenerate
bending of a regenrate, resulting in malalignment
increased articular pressures
increase in long-term arthritic changes
decrease in function and sporting ability
higher infection rates (if using exfix)
higher potential for failure of instrumentation
longer recovery period
I hope this helps?
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Lengthening and consolidation in externals takes 1.5 - 2 months per cm. this means 7.5 - 10 months in frames.
Comfortable running should be possible 6-9 months after frame removal, but is difficult to predict.
Interesting, about how long after frame removal are you allowed to jump? similar timeframe as running? (external only)
And what about working out the legs, doing leg press etc?
Also we have a diary here of a patient who did 9 cm in 10 months externals only, so with that in mind i assume it is possible but uncommon to heal faster than 1.5 - 2 months per cm. Since 9 cm in 10 months is ca 33 days per cm, ie slightly more than a month/cm
Thank you for all the info Dr. Franz
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Interesting, about how long after frame removal are you allowed to jump? similar timeframe as running? (external only)
And what about working out the legs, doing leg press etc?
Also we have a diary here of a patient who did 9 cm in 10 months externals only, so with that in mind i assume it is possible but uncommon to heal faster than 1.5 - 2 months per cm. Since 9 cm in 10 months is ca 33 days per cm, ie slightly more than a month/cm
Thank you for all the info Dr. Franz
I allow full weight bearing from day one as much as the patient can tolerate. If you want to jump, you are welcome to (as long as it is not off a buiding! :-). Generally I would say that jumping comfortably would be similar to running.
Our fastest healers have been at just below 1 month per cm (28 days), but the average is around 1.3 - 1.5. Not to create false hope, we add another 0.5.
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Hi Dr Birkholtz,
Is the loss of athletic ability after limb lengthening influenced more by the stretching of the soft tissues or more so the change in ratio between tibs/femurs? Or is it just the surgical trauma? I guess what I'm wondering is if a loss of athletic ability after one lengthening can be minimized by lengthening a second segment and getting the ratio between femurs/tibs closer to what they were originally. Or would a second lengthening just cause a further dip in athletic ability because of the additional surgical trauma?
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Hi Dr Birkholtz,
Is the loss of athletic ability after limb lengthening influenced more by the stretching of the soft tissues or more so the change in ratio between tibs/femurs? Or is it just the surgical trauma? I guess what I'm wondering is if a loss of athletic ability after one lengthening can be minimized by lengthening a second segment and getting the ratio between femurs/tibs closer to what they were originally. Or would a second lengthening just cause a further dip in athletic ability because of the additional surgical trauma?
Hi,
I am not aware of any data to suggest that it is purely due to the ratio change. I think it is more the muscle length changes as well as the surgical trauma. If this is the case, athletic ability will worsen with further surgery.
Not sure this is the aswer you wanted, though!
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Hi guys,
I have decided to montior this thread in the interest of safety and accurate information. Please note that in the interest of not appearing to promote myself, I will not enter into any discussions about finances in this thread. For any specific or cost-related queries, please email me at franz.birkholtz@walkamile.co.za.
Realistically I will probably only be able to monitor and reply once a week.
Warm regards,
FFB
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Well to (re)start things off:
As of now how many CLL have you done with the PERCICE 2?
How has the process been for these patients?
Have you kept in touch with any of your former patients; have any newly unreported long term complications arisen since this time?
Would you say that there should be a possible limit on the amount done with regards to tibia? Like say 5 cm?
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Well to (re)start things off:
As of now how many CLL have you done with the PERCICE 2?
How has the process been for these patients?
Have you kept in touch with any of your former patients; have any newly unreported long term complications arisen since this time?
Would you say that there should be a possible limit on the amount done with regards to tibia? Like say 5 cm?
If possible could there be a reply about the long term complications of going over the recommended amounts as it gets asked on here constantly. Example will a guy who does 9cm on one segment eventually recover the same in the end as a guy who did 5cm? What do these big lengthening do to the body so it doesn't totally recover the same?
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Dr. franz your commitment to providing safe and accurate information to us potential patients is as amiable as your knowledge and friendly attitude.
-You stated earlier that cosmetic humerus lengthening isn't recommended could you expand on why that is, which complications that tend to occur and if there are exceptions to this rule?
-Could you speak in more general terms about the permanent loss of athletic function that most if not all LL patients experience? I'd like to better understand the long-term effects on my body.
Thank you so much.
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Good to see Dr Birkholtz back.
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I have now done 3 cosmetic limb lengthenings with Precice 2. Our overall Precice experience is now over 15 nails. External fixator based lengthenings more than 1500.
As far as I am aware, none of our CLL Precice patients have had significant complications in the long term.
Tibial CLL should probably be limited to around 4-5cm. This has to do with muscle tension and contractures primarily. Although the muscles to grow in the process of distraction histogenesis, there is an element of stretching that has to take place as well and if this is excessive, contractures result (eg ballerina foot) and this may be permanent.
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If possible could there be a reply about the long term complications of going over the recommended amounts as it gets asked on here constantly. Example will a guy who does 9cm on one segment eventually recover the same in the end as a guy who did 5cm? What do these big lengthening do to the body so it doesn't totally recover the same?
See my previous post. it primarily has to do with the amount of stretching and tension exerted over a muscle tendon unit. If you exceed the 'safe distance', you may well end up with permanent contractures. This means that you lose joint movement. Of course longer distractions take more time, have higher non-union rates, are more painful etc etc (see previous posts in this thread).
A 5cm lengthening may recover full function over time, a 9cm one is much less likely to do so.
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Dr. franz your commitment to providing safe and accurate information to us potential patients is as amiable as your knowledge and friendly attitude.
-You stated earlier that cosmetic humerus lengthening isn't recommended could you expand on why that is, which complications that tend to occur and if there are exceptions to this rule?
-Could you speak in more general terms about the permanent loss of athletic function that most if not all LL patients experience? I'd like to better understand the long-term effects on my body.
Thank you so much.
Thanks for the kind words. If we think of the worst case scenario for CLL, it is probably severe functional loss of the affected limb(s). Loss of function in the lower limb is generally much better tolerated than losing function of arms or hands. For this reason CLL in the lower limb is more acceptable than in the upper limb.
The bone growth that occurs during humerus lengthening is generally good and the soft tissues adapt reasonably well. The major issue is potential for nerve damage and diminished hand function.
Range of motion of the joints are affected during CLL (even though the effect may be slight). Muscle length and power changes permanently. Loss of flexibility and explosive power. Loss of some proprioceptive capacity. Endurance loss. How much is lost and how much it will affect each individual is quite difficult to ascertain, but there seems to be a roughly linear relationship between these factors and the amount lengthened. Ie, the more you lengthen, the more of these you can expect.
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Thanks for the kind words. If we think of the worst case scenario for CLL, it is probably severe functional loss of the affected limb(s). Loss of function in the lower limb is generally much better tolerated than losing function of arms or hands. For this reason CLL in the lower limb is more acceptable than in the upper limb.
The bone growth that occurs during humerus lengthening is generally good and the soft tissues adapt reasonably well. The major issue is potential for nerve damage and diminished hand function.
Range of motion of the joints are affected during CLL (even though the effect may be slight). Muscle length and power changes permanently. Loss of flexibility and explosive power. Loss of some proprioceptive capacity. Endurance loss. How much is lost and how much it will affect each individual is quite difficult to ascertain, but there seems to be a roughly linear relationship between these factors and the amount lengthened. Ie, the more you lengthen, the more of these you can expect.
One last question if I may:
I plan to lengthen my femurs 5CM via an internal nail method, how do I as a patient best prepare for this surgery?
I already try to stretch and build my leg muscles, is there anything else and do you have any tips?
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Thanks for the kind words. If we think of the worst case scenario for CLL, it is probably severe functional loss of the affected limb(s). Loss of function in the lower limb is generally much better tolerated than losing function of arms or hands. For this reason CLL in the lower limb is more acceptable than in the upper limb.
The bone growth that occurs during humerus lengthening is generally good and the soft tissues adapt reasonably well. The major issue is potential for nerve damage and diminished hand function.
Range of motion of the joints are affected during CLL (even though the effect may be slight). Muscle length and power changes permanently. Loss of flexibility and explosive power. Loss of some proprioceptive capacity. Endurance loss. How much is lost and how much it will affect each individual is quite difficult to ascertain, but there seems to be a roughly linear relationship between these factors and the amount lengthened. Ie, the more you lengthen, the more of these you can expect.
Dr.Franz,
I certainly don't mean to negate your comments, considering that the humerus is as an important limb to hand as the spine is to the nervous system, but wouldn't those functionality comments be more applicable to the forearm. It seems like overall forearm lengthening would be the one most impacting the functionality of the hand. Also I do recall this study saying it'd be the easiest to lengthen out of all the possible segments; this of course doesn't mean it wouldn't actually effect functionality, but I digress:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323419/
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One last question if I may:
I plan to lengthen my femurs 5CM via an internal nail method, how do I as a patient best prepare for this surgery?
I already try to stretch and build my leg muscles, is there anything else and do you have any tips?
You need to prepare in terms of three aspects: 1) Mental strength. This process is brutal and takes a lot of mental tenacity. 2) Upper body strength. To help with walking rehab. Remember you will have to walk on your hands effectively for the first couple of weeks/months (depending on the technique you choose). 3) Flexibility. To allow muscles, nerves etc to adapt to lengthening.
The ideal preparation is probably Pilates / Yoga.
Bulking on limb muscles is probably the worst you can do, as it will resist the distraction forces more.
Anyway, that is my humble opinion.
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Dr.Franz,
I certainly don't mean to negate your comments, considering that the humerus is as an important limb to hand as the spine is to the nervous system, but wouldn't those functionality comments be more applicable to the forearm. It seems like overall forearm lengthening would be the one most impacting the functionality of the hand. Also I do recall this study saying it'd be the easiest to lengthen out of all the possible segments; this of course doesn't mean it wouldn't actually effect functionality, but I digress:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323419/
Yes, forearm lengthening will potentially have more of an effect on hand function than humeral lengthening. The issue with humerus is the radial nerve that contributes significantly to hand function. It is not injured often, but is devastating if it happens.
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Hi Dr Birkholtz,
It seems that most who use the Precice for femur lengthening perform an ITB release whereas the well-known surgeons who use an Albizzia nail choose not to do one. Is the ITB release done to make it easier for the Precice to distract? What would the consequence(s) be if one were to lengthen femurs without an ITB release done?
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Hi Dr Birkholtz,
I would also like to echo Uppland's sentiments regarding your contribution to this forum and the awareness you've raised regarding this surgery.
I am wondering what your views are on the surgery being done over two stages, eg right leg first then the left after the right leg can be used again.
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Hi Dr Birkholtz,
It seems that most who use the Precice for femur lengthening perform an ITB release whereas the well-known surgeons who use an Albizzia nail choose not to do one. Is the ITB release done to make it easier for the Precice to distract? What would the consequence(s) be if one were to lengthen femurs without an ITB release done?
My humble opinion is to follow the surgeons with the most experience. It seems that the guys with most Precice experience (read Paley) do ITB releases and the ones with most Albizzia experience (read Guichet and Betz) suggest that ITB release may not be necessary.
Personally I perform an ITB release because I believe it adds value.
Theoretically a tight ITB can give a hip flexion contracture, knee flexion contracture and/or failure to extend the nail. I have had to perform a release on somebody else's patient with a nail based lengthening and tight itb recently.
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Hi Dr Birkholtz,
I would also like to echo Uppland's sentiments regarding your contribution to this forum and the awareness you've raised regarding this surgery.
I am wondering what your views are on the surgery being done over two stages, eg right leg first then the left after the right leg can be used again.
I think it is fantastic if you have the stamina and budget to sustain the process.
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Adding to Nightwish,
Would you be willing to use that method to length? If so, I know it's probably gonna be more time consuming, but would it also be more expensive?
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Adding to Nightwish,
Would you be willing to use that method to length? If so, I know it's probably gonna be more time consuming, but would it also be more expensive?
It is certainly something to consider if the patient prefers that route.
The issue is the cost of physio and hospitalisation is roughly the same whether we do one or two sides. This means that doing them separately is around 1.5 times as expensive as doing them together.
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any chance you have an idea when precice 3 is coming out?
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hey Dr. Franz,
how likely is it for severe complications to occur "while" lengthening as opposed to during surgery?
the main complications during lengthening we know are nerve damage, non-consolidation.
is it possible that things might be really unpredictable when it comes to these while lengthening?
should someone lengthening be in constant fear of something like this happening every second of the months of lengthening?
since you mentioned mental stability, I think this would be personally one of the scariest things while lengthening. constant dilemma, fear and paranoia.
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any chance you have an idea when precice 3 is coming out?
Unfortunately I don't know
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hey Dr. Franz,
how likely is it for severe complications to occur "while" lengthening as opposed to during surgery?
the main complications during lengthening we know are nerve damage, non-consolidation.
is it possible that things might be really unpredictable when it comes to these while lengthening?
should someone lengthening be in constant fear of something like this happening every second of the months of lengthening?
since you mentioned mental stability, I think this would be personally one of the scariest things while lengthening. constant dilemma, fear and paranoia.
The complications of surgery can be divided into acute, early post-op, during distraction, during consolidation and long-term.
Examples are:
Acute (during surgery): anaesthetic complications, fat embolism syndrome, excessive bleeding, damage to arteries and nerves with the osteotomy, unwanted propagation of the osteotomy (ie bigger break than expected)
Early post-op: pain, stiffness, wound infection, deep vein thrombosis and pulmonary embolism
During distraction: device failure, premature consolidation, slow bone formation, joint contractures
During consolidation: delayed or non-union, regenerate bending, device failure
Long-term: functional impairment, arthritic changes
The good news is most of these can be managed by an experienced doctor. The thing that makes a surgeon good is not only surgical skill, but the way that they prevent and manage complications. If that is done with care and empathy, that is a great surgeon.
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The complications of surgery can be divided into acute, early post-op, during distraction, during consolidation and long-term.
Examples are:
Acute (during surgery): anaesthetic complications, fat embolism syndrome, excessive bleeding, damage to arteries and nerves with the osteotomy, unwanted propagation of the osteotomy (ie bigger break than expected)
Early post-op: pain, stiffness, wound infection, deep vein thrombosis and pulmonary embolism
During distraction: device failure, premature consolidation, slow bone formation, joint contractures
During consolidation: delayed or non-union, regenerate bending, device failure
Long-term: functional impairment, arthritic changes
The good news is most of these can be managed by an experienced doctor. The thing that makes a surgeon good is not only surgical skill, but the way that they prevent and manage complications. If that is done with care and empathy, that is a great surgeon.
Thanks Dr Franz!
From what I can guess, non-union, regenerate bending, device failure cannot be controlled by the surgeon. Is that right?
And did you miss nerve damage during distraction? isn't that a possibility? something like "I was at 6.9cm yesterday when I decided to make it 7cm. I haven't been able to feel one part of my left foot ever since." ? is that how it can happen?
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Also, Dr. Franz, this doesn't concern CLL, but what is your take on HGH for normal kids who are just short and meant to be short?
Considering how ghastly this surgery is, do you think it's better to play the HGH card and see how it goes when you're young?
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Also, Dr. Franz, this doesn't concern CLL, but what is your take on HGH for normal kids who are just short and meant to be short?
Considering how ghastly this surgery is, do you think it's better to play the HGH card and see how it goes when you're young?
Good question. My concern is two-fold: Firstly, not every kid who ends up as a short adult will necessarily want to be taller. The question is when is it appropriate for a parent to prophylactically adjust the kid's growth without their consent. The second more important issue is whether there are any long-term negative effects to HGH. It is hormonal treatment and we simply do not really know the long-term safety profile.
Hope this helps
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Thanks Dr. Franz.
I think you missed my earlier question.
Can nerve damage happen overnight while lengthening? Hypothetically, if you are doing fine now and distract by 1mm, is it possible that your nerve could have got damaged?
Or are there always gradual signs that show an upcoming complication like nerve damage?
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Thanks Dr. Franz.
I think you missed my earlier question.
Can nerve damage happen overnight while lengthening? Hypothetically, if you are doing fine now and distract by 1mm, is it possible that your nerve could have got damaged?
Or are there always gradual signs that show an upcoming complication like nerve damage?
Jip, missed your question. Sorry.
It is possible. Nerves do not particularly like stretching and although they are elastic up to a point, they stop working after stretching beyond a certain point. Think of an elastic band that can stretch freely, but stops at some point and can break. Now the nerve doesn't typically break, but stops functioning. If the stretch is discontinued, the nerve can recover, but there is also a point at which that nerve function loss can become permanent. This is different for different people, so it is not possible to give accurate amounts/distances. In general terms, this is one of the reasons why we have safe limits for CLL and should be careful to go beyond that.
Sometimes the earliest sign that the nerve may be in trouble is a tingling sensation, almost like when your foot goes to sleep. We call this paresthesia. Your doctor should be alerted of this immediately.
My approach is then to stop distraction for a day or two and recommence at a slower rate. Should the symptoms not improve, I will start talking to the patient about stopping distraction altogether or performing a nerve release.
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Thank you Dr. Franz.
What nerves are the most likely to be damaged? what is the functional loss if a permanent nerve damage happens? complete loss of function of leg or something more localized like being unable to move a toe?
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Does the femur or the tibia play a more significant role in stride length, and how would CLL Impact waking and running stride overall?
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Thank you Dr. Franz.
What nerves are the most likely to be damaged? what is the functional loss if a permanent nerve damage happens? complete loss of function of leg or something more localized like being unable to move a toe?
Hi, the most common nerve is the peroneal nerve during tibial lengthening. This can lead to a foot drop.
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Does the femur or the tibia play a more significant role in stride length, and how would CLL Impact waking and running stride overall?
I have no idea 😀. Presumably both will contribute to stride length and I do not think that the ranges we lengthen in will make a big difference whether it is femur or tibia.
Stride length will probably increase slightly after CLL, but will possibly be offset by tighter muscles.
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Hi Dr Franz,
thank you for your kindness and availability.
if the peroneal nerve during tibia lengthening is damaged, it can lead to a foot drop. Is the foot drop permanent or can be resolved?
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Also is nerve damage uncommon during femoral lengthening? Which nerve is most prone to damage there?
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Hi Dr Franz,
thank you for your kindness and availability.
if the peroneal nerve during tibia lengthening is damaged, it can lead to a foot drop. Is the foot drop permanent or can be resolved?
It depends on the severity of the damage to the nerve. So it can recover, but can take a long time to do so. Occasionally it will not recover. This is usually the case with overstepping the safe limits and/or with deformity corrections together with lengthenings.
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Also is nerve damage uncommon during femoral lengthening? Which nerve is most prone to damage there?
Nerve dysfunction during femoral lengthening is more due to the femoral nerve and usually translates into sensory disturbances (changes in feeling / numbness / tingling)
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What is the worse scenerio?
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Which scenario can be favorable for a solid recovery? Assuming there is no cost factor.
1. 2-3 cm Internal femur (Precice), 2 cm External Tibia
2. 4-5 cm Internal femur (Precice)
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Dr. Franz, thanks for been kind to us and patient with our endless questions.....this is a pretty new procedure in general hence our curiosity, doubt and fear. Very few doctors so far have been advocates of lengthening limits, that makes me take you more seriously since it's a very logical warning. Once you get time please i have the following question:
Which scenario can be favorable for a solid recovery? Assuming there is no cost factor.
1. 2-3 cm Internal femur (Precice), 2 cm External Tibia
2. 4-5 cm Internal femur (Precice)
I'm residing in the Netherlands (177 cm) and trust me i am a pretty short guy there, and yes it's pretty hard for a short guy there especially if you are in a showbiz industry where no morals apply as long as you get a win. In short, CLL will change my life and i will create more opportunities by simply becoming average. I know it's a pretty tough road, but i have heavily invested here so rather than ignoring this social stigma, i believe i have a legit reason to do CLL. By the way, even girls are taller than me!
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Dr. Franz, thanks for been kind to us and patient with our endless questions.....this is a pretty new procedure in general hence our curiosity, doubt and fear. Very few doctors so far have been advocates of lengthening limits, that makes me take you more seriously since it's a very logical warning. Once you get time please i have the following question:
Which scenario can be favorable for a solid recovery? Assuming there is no cost factor.
1. 2-3 cm Internal femur (Precice), 2 cm External Tibia
2. 4-5 cm Internal femur (Precice)
I'm residing in the Netherlands (177 cm) and trust me i am a pretty short guy there, and yes it's pretty hard for a short guy there especially if you are in a showbiz industry where no morals apply as long as you get a win. In short, CLL will change my life and i will create more opportunities by simply becoming average. I know it's a pretty tough road, but i have heavily invested here so rather than ignoring this social stigma, i believe i have a legit reason to do CLL. By the way, even girls are taller than me!
Interesting question. I think that your first scenario has a better chance of recovery. We know that CLL complications are related to the amount of lengthening per segment. Both however are short overall distances and should give good recovery.
Remember that tibial lengthening almost always gives the most bang for your buck, because visually people tend to use the knee level to estimate overall height. Ie longer tibias make you appear longer much easier than the same amount of femoral lengthening.
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Thanks a lot Dr.Franz, i thought you would never respond since i'm above the recommended limit for CLL ;D
Well if you don't mind, i have another one!
Tibia lengthening has been associated with late recovery, more complications than femur lengthening according to a lot of diaries i have gone through, in that case:
-Which option is better if i decide to do Tibia, Internal or External? (If Internal, is there a way to evade knee complications?)
-I remember in one of your post recommending a weaker/softer bone for CLL rather than strong bone. Does weak mean, small/thin bones?
-Let's assume i smoked for 2 years then i stopped last year, can that complicate my procedure if i do it early 2016?.....i mean, will the residue still be in my system to affect the procedure?
-For some of us who don't take pain pills due to stomach ulcers, can we use medical marijuana back in Amsterdam after lengthening as an alternative or it doesn't have significant pain relief like the counter painkillers?
-I do mountain climbs and hike at least twice every year, how many years or month are more realistic to safely go back to related activities?
Thanks for taking this seriously, we need people like you to enlighten us about this procedure. By the way, i have an African American friend of mine who is also interested with CLL but he is kinda worried about the racism nature in South Africa and wonders if this can interfere with his CLL procedure?!???
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hello,
i am 5ft 10in
is there any limitation for surgery
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Thanks a lot Dr.Franz, i thought you would never respond since i'm above the recommended limit for CLL ;D
Well if you don't mind, i have another one!
Tibia lengthening has been associated with late recovery, more complications than femur lengthening according to a lot of diaries i have gone through, in that case:
-Which option is better if i decide to do Tibia, Internal or External? (If Internal, is there a way to evade knee complications?)
-I remember in one of your post recommending a weaker/softer bone for CLL rather than strong bone. Does weak mean, small/thin bones?
-Let's assume i smoked for 2 years then i stopped last year, can that complicate my procedure if i do it early 2016?.....i mean, will the residue still be in my system to affect the procedure?
-For some of us who don't take pain pills due to stomach ulcers, can we use medical marijuana back in Amsterdam after lengthening as an alternative or it doesn't have significant pain relief like the counter painkillers?
-I do mountain climbs and hike at least twice every year, how many years or month are more realistic to safely go back to related activities?
Thanks for taking this seriously, we need people like you to enlighten us about this procedure. By the way, i have an African American friend of mine who is also interested with CLL but he is kinda worried about the racism nature in South Africa and wonders if this can interfere with his CLL procedure?!???
Firstly, the choice between external or internal is best made on an individual basis. Cost-wise exfix only tibias is the cheapest, followed by LON/LATP. Fully internal lengthening is the most expensive. Knee pain after nails seems to be lower in our patient population than what is quoted in literature.
The recommendation is that, due the the resistance during lengthening, supple, flexible legs are better than bulky muscular ones.
Smoking effects on bone healing should be negligible after two years of cessation.
Not all the analgesics burn the stomach. It is mostly the non-steroidals. In principle I cannot condone the use of Marijuana for this purpose. As far as I am aware, it should not have a negative effect on bone healing, though.
Give yourself at least 18 months to 2 years to return to high strain activities.
90 percent of our country's population is black, so racism should not be an issue.
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hello,
i am 5ft 10in
is there any limitation for surgery
Our official guideline is a limit of 165cm, but it is something that needs to be individualized in each patient. You are welcome to contact me to discuss further at franz.birkholtz@walkamile.co.za
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Finally someone gave me the answers! Thanks Dr. Franz :)
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Would you be willing to perform plating and frame removal for patients who got their frames installed and lengthening done with another doctor?
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Would you be willing to perform plating and frame removal for patients who got their frames installed and lengthening done with another doctor?
Obviously I would prefer to do this in planned cases where I performed the first surgery. Having said that, I am always available to help patients with problems, including complications or a change in plans. This is a sensitive area, since I can only take over a patient's care if they request it. The first surgeon is usually the best person to continue the treatment.
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Do you think femur leng. with Lon is safe ?
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Hi Dr. Franz,
with regards to the rubber band analogy, is there really such a thing as a "safe limit"?
I understand that if a rubber band is stretched *beyond a point*, it loses its strength and elasticity permanently. But even if a rubber band is *slightly* stretched and held for hours together, it would still lose strength and elasticity. Does this analogy hold 1:1 with soft tissues, muscles and nerves?
Thank you
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Dr. Birkholtz,
Perhaps this is an odd question. How much wheight would be gained after lengthening 5cm´s on the femurs compared to the same amount on the tibias? It obviously depends on the individual and the size of the bones but I´d like to know how much more wheight would be gained on the femurs. The idea of being light for the height you get after lengthening the tibias displeases me a lot and is one of the reasons why I lean towards a femur lengthening. Thanks in advance for your reply!
Regards,
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Do you think femur leng. with Lon is safe ?
Good question, but not easy to answer. AS with any surgery it is as safe as the surgeon you choose.
It is technically quite difficult and has a risk of infection, so we tend to shy away from it.
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Hi Dr. Franz,
with regards to the rubber band analogy, is there really such a thing as a "safe limit"?
I understand that if a rubber band is stretched *beyond a point*, it loses its strength and elasticity permanently. But even if a rubber band is *slightly* stretched and held for hours together, it would still lose strength and elasticity. Does this analogy hold 1:1 with soft tissues, muscles and nerves?
Thank you
You are right. There is no absolute safe limit, but from our experience in managing thousands of cases of deformity, congenital conditions, bone defects etc, the least complications happen below the 5.5cm mark.
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Dr. Birkholtz,
Perhaps this is an odd question. How much wheight would be gained after lengthening 5cm´s on the femurs compared to the same amount on the tibias? It obviously depends on the individual and the size of the bones but I´d like to know how much more wheight would be gained on the femurs. The idea of being light for the height you get after lengthening the tibias displeases me a lot and is one of the reasons why I lean towards a femur lengthening. Thanks in advance for your reply!
Regards,
Hi, good question. I don't have a scientific answer for you, but the weight gain between femoral or tibial lengthening should be very similar.
There is probably more weight gain with the lack of sports and BicMacs because of boredom during lengthening! ;-)
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Hello dr.
I would like to know, from your past experience, what was the safest upper limit of internal femural lengthening in centimeters that you have wintnessed? I mean how many long term complications did you encountere?
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Hello dr.
I would like to know, from your past experience, what was the safest upper limit of internal femural lengthening in centimeters that you have wintnessed? I mean how many long term complications did you encountere?
He has already made it clear that 5-6cm for Femurs is the safest limit in his eyes.
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Hi Dr Birkholtz
I want to know what you think about pre-op preparation.
How important is flexibility?
I've heard conflicting things about leg muscle/ strength.
Some say strong muscular legs are good and others say they are bad and suggest reducing muscle mass before the procedure. What is your view on this?
What would be optimal?
Would strong and flexible legs like that of a martial artist or gymnast be ideal?
Thank You
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Hello dr.
I would like to know, from your past experience, what was the safest upper limit of internal femural lengthening in centimeters that you have wintnessed? I mean how many long term complications did you encountere?
It is so individually dependent that it is very difficult to give a blanket answer. For femoral cll our max gain has been just less than 80mm without issues, but this is not the norm. Relatively safe limits on femur is around 55-65mm
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Hi Dr Birkholtz
I want to know what you think about pre-op preparation.
How important is flexibility?
I've heard conflicting things about leg muscle/ strength.
Some say strong muscular legs are good and others say they are bad and suggest reducing muscle mass before the procedure. What is your view on this?
What would be optimal?
Would strong and flexible legs like that of a martial artist or gymnast be ideal?
Thank You
Flexibility is everything. Core strength and upper body strength is also important. Not weight lifting strength, but functional strength to be able to use your arms to assist with mobilizing (ie crutches). Great excercizes here are things like (simple?) push-ups, pull-ups, planking etc. I think pilates and yoga would be better time spent than weight lifting or building muscle bulk. Generally good physical fitness will stand you in good stead as it also gives you mental tenacity. This is a brutal process and you will need all the mental discipline and strength that you can muster.
Gymnasts and martial artists would have a great advantage. Of course I am biased as a karate practitioner ;-)
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It is so individually dependent that it is very difficult to give a blanket answer. For femoral cll our max gain has been just less than 80mm without issues, but this is not the norm. Relatively safe limits on femur is around 55-65mm
First, thank you for your answer.
Secondly, when you say without issues, do you mean that after the process is over the people can walk normally (As if they never had an operation)?
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Dr. Birkholtz, which do you prefer LON or LATN? Is there any way to avoid the knee pain or damage, and how much time does using these nails save. Are they worth it or do you prefer straight EXFIX?
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First, thank you for your answer.
Secondly, when you say without issues, do you mean that after the process is over the people can walk normally (As if they never had an operation)?
This was covered in earlier posts I believe. No amount of lengthening will leave you completely normal. There is always an effect. The longer the lengthening the more the effect. Other factors like quality of surgery, rehab as well as complications play a role. The reason why the surgeon needs to be chosen carefully.
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Dr. Birkholtz, which do you prefer LON or LATN? Is there any way to avoid the knee pain or damage, and how much time does using these nails save. Are they worth it or do you prefer straight EXFIX?
It is a very individual choice. For example LON is easier if the bones are straight and LATN probably better if there is an existing deformity.
For a 5cm lengthening the exfix time for exfix only lengthening is around 7-8 months.
With LON or LATN, exfix time is around 2.5 months. Quite a difference.
Knee pain is minimized using special nailing techniques.
Bear in mind that the incidence of knee pain will also be present with the lengthening nails like Precice etc.
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Hello Dr franz
Can you tell us how to choose a doctor? The obvious criteria are what method he offers and how fluent and honest he is at explaining stuff.
Other than this we are all medical laymen who just can't tell the difference between very basic things. It becomes hard to decide especially if we don't have 150k dollars for this surgery and recovery.
Is there a set of important things to consider?
Also many docs have little cosmetic LL experience but have good correctional experience. Is this a factor to consider?
We sincerely appreciate your presence here. Than you.
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Hello Dr franz
Can you tell us how to choose a doctor? The obvious criteria are what method he offers and how fluent and honest he is at explaining stuff.
Other than this we are all medical laymen who just can't tell the difference between very basic things. It becomes hard to decide especially if we don't have 150k dollars for this surgery and recovery.
Is there a set of important things to consider?
Also many docs have little cosmetic LL experience but have good correctional experience. Is this a factor to consider?
We sincerely appreciate your presence here. Than you.
This is a good question. Please bear in mind that my answer is not intended in any way to try and gain more patients. I have enough work as it is.
If I choose a surgeon I look for honesty, integrity, skill and the ability to form a relationship of trust. Pretty much in that order. Price should be the least important consideration. Also, do not choose a surgeon based on the technique yo want. If your limb lengthening surgeon is not comfortable performing individualised surgery (ie different types / techniques) I would look elsewhere.
Although CLL experience is reasonably important, bear in mind that generally CLL is technically a lot easier than correction of deformity, restoration of leg length discrepancy or restoration of non-unions of bone defects. I would much rather choose someone with a lot of experience in different techniques and who is comfortable preventing and managing complications in difficult cases. He or she should then be much more comfortable in performing 'simple' lengthenings.
I can not choose your surgeon, but be careful because you need to trust this person implicitly. The wrong choice can ruin your life and give you bigger problems than height dysphoria.
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This is a good question. Please bear in mind that my answer is not intended in any way to try and gain more patients. I have enough work as it is.
If I choose a surgeon I look for honesty, integrity, skill and the ability to form a relationship of trust. Pretty much in that order. Price should be the least important consideration. Also, do not choose a surgeon based on the technique yo want. If your limb lengthening surgeon is not comfortable performing individualised surgery (ie different types / techniques) I would look elsewhere.
Although CLL experience is reasonably important, bear in mind that generally CLL is technically a lot easier than correction of deformity, restoration of leg length discrepancy or restoration of non-unions of bone defects. I would much rather choose someone with a lot of experience in different techniques and who is comfortable preventing and managing complications in difficult cases. He or she should then be much more comfortable in performing 'simple' lengthenings.
I can not choose your surgeon, but be careful because you need to trust this person implicitly. The wrong choice can ruin your life and give you bigger problems than height dysphoria.
Hi Dr Franz,
I'm wanting to lengthen only 5cm, but concerned with contracture.. Would I lengthen 5.5cm to account for possible contracture or is there a way to guarentee that we can avoid bone compression altogether?